Abnormal Uterine Bleeding

Dr. Jasmina Begum

Assistant Professor
AIIMS, Bhubaneswar

01/25/22 AIIMS BBSR 1

 Specific Learning Objectives
2

By the end of this class you will be able to learn

1.What is normal and abnormal uterine bleeding
2.Definitions of different terminologies used in AUB
3.Etiological classification of AUB
4.Acronym PALM-COIEN
5.Evaluation in a case of AUB
 Outline
3 3

Normal Menstruation
Definition of AUB
Prevalence
Impact on women’s life
Revised FIGO AUB systems
Etiology of AUB
Evaluation and Diagnosis
Management Algorithms for AUB
 MENSTRUATION

“Menstruation is a woman's monthly bleeding from her

reproductive tract induced by hormonal changes of the
menstrual cycle. The length of a menstrual cycle is the
time from the start of a period to the start of the next.4
 FIGO- AUB Systems – 1
5

 The normal range (shortest to longest) varies with age: 18–25 y of age, ≤9
d; 26–41 y, ≤7 d; and for 42–45 y, ≤9 d Harlow et al., 2000.
 Summary of changes to FIGO System 1
6
(normal and abnormal uterine bleeding)

The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of
abnormal uterine bleeding in the reproductive years: 2018 revisions. Int J Gynecol Obstet 2018; 143: 393–
408
 Key points
7

 Menstruation is controlled by cyclical hormonal

changes
 Normal frequency is between 24-38 days
 Normal duration is upto 8 days
 Normal volume: Subjective (does not interfere
with a woman's physical, social, emotional, and/or
quality of life)
 Regular cycle to cycle variation is between ≤7–9
days
Abnormal Uterine Bleeding (AUB)

Definition:
AUB is a leading cause for gynecological
Bleeding that in
consultations is unlike normal
the peri, menstrual flow
post-menopausal age
in terms of frequency,
groups and among adolescents regularity, duration and
quantity. It includes infrequent or frequent
bleeding, heavy menstrual bleeding and
intermenstrual bleeding.
Approx. 1/3 women are affected at some time
rd

in their life.
The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of
abnormal uterine bleeding in the reproductive years: 2018 revisions. Int J Gynecol Obstet 2018; 143: 393–408
 AUB Spectrum of Problem
9

Prevalence increases with age, it reaches 24% in women

Women affected with AUB at
aged 36 to
given 40 of
point years.
time -30 % Women affected with AUB at
given point of time -17.9%
1. Sharma A, Dogra Y. Trends of AUB in tertiarry centre of Shimla hills.J. Midlife Health .2013;4:67-8. 2. Chattopadhyay S, Nigam A, Goswami S. Eur
Rev Medi Pharmacol Sci. 2011;15:764- 7 68, 3. The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of
causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. Int J Gynecol Obstet 2018; 143: 393–408
.
 Impact of AUB on Women’s life
10
Impact of HMB

1.Major impact decreases

QOL
2.60% Women of HMB
ended up having a
hysterectomy within 5 yrs
of diagnosis
3.About 1/3rd
hysterectomies for HMB
results in removal of
anatomically normal
uterus
 Pathophysiology
A. Endometrium has two distinct zones

1. Functionalis layer

2. Basalis layer

A. Functionalis layer: surface epithelium and subepithelial

plexus of capillaries.

B. Basal layer is insensitive to hormonal changes.

C. Spiral artery stretch to supply the functionalis layer and

ends in subepithelial capillary plexus.
 Pathophysiology
12
• Endometrium normally produces Prostaglandins (PGs) from the
arachidonic acid.
• Such PGs include : PGE2, PGI2, PGF2α, Thromboxane A2
• PGE2 & PGI2 - Vasodilation & Platelet aggregation
• PGF2α, Thromboxane A2 - Vasoconstriction Platelet aggregation

A. In PRE-OVULATORY phase, endometrial proliferation occurs under

•theAs long as progesterone (in optimum levels) is provided by corpus
luteum,
effectthis phase maintains.
of estrogen. (PGF2α /PGE2 : 1)
•B.Once corpus luteum ceases phase,
In POST-OVULATORY to function - MENSES
progesterone causes endometrial
differentiation and stabilisation. (PGF2α/PGE2=2:1)
Contd.

