Abnormal Uterine

Bleeding

Syamel Muhammad, dr. SpOG K.Onk

 Objectives
2

A.Discuss the classification of abnormal uterine

bleeding
B. Understand the evaluation of abnormal uterine
bleeding in reproductive aged women
C.List the non surgical treatment options of abnormal
uterine bleeding
D.Discuss the indications for surgical management for
abnormal uterine bleeding
 Many terms
3

Menorrhagia
Menometorrhagia
Hypermenorrhea Metrorrhagia

Polymenorrhea Oligomenorrhea

Amenorrhea
 Nomenclature
4

Acute AUB
“an episode of bleeding in a woman of reproductive age, who
is not pregnant, that, in the opinion of the provider, is of
sufficient quantity to require immediate intervention to prevent
further blood loss.”

Chronic AUB
“bleeding from the uterine corpus that is abnormal in duration,
volume, and/or frequency and has been present for the
majority of the last 6 months.”
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What’s normal bleeding?

6
 What volume of blood is in a soaked,
regular-sized tampon or pad?
7

A. 5 L
B. 10 mL
C. 5 mL
D. I don’t know, I’m a dude!
E. 1 mL
 What’s normal?
8

Character Descriptive term Normal limits

Frequent <21

Frequency of menses, d Normal 21-38

Infrequent >38
Regularity of menses: cycle-to- Absent No Bleeding
cycle variation over 12 months, Regular Variation ± 2-20
d Irregular Variation >20

Prolonged >8
Duration of flow, d Normal 3-8
Shortened <3
Heavy >80
Volume of monthly blood loss,
mL
Normal 5-80
Light <5
1 normally soaked “regular” product is approximately 5mL of blood, a “super” or
“maxi” size holds 10mL
 9

Etiology of AUB
If I had a coin in my palm for every women with
AUB…
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 Classification: PALM-COEIN
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Causes of AUB in nonpregnant reproductive-aged women

International Federation of Gynecology and Obstetrics, 2011
 Structural causes (PALM)
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A.Polyps – AUB-P
◦ endocervical or
endometrial
B.Detected by ultrasound
or sonohysterography
C.Often irregular, light
bleeding
 Structural causes (PALM)
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A.Adenomyosis –AUB-A
B. Controversial as a
cause of bleeding
C.Diagnosed with
ultrasound, MRI,
pathology
 Structural causes (PALM)
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A.Leiomyoma – AUB-L
◦ Submucous
◦ Intramural
◦ Subserosal
B.Diagnosed with exam,
ultrasound, MRI, CT
C.Heavy, regular bleeding
 Structural causes (PALM)
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A.Malignancy and
hyperplasia – AUB-M
B. Diagnosed by biopsy
C.Irregular bleeding
 Non-structural causes COEIN
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Coagulopathies or bleeding disorders

Ovulatory dysfunction
Endometrial
Iatrogenic sources (medications, smoking)
Not yet classified
 Causes of AUB - Anovulatory
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A.Most common cause

of AUB
B. Many reasons for
anovulation
1. Physiologic
2. PCOS
3. Stress, weight change,
exercise
4. Endocrine
◦ Thyroid, PRL
◦ Secreting tumors
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So She’s bleeding, now what?!?

 Diagnosis: H&P
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A. History
1. Acute vs Chronic
2. Characterize bleeding pattern
3. Menstrual bleeding hx (incl. severity and assoc pain)
4. FamHx: AUB/ bleeding disorders
5. Meds: warfarin, heparin, NSAID, OCP, ginkgo, ginseng,
motherwort
B. Physical
1. PCOS: obesity, hirsutism, acne
2. Thyroid dysfunction: cold/heat intolerance, dry skin, lethargy,
proptosis
3. DM: acanthosis nigricans
4. Bleeding disorder: petechiae, pallor, signs of hypovolemia
5. Pelvic exam
◦ Is it from the uterus?!
 Diagnosis: Labs and Imaging
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A. Labs
1. Pregnancy test (Strong recommendation)
2. CBC (Strong recommendation)
3. Targeted screening for bleeding disorder (when indicated)
4. TSH
5. Gonorrhea/Chlamydia in high risk patients
B. Imaging:
1. TVUS
2. Sonohysterography
3. Hysteroscopy
4. MRI
C. Endometrial biopsy
 Practice bulletin no. 128: diagnosis of abnormal uterine bleeding in reproductive-aged
women. Obstet Gynecol. 2012 Jul;120(1):197-206. doi:
10.1097/AOG.0b013e318262e320.
Uterine Evaluation
21
 Who should get an EMB?
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A.Women aged > 45 years as first-line test

B.Women aged > 35 years as first-line test
C.Women aged < 45 years with risk factors for endometrial
cancer
D.Women aged < 35 years with risk factors for endometrial
cancer
E.Women with persistent bleeding refractory to medication,
regardless of age
 Who should be offered EMB?
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◦ women aged > 45 years as first-line test

