Abnormal Uterine

Bleeding
Jenna Jurecky
AUB
Menstrual bleeding that is abnormal
and/or irregular in frequency,
duration, and/or intensity
PALM
COEIN
 Work up
Physical examination

• Ensure patient is hemodynamic stable

• Pelvic exam
• Swabs to rule out cervicitis due to gonorrhea/chlamydial infection
• Pap smear to rules out cervical carcinoma

Labs

• β-hCG to rule out pregnancy

• CBC to rule out anemia
• Platelet count, PT, and PTT to rule out bleeding disorders
• Depending on patient, can get TSH, FSH, prolactin, Fe
 Work up
Imaging

• Pelvic U/S can help rule out structural anomalies (e.g.,

leiomyoma, adnexal mass) and evaluate endometrial thickness

Endometrial biopsy

• Indication depends on age of patient and presence risk factors

• Some risk factors include being postmenopausal, endometrial
thickness ≥ 4 mm, obesity, PCOS, DMII, tamoxifen therapy,
Lynch syndrome
 • Pharmacological
• Acute AUB in hemodynamically stable patient
• High dose estrogen to stop bleeding
• Progestin- mature and slough off endometrium
• 5 to 10 mg nightly until the bleeding stops
• OCPs- addition of estrogen helps with hemostasis
• One pill every eight hours until the bleeding stops (usually
within 48 hours, then
• •One pill every 12 hours for 2 days, then
Management • •One pill once per day for a total of at least 21 days
• Tranexamic acid- as nonhormonal option
• Not actively bleeding
• OCPs as normally prescribed
• Norethindrone acetate 5 mg orally nightly for the first 5 to 10 days of
each calendar month, or
• •Oral micronized progesterone 200 mg nightly for the first 12 days of
each calendar month, or
• Medroxyprogesterone acetate 10 mg orally nightly for the first 10 days
of each calendar month
 • Surgical
• D&C, Endometrial ablation, hysterectomy, etc.
• Can be considered if there is:
Management • Severe bleeding/hemodynamic instability
• Patient unresponsive to hormonal treatment
• Hormonal treatment contraindicated (e.g., breast cancer)
• Underlying medical condition requiring surgical repair
Structural: PALM
• Polyps- within the uterine wall, extends into uterine cavity, benign
• Pedunculated or sessile, single or multiple, various sizes
• Risk factors: HTN, obesity, Tamoxifen or hormone replacement therapy, Lynch syndrome
• Symptoms: usually asymptomatic; irregular bleeding, spotting, menorrhagia, and postmenopausal
bleeding, fertility issues
• Treatment: removal via hysteroscopy
• Express estrogen and progesterone receptors so avoid hormonal treatments (estrogen stimulates
growth)
• Adenomyosis
• Leiomyomas (fibroids)
• Malignancy or hyperplasia
Structural: PALM
• Polyp
• Adenomyosis- endometrial tissue within the myometrium due to hyperplasia of the endometrial basal layer
• Symptoms:
• may be asymptomatic
• Can present with dysmenorrhea, AUB, chronic pelvic pain worse during menses
• Physical findings: globular, uniformly enlarged uterus that is soft but tender on palpation
• Treatment: OCPs, progestin (IUD, continuous-use pill), NSAIDs, GnRH agonists, hysterectomy
• Leiomyomas (fibroids)
• Malignancy or hyperplasia
Structural: PALM
• Polyp
• Adenomyosis
• Leiomyomas (fibroids)
• Can be subserosal, intramural, submucosal, cervical
• More common with: nulliparity, early menarche (< 10), increased incidence in African American
individuals, obesity, family history, age: 25–45 years
• Symptoms: increased frequency of bleeding, heavy bleeding, dysmenorrhea, mass effects, issues with
fertility, dyspareunia
• Physical findings: enlarged, firm and irregular uterus
• Treatment: OCPs, progestin, NSAIDs, tranexamic acid, GnRH agonists, myomectomy, uterine artery
embolization, hysterectomy
• Malignancy or hyperplasia
Structural: PALM
• Polyp
• Adenomyosis
• Leiomyomas (fibroids)
• Malignancy or hyperplasia
• Symptoms: AUB, especially postmenopausal; might have weight loss, pelvic pain
• Physical findings: usually normal; potentially palpable masses
• Treatment: hysterectomy, chemo/radiation
 Non-structural:
COEIN
• Coagulopathy (i.e. Von Willebrand's, hemophilia, leukemia, liver disease)
• Symptoms: heavy menstrual bleeding since menarche, heavy bleeding after childbirth or during surgery,
gum bleeding after dental work, easy bruising, and frequent nosebleeds
• Treatment: treat underlying disorder
• Ovulatory disorder
• Endometrial
• Iatrogenic
• Not otherwise classified
 Non-structural:
COEIN
• Coagulopathy
• Ovulatory disorder (i.e. hypothalamic pituitary dysfunction, PCOS, hypothyroidism)
• Symptoms and treatment dependent on underlying cause
• Endometrial
• Iatrogenic
• Not otherwise classified
 Non-structural:
COEIN
• Coagulopathy
• Ovulatory disorder
• Endometrial
• Ex: endometriosis
• Symptoms: chronic pelvic pain that worsens before the onset of menses, uterosacral tenderness,
dysmenorrhea, dyspareunia, infertility, dyschezia
• Treatment: OCPs, NSAIDs, surgery
• Iatrogenic
• Not otherwise classified
 Non-structural:
COEIN
• Coagulopathy
• Ovulatory disorder
• Endometrial
• Iatrogenic (i.e. IUD, medications)
• Not otherwise classified
A) Combined oral contraceptives- contraindicated in this patient because of her smoking history and age (>
35 years), both of which increase her risk of venous thromboembolism