• Absence of progesterone
• Absence of PGF2α and relative increase in PGE2
• Increase in Tissue Plasminogen Activator ( TPA)
• Decrease in Endothelin
Contd.
 Many terms (Old Terminologies)
15

Menorrhagia
Menometorrhagia
Hypomenorrhea Metrorrhagia

Polymenorrhea Oligomenorrhea

Amenorrhea
Dysfunctional Uterine
16
Gray areas of Prior Definitions:
1.Confusing and inconsistent nomenclature
2.Failed to describe plethora of potential causes
3.Lack of standardized methods for investigation
4.It results in investigative leverage

 FIGO in 2011 eliminated misleading terms

 A new classification system known is by acronym “PALM-
COIEIN”
 It classifies by bleeding pattern & aetiology
 To create universal nomenclature system to describe
abnormal uterine bleeding abnormalities in nongravid
reproductive aged women
17
18

The two FIGO systems of

Classification, 2018 Revisions
 Nomenclature
19 19

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.”
 Nomenclature
20 20

Heavy menstrual bleeding (HMB)

“a symptom (not a diagnosis), that has been defined (in
clinical situations) by NICE as “excessive menstrual blood loss,
which interferes with a woman’s physical, social, emotional
and/or material quality of life.”

Intermenstrual bleeding (IMB)

“occurs between clearly defined cyclic and predictable menses.
Such bleeding may occur at random times or may manifest in
a predictable fashion at the same day in each cycle. ”
 FIGO AUB Systems -2
21

Category N:
Potential entities,
may /may not be
defines by HP or
Imaging technique

PALM group : “discrete (structural) COEI group: “entities (non-

entities” structural)
22
AUB-P
Categorized as either present or absent
TVUS is not 100% sensitive in diagnosis
TVUS indicate the presence of endometrial polyp(s),
or there are leiomyomas that may encroach on the
endometrial cavity, imaging with more sensitive
techniques is recommended.
 AUB-A
23

FIGO AUB System 2, suggested the transvaginal

ultrasonography- based morphological uterus
sonographic assessment (MUSA) criteria for
diagnosis.

Asymmetrical thickening
For the present (A), Myometrial
at least, cysts (B),
the presence hyperechoic
of two or moreislands
of
(C), fan-shaped shadowing (D), echogenic subendometrial lines and buds
these criteria are highly associated with adiagnosis
(E), translesional vascularity (F), irregular junctional zone (G) and
of adenomyosis.
interrupted junctional zone (H)
 AUB-L
Hybrid leiomyomaType 5, subserosal
24
Type 7, subserosal
≥ 50% intramural
pedunculated
Type 6,
subserosal, <50%
intramural

Type 0,
pedunculated
intracavitary Type 8, other (e.g.
cervical,parasitic)
Type 4, intramural
Type 1, submucosal <50% intramural
Type 3, 100% intramural, but in
contact with the endometrium
Type 2, submucosal ≥50%
intramural
 Etiology of AUB

01/25/22 AIIMS BBSR 25

 FIGO classification of the causes of AUB:
26 examples
Assuming pregnancy is excluded,
Structural
P - Endometrial polyps, cervical polyps
A – Adenomyosis
L - Leiomyoma (subclassification)
M - Premalignancy (endometrial hyperplasia)
Malignancy of the genital tract (cervical,
endometrial, ovarian, vaginal, vulval,
sarcoma of endometrium or myometrium)
 FIGO classification of the causes of AUB
27
examples
Non-structural
C - Systemic coagulopathy, e.g. thrombocytopenia, von Willebrand's
disease, leukaemia,
O - Disorders of ovulatory function, e.g. polycystic ovary syndrome,
congenital adrenal hyperplasia, hypothyroidism, Cushing's disease,
hyperprolactinaemia
E - Primary endometrial disorders, e.g. disturbances of local
endometrial haemostasis, vasculogenesis or inflammatory response,
chronic endometritis
 FIGO classification of the causes of AUB:
28 examples

