Abnormal Uterine

Bleeding
Emmanuel Dagala, MD, FPOGS
Obstetrician-Gynecologist
 Outline

• Definition of Terms
• Causes / Etiology
• Epidemiology
• Diagnosis and Management
 Outline

•Definition of Terms
• Causes / Etiology
• Epidemiology
• Diagnosis and Management
 Definition of Terms

• Abnormal uterine bleeding (AUB)

▫ Any significant deviation from normal
frequency, regularity, volume and duration of
menstrual bleeding
▫ Used to describe all abnormal menstrual signs
and symptoms arising from the uterine corpus
 Definition of Terms
• What is Normal?
Clinical Dimensions of Menses Descriptive Normal limits
Terms (mid-reproductive years)
FREQUENCY of menses Frequent <24
(days) Normal 24-38
Infrequent >38
REGULARITY of menses Absent
-cycle to cycle variation Regular 2-20 day variation
(days)
Irregular >20 day variation
DURATION of flow Prolonged >8.0
(days) Normal 4.5-8.0
Shortened <4.5
VOLUME of blood loss Heavy >80
(ml) Normal 5-80
Light <5
 Definition of Terms
• What is Normal?
▫ Normal limits are set on basis of medians and 95%
confidence intervals
▫ Developed in a consensus meeting of clinicians and
scientists in Washington based primarily on:
 Independent WHO analysis
 Published population data
 Definition of Terms
• Heavy Menstrual Bleeding (HMB)
▫ Most common clinically significant disturbance in
uterine bleeding
▫ Excessive bleeding from organic causes
▫ Replaced the old term “menorrhagia”
• Dysfunctional Uterine Bleeding (DUB)
▫ HMB or irregular bleeding without recognizable
organic pathology
▫ Diagnosis of exclusion
▫ Ovulatory or anovulatory
 Definition of Terms
• Heavy Menstrual Bleeding (HMB)
Nursing Intervention:
▫ Most common clinically significant disturbance in
•AUB: ranges from modestly heavy
uterine bleeding
bleeding to excessive bleeding
▫ Excessive bleeding from organic causes
•Associated with HYPOVOLEMIC SHOCK
▫ Replaced the old term “menorrhagia”
•Monitor vital signs more frequently
• Dysfunctional
•ImmediateUterine
IV accessBleeding (DUB)
for fluid replacement
▫ HMB•Facilitate cross-matching
or irregular of blood
bleeding without for
recognizable
transfusion
organic pathology
•Watch
▫ Diagnosis ofout for signs of shock
exclusion
•Requires urgent / emergent
▫ Ovulatory or anovulatory
intervention
 Outline

• Definition of Terms
•Causes / Etiology
• Epidemiology
• Diagnosis and Management
 Etiology

AUB

Reproductive
Systemic Iatrogenic
Tract
 Etiology – Reproductive Tract
• Pregnancy-related
▫ Abortion
▫ Ectopic pregnancy
▫ Placenta previa
▫ Abruptio placenta
▫ H. Mole
▫ Choriocarcinoma
 Etiology – Reproductive Tract
• Pregnancy-related
Nursing Intervention:
▫ Abortion
•For any reproductive age woman
▫ Ectopic pregnancy
presenting with abnormal bleeding,
▫ Placenta
always perform
previa a PREGNANCY test to rule
in / rule placenta
▫ Abruptio out pregnancy
▫ H. Mole
▫ Choriocarcinoma
 Etiology – PALM COEIN
• Lesions in the reproductive tract
▫ PALM COEIN Classification
 Etiology – PALM COEIN
• Lesions in the
reproductive
tract
▫ PALM COEIN
Classification
Etiology – PALM COEIN