◦ women with persistent bleeding refractory to medication,
regardless of age
◦ women aged < 45 years with risk factors for endometrial
cancer, such as
◦ obesity (body mass index > 30 kg/m2)
◦ nulliparity
◦ hypertension
◦ irregular menstruation
◦ polycystic ovary syndrome
◦ diabetes
◦ hereditary nonpolyposis colorectal cancer
◦ family history of endometrial cancer
Practice bulletin no. 128: diagnosis of abnormal uterine bleeding in reproductive-aged women. Obstet Gynecol. 2012 Jul;120(1):197-206. doi:
10.1097/AOG.0b013e318262e320.
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Endometrial
biopsy
 EMB Considerations
25
A. Consent
1. Cramping is common
2. vaginal bleeding for several days
3. vasovagal
4. pelvic infection
5. uterine perforation (1 to 2 per 1000 procedures - vs 3 to 26 per 1000 D&C)
B. Contraindications
1. Active vaginal/pelvic infection
2. bleeding diathesis
3. pregnancy
C. Preprocedure prep
1. Anesthesia not required, consider NSAID 30-60 min prior
2. Difficult passage - consider 200 to 400 µg misoprostol night before (PV>PO)
3. Don’t need prophylactic abx Comparison of endometrial aspiration biopsy techniques: specimen adequacy.
Sierecki AR, Gudipudi DK, Montemarano N, Del Priore G Reprod Med. 2008;53(10):760.
 EMB procedure
26

A. Bimanual Am Fam Physician. 2001 Mar 15;63(6):1131-5, 1137-41.

Endometrial biopsy. Zuber TJ

B. Speculum then clean cervix

C. +/- tenaculum (if not axial)
D. Insert pipelle - stop @ resistance (avg 6-8cm)
E. Pincer grasp, Pull out piston for suction
F. Corkscrew combined w/ cephalic-caudal motion to sample entire
endometrial surface
G. Don’t remove until sampling completed
H. Expel the specimen into a formalin container (replace piston)
I. Consider second pass if insufficient tissue
◦ If the biopsy material looks like a dark red earthworm and does
not disintegrate in the formalin, it is likely that appropriate biopsy
material has been obtained.
 How reliable is the EMB result?
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For diagnosis of endometrial cancer, outpatient endometrial

biopsy had
◦ likelihood ratio 66.48 (95% CI 30.04-147.13) for a positive
test result
◦ likelihood ratio 0.14 (95% CI, 0.08-0.27) for a negative test
result BJOG 2002 Mar;109(3):313

In cases of abnormal uterine bleeding in which symptoms persist

despite a negative biopsy, further evaluation and input from
individual patients is recommended.
only 34% of patients had an adequate sample
Saso S, et al. Endometrial cancer. BMJ.2011;343:d3954.
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MRI U/S

Sonohysterogram Hysteroscopy
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Management
 Management
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A.Medical management should be initial treatment for

most patients
B.Need for surgery is based on various factors
(stability of patient, severity of bleed,
contraindications to med management, underlying
cause)
◦ Type of surgery dependent on above + desire
for future fertility
C.Long term maintenance therapy after acute bleed is
controlled
 Treatment - Acute
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A. Unstable?
1. High dose hormones vs D&C
◦ IV estrogen – 25 mg IV q 4-6 hours x 24 hrs
2. Endometrial balloon tamponade
B. Stable
1. Oral meds
◦ Monophasic OCPs – One TID for seven days, then daily for
at least one cycle
◦ Medroxyprogesterone (Provera) – 20 mg TID for seven
days, then daily for at least three weeks
◦ Tranexamic acid (Lysteda) – 1.3 mg TID on days 1-5 of
cycle
 Chronic Treatment Considerations
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A. Etiology and severity of bleeding (eg, anemia, interference with

daily activities)
B. Associated symptoms (eg, pelvic pain, infertility)
C. Contraceptive needs or plans for future pregnancy
D. Contraindications to hormonal or other medications
E. Medical comorbidities
F. Patient preferences regarding medical versus surgical and
short-term versus long-term therapy
 Non-surgical treatment Options
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A. Expectant management
B. NSAIDs
C. Antifibrinolytic agents - Tranexemic acid (Lysteda)
D. Hormonal methods
1. Combination methods
2. Levonorgestrel IUD
3. Cyclic progestin
4. GnRH agonists (leuprolide)
E. Metformin and other insulin-sensitizing drugs for irregular
bleeding in women with polycystic ovary syndrome
 Surgical Management Options
34

A. D&C
B. Endometrial Ablation
C. Uterine Artery Embolization
D. Hysterectomy
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Thank you!

Now let’s go play with Pipelles!