I - Iatrogenic causes, e.g. exogenous sex steroid

administration (combined oral contraceptives,
progestins, tamoxifen), intrauterine contraceptive
device, phenothiazines and tricyclic
antidepressants, anticoagulants
N - Generally rare causes, e.g. arteriovenous
malformations, myometrial hypertrophy, uterine
“niche” or isthmocele, endometriosis
 NOTATION
29
FIGO AUB 2018
Encourages use of a matrix for the evaluation of
patients
FIGO AUB 2011
After the patient has undergone appropriate
investigation they are categorized as follows
AUB P0A0L1(SM)M0 - C0O1E 0I0N0
or

Abbreviated FIGO description AUB-LSM; -O

 NOTATION
30

FIGO AUB 2011

FIGO AUB 2018
After the patient has undergone appropriate
Encourages use of a matrix for the
investigation they are categorized as follows
evaluation of patients
AUB P0A0L1(SM)M0 - C0O1E 0I0N0
or

Abbreviated FIGO description AUB-LSM; -O

FIGO AUB System 2 diagnostic matrix
31
 Key points
32
 For nomenclature and definitions of normal and abnormal
uterine bleeding symptoms, revised FIGO-AUB system
1should followed
 Causes of AUB should be classified as per the revised
FIGO-AUB system 2
 For the diagnosis of adenomyosis, use of the MUSA criteria
 FIGO guidance for distinguishing amongst the leiomyoma
subtypes
 Maintaining a minimum data set based on FIGO
subclassification system for leiomyomas
Evaluation, Investigations & Diagnosis
 Diagnosis & Evaluation
Through history
34 Preliminary assessment
Acute/Chronic, Exclude
pregnancy Investigations
Menstrual a. Duration Assess Pallor, weight, BMI,
pattern b. Cycle length features of PCOS, Hirsutism,
c. Regularity Thyroid disorder a. Laboratory
d. Amount Abdominal Uterine size in testing
e. IMB Examination wks of gest.
b. Imaging
Pain a. Dysmenorrhea Per speculum Cervical lesion
b. Intermenstrual examination & discharge
pain PAP Smear c. Specified test
c. Dyspareunia
Per Vaginal Uterus size,
Concomitant a. Anticoagulant examination contour, d. Endometrial
medications b. Antidepressant consistency, histopathology
c. Antipsychotic tenderness,
d. COCP, IUCD adnexal mass &
History suggestive of bleeding tenderness
diathesis, thyroid disorder, PCOS
 Diagnosis & Evaluation cont…
35 Laboratory Testing
History of HMB CBC with Platelet count is
recommended or all women with
AUB
Pregnancy Urine or Serum ß Hcg assay

Thyroid Disorders TSH, T3 & T4 (total and free )

(When clinically indicated)

Coagulation disorders • Bleeding time, Prothrombin time,

(When clinically indicated) Partial thromboplastin time in
adolescents and in adults with screen
positive for coagulopathies
• vWF. factor antigen, Ristocetin
factor, factor VIII

The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding
in the reproductive years: 2018 revisions. Int J Gynecol Obstet 2018; 143: 393–408.
The Federation of Obstetrics and Gynaecology society of India. Good Clinical Practice Recommendation for AUB . 2016,
 Diagnosis & Evaluation
36
Imaging
Ultrasound imaging
mandatory (2D TVUS,TAS) MRI Optional Hysteroscopy
Doppler Malignancy cases,
sonography polyp, suspected To differentiate fibroid Not indicated for all
AV malformations, from adenomyosis cases of AUB
to differentiate a.Direct visualization
between fibroid and of intracavitary lesions
adenomyosis Map exact location of
fibroid before planning b.Facilitates directed
3D USG For evaluating intra conservative surgery and biopsy
myometrial lesion prior to UAE for fibroid
in selected patients
for fibroid,
adenomyosis,
SIS Intra cavitary lesion
when suspected and
hysteroscopy not
available
37 37