Single
etiology

Multiple
Etiologies
 Etiology – Single
• Polyps
▫ Endometrial
▫ Endocervical
• Adenomyosis
▫ Endometrial tissue in the
myometrial surface
• Leiomyoma
▫ Benign fibromuscular tumors
• Malignancy
▫ Endometrium
▫ Sarcoma
 Etiology – Multiple
• Coagulopathies
• Ovulatory dysfunction
• Endometrial
• Iatrogenic
• Not yet classified
 Etiology – Coagulopathies
• Blood dyscrasias
▫ Thrombocytopenia
• Thyroid function
▫ Hyperthyroidism
▫ Hypothyroidism
• Hepatic dysfunction
▫ Deficient clotting factors – coagulopathies
▫ Liver disease – unable to metabolize estrogen
• Renal dysfunction
▫ HPO axis-related gonadal-resistance to
hormones
 Etiology – Ovulatory
• Endometrial molecular mechanisms
▫ Disordered regulation of endometrial gene
expression
▫ Not yet fully studied
 Etiology – Endometrial
• Primary disorder in the endometrium
• Deficiency in local production of
vasoconstrictors
▫ Endothelin-1
▫ Prostaglandin F2
▫ Accelerated lysis of endometrial clot
▫ Excessive production of plasminogen activator
 Etiology – Iatrogenic
• Intrauterine Device (IUD)
• Smoking
• Contraceptive hormones
▫ Breakthough bleeding in the first few months
of hormonal use
▫ Not all bleeding is due to contraceptive use
• Medications
▫ Anticoagulant
▫ Tranquilizers
▫ Digitalis
▫ Dilantin
 Etiology Not yet Classified
• Endometritis
• AV malformation
• Myometrial hypertrophy
 Outline

• Definition of Terms
• Causes / Etiology
•Epidemiology
• Diagnosis and Management
 Epidemiology
• U.S.: women with HMB : 72% are employed
• Cost: $ 1,692 annual cost of work loss due to
HMB
• Usual cause of hospital admission:
▫ HMB due to anovulation 46%
▫ HMB due to hematologic disease 33%
 Epidemiology
• 43% of female athletes who train PRIOR to
menarche have menstrual irregularities
▫ Oligomenorrhea – due to too much low body fat and
sports stress
• Type of menstrual irregularties in athletes
▫ Oligomenorrhea – ball game players and distance
runners
▫ Menorrhagia / HMB – swimmers and sprinters
 Outline

• Definition of Terms
• Causes / Etiology
•Epidemiology
•Diagnosis and Management
 Diagnosis

• History
• Physical Exam
• Lab tests
• Imaging tests
 Diagnosis
• History
▫Age
▫Risk factors
▫ Character, nature of bleeding
▫ Related symptoms
▫ Family history
▫ Intake of medications
▫ Pain symptoms
 Diagnosis
• History
Nursing Intervention:
▫ Detailed
•Elicit all symptoms in patient pertaining
▫ Character,
to bleeding:nature of bleeding
▫ Related
•Frequency
symptoms
▫ Family history
•Volume
▫ Intake of medications
•Regularity
▫ Pain symptoms
•Duration
 Diagnosis
• Physical Exam
▫ Assess for vital signs, anemia, etc.
▫ Palpate for uterine enlargement
▫ Examine internal and external
genitalia for gross pathology
▫ Bimanual exam
 Uterine size
 Tenderness
 Adnexal Mass
Young, Fertile
 High risk-Cancer