B) Reassurance and follow-up- this patient's heavy menstrual bleeding and severe cyclical pain significantly
reduce her quality of life, so she requires treatment

C) Endometrial ablation- good treatment option for patients with ovulatory HMB and no desire for future
pregnancies when medical therapy is unsuccessful or contraindicated (NSAIDs provided minimal relief and
OCPs are contraindicated)

D) Hysterectomy- last resort option if other treatments have failed

E) Copper intrauterine device- not indicated for the treatment of HMB, and in fact, may worsen symptoms
A) Tranexamic acid- second-line agent used for treating blood loss in acute AUB when other options have failed (should not be
used in women at a high risk of thrombosis)

B) Endometrial ablation- should only be performed in patients who do not wish to bear any more children

C) Uterine artery embolization- first-line therapy in women with AUB due to uterine arteriovenous malformation (AVM).
Uterine AVMs are very rare and can be congenital or acquired after surgery. This patient has no history of surgical procedures
performed on the uterus or profuse bleeding during menses since menarche, making an AVM unlikely

D) Uterine curettage- D&C with concomitant hysteroscopy is the preferred approach in hemodynamically unstable women
with severe AUB after immediate supportive measures have been implemented

E) Conjugated estrogen therapy- administration of high-dose oral conjugated estrogen is the treatment of choice in
hemodynamically stable women with acute AUB, irrespective of the underlying cause

F) Intrauterine tamponade- initial step to decrease severe bleeding in a hemodynamically unstable woman with acute abnormal
intrauterine bleeding
A) Endometrial ablation- is used to treat noncancerous causes of abnormal uterine bleeding (e.g., fibroids). While it would
reduce the bleeding, it would be inappropriate for the diagnosis and/or treatment of endometrial hyperplasia

B) Endometrial biopsy- indicated as a first-line test in the diagnostic workup of patients with abnormal uterine bleeding who
are more than 45 years old, or in patients younger than age 45 who have risk factors for endometrial cancer (obesity, polycystic
ovary syndrome, nulliparity, early menarche, diabetes mellitus, tamoxifen therapy) or do not respond to medical management

C) Abdominal ultrasonography- transvaginal rather than abdominal ultrasound is used to rule out structural anomalies and
evaluate endometrial thickness in AUB

D) Combined oral contraceptives- Combined oral contraceptives are commonly used by premenopausal women with abnormal
uterine bleeding, but this patient has several risk factors for endometrial cancer (e.g., age > 35 years, obesity, nulliparity, early
menarche), which warrants further investigation

E) Diagnostic laparoscopy- used to confirm intra-abdominal pathology like endometriosis. However, the patient does not have
dysmenorrhea, dyschezia, and/or infertility consistent with endometriosis, so laparoscopy is not necessary to establish
diagnosis in this patient.