MRI
TVS

Sonohysterogram Hysteroscopy
Diagnosis and Evaluation cont…
Screening for Coagulopathies in women with AUB
A.Initial screening by structured history
B.1.Patient
HMB sincewith postive screening result:
menarche
2.Further evaluation
One of the following: and consultation with
hematologist and/or testing
Postpartum hemorrhage, of von
Surgical Willebrand
related bleeding
factor andassociated
Bleeding Ristocetin
withcofactor
dental work
3. Two or more of the following symptoms:
a. Bruising 1–2 times per month
b. Epistaxis 1–2 times per month
c. Frequent gum bleeding
d. Family history of bleeding symptoms
 Who should be offered EMB? cont..
39

◦ Women aged > 45 years as first-line test

◦ Women with persistent bleeding, unexplained, 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
The two
. FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the
reproductive years: 2018 revisions. Int J Gynecol Obstet 2018; 143: 393–408.
The Federation of Obstetrics and Gynaecology society of India. Good Clinical Practice Recommendation for AUB . 2016,
40

Endometrial
biopsy
 Algorithm for the diagnosis of
AUB Presentation with AUB
41

Medical history, Clinical Positive h/o

assessment medication
Suspected
linking to AUB
coagulopathies

Lab Investigations, songraphy

Consultation with (TAS,TVUS), MRI, SIS AUB-I
Hematologist,
specific test
Suspected
Increased Endometrial Structural
Normal thickness on imaging Abnormalities
AUB-C
Endometrial tissue
sampling Assessment of
target lesions
Hyperplasia, Carcinoma
AUB-A, AUB-
AUB-M AUB-E,O L, AUB-P
Yes No
 Summary
42

1. Proper history and clinical examination

2. Laboratory investigations
3. TVUS (1ST imaging modality)
4. Hysteroscopy, SIS in specific conditions
5. MRI is optional
6. Indicated cases endometrial biopsy/ hysteroscopic directed biopsy
done
 Management Algorithms for Patients of
AUB

01/25/22 AIIMS BBSR

 Treatment of abnormal uterine bleeding
Treatment goals for patients with AUB include regulation of
menstrual cycles, minimization of blood loss and improvement in
quality of life.

Treatment options include pharmacological approaches (either

hormonal or non-hormonal), and surgical or radiological
procedures.

Awareness, reassurance and keeping a healthy lifestyle will

contribute to the treatment options for AUB.
 Management
Current Treatment options

Pharmacological agents Surgical

General Measures
•Antifibrinolytic •Endometrial ablation (EMA)
•NSAIDs  considered appropriate for women
Treatment of anemia
•Oral contraceptives
:
those who completed their family,
Oral
•Cyclic iron therapy (Hb<11gm%)
Progestins  not suitable for large uterus
•GnRH analogue
Packed cell transfusion (If Hb<5gm% , <10gm%
•LNG- IUS •Hysterectomy
when planned for surgery) should not used as 1st line treatment
of HMB unless other treatments are
Lifestyle modification : contraindicated or refused by the
patient.
Weight reduction by diet & exercise.
•Uterine artery embolization
New and still experimental
 Treatment - Acute
46

• Unstable?
1. High dose hormones vs D&C
◦ IV estrogen – 25 mg IV q 4-6 hours x 24 hrs
2. Endometrial balloon tamponade
• 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
 Management Algorithms for Patients of
AUB- PALM