Refer to
OB-GYN
 Menopausal

Refer to
OB-GYN
 Diagnosis
• Lab tests
▫ Pregnancy test (reproductive age)
▫ CBC
▫ Coagulation tests
▫ Hormone testing (not routine)
 FSH, LH, estradiol, progesterone
 Thyroid
 Diagnosis
• Imaging
▫ Ultrasound – first line
diagnostic tool
 Endometrial thickness
 Presence of mass
 Other findings:
adenomyosis, etc
 Diagnosis
• Imaging
▫ Saline infusion
sonography – (SIS)
useful in providing
evaluation of
intracavitary lesions
in the uterus
 Diagnosis
• Imaging
▫ Hysteroscopy
 Used when ultrasound is
inconclusive
 Used to detect exact
location and possibly
excise benign lesions
 Diagnosis
• Biopsy
▫ Endometrial biopsy
 Postmenopausal bleeding
 Premenopausal with heavy /
irregular bleeding
 Postmenopausal with
atypical cells on pap smear
 Breast cancer patients on
Tamoxifen
 Women who are still
“menstruating after 52”
 Management – Medical
• High dose estrogen or
Combined OCPs
• Progestins
• Tranexamic acid
• Hormonal IUDs
 Management – Medical
• High dose estrogen
▫ 10 mg/day in 4 divided
doses
▫ 25mg q 2-4 hrs for up to
24 hrs
▫ Continue for 7-10 days
 Management – Medical
• Combined OCPs
▫ <35ug ethinylestradiol per
tablet
▫ 4 tabs continued for 5-
7days PO , tapered to 1
tab a day over 21 days
 Management – Medical
• Progesterone
▫ Cyclic progestogen
▫ Administered on Day 15 or 19 to Day 26 of the cycle
• Tranexamic acid
▫ Anti-fibrinolytic
▫ Caused greater reduction in HMB
• Danazol – limited acceptability
• NSAIDs
▫ Cause reduction in bleeding
▫ Less effective compared to tranexamic acid
 Management – Medical
• Levonorgestrel-releasing IUD
▫ Effective
▫ Reversible
▫ Reduces blood loss and h-
dysmenorrhea
▫ Side effects:
 Breast tenderness
 Intermenstrual bleeding
 Management – Surgical
• Dilatation and curettage
▫ Performed for acute bleeding
unresponsive to medical treatment
▫ Blood loss reduced for first month
after D&C, but must be given
adjunct hormonal treatment
depending on histopath
 Management – Surgical
• Endometrial ablation
▫ Normal uterus - no structural or
histological abnormality
▫ Small fibroids
▫ Uterus no bigger than 10 weeks
AOG
 Management – Surgical
• Hysterectomy
▫ For failed medical treatment
▫ Investigations to establish
cause of HMB rule out cancer
▫ When bleeding is causing life-
threatening anemia
▫ Patient preference (after
counseling)
 Management – Surgical
• Hysterectomy
Nursing Intervention:
▫ For failed medical treatment
•In addition to the difficulties with the
▫ Investigations to establish
diagnosis and treatment of the physical
cause of HMB rule out cancer
condition, the psychosocial implications
▫ When bleeding is causing life-
for these patients
threatening anemia
can also be
overwhelming
▫ Patient preference (after
•RNs are in a unique position to help
counseling)
patients manage both physical and
emotional issues of DUB
 Management – Surgical
• Hysterectomy
Nursing Intervention:
▫ For failed medical treatment
•Nurses in family practice, women's
▫ Investigations to establish
health, and even pediatrics may
cause of HMB rule out cancer
encounter AUB, and they can help
▫ When bleeding is causing life-
perform the majority
threatening anemia
of the workup
including office hysteroscopy with
▫ Patient preference (after
specialized training
counseling)
•If medical therapy fails, a gynecologic
surgeon should be consulted.
 Management – Surgical
• Hysterectomy
Nursing Intervention:
▫ For failed medical treatment
•After initial treatment resolves, the
▫ Investigations to establish
patient needs to be educated regarding
cause of HMB rule out cancer
the probable need for chronic therapy
▫ When bleeding is causing life-
and meticulous
threatening anemia
journaling of a menstrual
calendar
▫ Patient preference (after
counseling)
 Management – Surgical
• Hysterectomy
Nursing Intervention:
▫ For failed medical treatment
•Nurses should be aware of local support
▫ Investigations to establish
or counseling groups and educate patients
cause of HMB rule out cancer
who may benefit from these resources to
▫ When bleeding is causing life-
seek additional
threatening anemia
emotional and social
support
▫ Patient preference (after
counseling)
Thank you!
Emmanuel Dagala, MD, FPOGS
Obstetrician-Gynecologist