01/25/22 47 AIIMS BBSR

 Treatment Algorithm for AUB-P

01/25/22 48 AIIMS BBSR

 Treatment Algorithm for AUB-A

For managing AUB –A, individualize

•Age
•Symptoms (AUB, pain)
•Associated pathological entities
•Fertility desire

01/25/22 49 AIIMS BBSR

 Treatment Algorithm for AUB-L

01/25/22 50 AIIMS BBSR

 Treatment Algorithm for AUB-L, cont…

01/25/22 51 AIIMS BBSR

 Treatment Algorithm for AUB-L, cont…

New promising options:

1. Mifepristone (low dose 5-10mg/d)

(Grade A; Level 1)

2. Uterine artery embolization (Grade A; Level 1)

3.MRI guided high intensity focused ultrasound
(Grade A; Level 1)
01/25/22 52 AIIMS BBSR
 Treatment Algorithm for AUB-M

01/25/22 53 AIIMS BBSR

 Management Algorithms for Patients of
AUB- COIEN

01/25/22 54 AIIMS BBSR

 Treatment Algorithm for AUB-C

Specific care:
1.Refractory cases of von Willebrand disease ,failed medical mangement ,
specific factor replacement or desmopression given .
2.When Surgical interventions indicated- factor replacement/
desmopression
3.NSAIDs and intramuscular injections are contraindicated
01/25/22 55 AIIMS BBSR
 Treatment Algorithm for AUB-O

Women with AUB-O

Women not desiring Cyclical luteal-phase Norethisterone cyclically

conception progestins (for 21 days) in acute
Presently , COCs – 1st (for 10-14 days) episodes of bleeding for
line therapy short term management
(GRADE A ; LEVEL 1) of 3 months

If COCs are contraindicated /

patient unwilling for COCs Assess response after 1 year
of medical management &
LNG-IUS(GRADE A ; judge to continue/discontinue
LEVEL 1) existing therapy

In adolescents with AUB-O , Failure of medical management /

Both hormonal and non hormonal therapies evidence of persistent AUB
01/25/22 can 56
be prescribed (GRADE A ; LEVEL 4 )AIIMS BBSR (Grade A ; Level 4) –
 Treatment Guidelines for AUB-E

Management of AUB-E can be similar to the

management of AUB-O (Grade a ; level 4) except
progestin therapy which is effective only when
given cyclically for 21 days and is not effective if
given only in luteal phase of cycle.

01/25/22 57 AIIMS BBSR

 Treatment Guidelines for AUB-I

•Whenever feasible , medications causing AUB

should be changed to other alternatives , if no
alternatives are available
•LNG – IUS is recommended for treatment
(GRADE A ; LEVEL1)

01/25/22 58 AIIMS BBSR

 Treatment Algorithms for AUB-N

Women with AUB-N

01/25/22 59 AIIMS BBSR

 Case Scenario 1
60

• A 13 yr, old girl comes to OPD, C/o continuous, painless HMB last 22 days,
• Age of menarche: 22 days back
• No h/o of brusibility, epistaxis, or gum bleeding
• Family and past history not suggestive
• No drug intake, not sexually active
• O/E:
• Vitals stable, pallor mild, no petechiae, wt 67 kg, BMI 28
• No acne, acanthosis nigricans, features of hirsutism
• P/A: soft, no organomegaly, P/S, PV not done

60
 Case Scenario 1
• What will be your approach to this case?

• What is your impression?

HB- 10.8gm%
CBC TFT- Normal
Thyroid profile Coagulation profile: Normal
Coagulation profile USG: Uterus normal size,
TAS for structural entities ET 6 mm, B/L ovaries
normal
01/25/22 AIIMS BBSR 61
 AUB-O

01/25/22 AIIMS BBSR 62

 Management in at Puberty/Adolescent
• Reassurance and counselling
• Both hormonal and nonhormonal therapies can be given (Grade
1; Level 4)
• Nonhormonal tt is the primary option
• Tablet tranexamic acid 1 gm , QID, for 5 days
• Hormonal tt is the secondary ones
• Correction of anaemia and other associated symptoms
• Weight reduction and lifestyle modifications
01/25/22 AIIMS BBSR 63
 Management in at Puberty/Adolescent

01/25/22 AIIMS BBSR 64

 Management in at Puberty/Adolescent

01/25/22 AIIMS BBSR 65

 Monitoring Response
• Menstrual calendar for atleast 3months
• Teleconsultation/ In person follow up while on pills
• Assess again at 1 year to decide to stop or to continue tt

01/25/22 AIIMS BBSR 66

 Case Scenario: 2

34 years old lady, c/o painless HMB for 1 years

Cycles are 10 -12 days/ 40 -60 days
P2 L2, not undergone BTL
No h/o DM, HTN, malignancy in family
Mild pallor, no neck swelling, average built
P/A : No organomegaly
P/S : Cervix , vagina normal
P/V : uterus 8 weeks size, adenexa normal

01/25/22 AIIMS BBSR 67

 Case Scenario 2
• What will be your approach to this case?

• What is your impression?

HB- 10.8 gm%
CBC TFT- Normal
Thyroid profile Coagulation profile: Normal
Coagulation profile USG: Uterus normal size,
TAS for structural entities ET 8 mm, B/L ovaries
normal
01/25/22 AIIMS BBSR 68
 Case Scenario 2
• What is the role of Endometrial biopsy?

01/25/22 AIIMS BBSR 69

 Case Scenario 2

01/25/22 AIIMS BBSR 70

 Treatment Algorithm for AUB-O

Women with AUB-O

Women not desiring Cyclical luteal-phase Norethisterone cyclically

conception progestins (for 21 days) in acute
Presently , COCs – 1st (for 10-14 days) episodes of bleeding for
line therapy short term management
(GRADE A ; LEVEL 1) of 3 months

If COCs are contraindicated /

patient unwilling for COCs Assess response after 1 year
of medical management &
LNG-IUS(GRADE A ; judge to continue/discontinue
LEVEL 1) existing therapy

In adolescents with AUB-O , Failure of medical management /

Both hormonal and non hormonal therapies evidence of persistent AUB
01/25/22 can 71
be prescribed (GRADE A ; LEVEL 4 )AIIMS BBSR (Grade A ; Level 4) –
 Reproductive age
• Other treatment options in AUB-O

01/25/22 AIIMS BBSR 72

 Cade Scenario 3

42 years old obese female c/o HMB for 3 years

Diabetic, controlled with drugs
No HTN, hypothyroid
Pallor present
TVS uterus 10 weeks,
ET 12 mm
B/L ovaries normal

01/25/22 AIIMS BBSR 73

• What is the role of Endometrial biopsy?

EB shows
Endometrial Hyperplasia without atypia ( AUB-
M)

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 Perimenopausal age. AUB-M

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 Treatment Algorithm for AUB-M

01/25/22 76 AIIMS BBSR

 Level of evidences
Strength of Recommendation (adapted from AACE Task force)

01/25/22 AIIMS BBSR

 Take home message
• AUB is a commonest problem from menarche to
menopause
• The FIGO systems -1 and System-2 are designed to
facilitate evaluation and diagnosis
• The revised system system encourages the use of
matrix concept to guide evaluation
• Consider individualized approach in management
• Newer drugs are promising but needs evaluation
carefully
• Evidence based management will avoid unnecessary
hysterectomies
01/25/22 AIIMS BBSR 78
 References
• The two FIGO systems for normal and abnormal
uterine bleeding symptoms and classification of
causes of abnormal uterine bleeding in the
reproductive years: 2018 revisions. Int J Gynecol
Obstet 2018; 143: 393–408.

• The Federation of Obstetrics and Gynaecology

society of India. Good Clinical Practice
Recommendation for AUB 2016.

01/25/22 AIIMS BBSR 79

80

THANK YOU