Abnormal Uterine Bleeding

Presenter :
Muhammad Eimaduddin bin Sapiee @
Muhammad Syafiei
Iffah

Supervisor :
Dr Nazihah
Dr Sumayyah
 Menstrual Cycle
● Definition : cyclic uterine bleeding caused by
shedding of secretory endometrium
● Characteristics
● Menarche : the first menstrual period of
female(10-16 years old)
● Duration : 2-7 days
● Amount : 20-80ml
● Length : 3-5 weeks
● Cycle : 21-35 days
 Abnormal Bleeding from Genital
Tract
● Duration
● Menorrhagia - prolonged or excessive uterine
bleeding
● Hypomenorrhea - short or scanty uterine bleeding
● Length of cycle
● Polymenorrhea - menstrual cycles < 21 days
● Oligomenorrhea - menstrual cycles > 35 days
AUB Classification by FIGO(PALM-
COEIN)
● Polyp
● Adenomyosis
● Leiomyoma
● Malignancy and hyperplasia
● Coagulopathy
● Ovulatory dysfunction
● Endometrial
● Iatrogenic
● Not yet classified
 Endometrial polyps
● Localized overgrowth tissue, containing glands,
stroma, and blood vessels, covered with
epithelium
● Stimulated by estrogen
● Diagnosed by visualization and removal by
hysteroscopy
● Send for HPE to exclude malignancy
 Adenomyosis
● Extension of endometrial glands and stroma in
the uterine myometrium
● Common in patient with multipara and history of
LSCS, D&C, and spontaneuous abortion
● Patient came with menorrhagia, secondary
dysmenorrhea and pressure symptoms
● Enlarged asymmetrical uterus on TAS
● Definite treatment by surgical intervention ie :
total abdominal hysterectomy
 Leiomyoma (Fibroids)
● Benign tumors of the uterine myometrium
● Estrogen dependent
● Common in child bearing age, black, and
nulliparous
● Classified according to site : submucous,
intramural and subserous fibroids
● Can cause bleeding by increased vascularity of
uterus(red degeneration in pregnancy),
endometrial hyperplasia, ovarian congestion or
malignant changes
● Most of fibroids are asymptomatic that need no
intervention
● Intervention needed if give rise to symptoms
like bleeding, pain, infertility, and huge size that
lead to compressive symptoms
● Investigation by ultrasonography, HSG,
hysteroscopy and CT/MRI
● Definitine treatment are surgical intervention
● Myomectomy -want to keep uterus
● Hysterectomy -when myomectomy contraindicated
 Malignancy
● Most common cancers in woman are cervical
and endometrial cancers
● Usually presented with painless PV bleed(coital
bleed or intermenstrual bleeding)
● Risk factors : prolonged exposure to
hyperestrogenic state
● Chronic anovulation
● PCOS
● Obesity
● Nulliparity
● Iatrogenic (on HRT)
● Opportunistic screening by pap smear and
endometrial sampling in risky groups
● In highly suspicion of malignancy, for tumor
markers and imaging investigations
● Definite diagnosis by HPE
● Treatment by surgical, radiotherapy or
chemotherapy
 Coagulopathy
● Presence of blood coagulation disorder in
patients that lead to heavy menses
● Examples like von Willebrand disease,
prothrombin deficiency, leukemia, idiopathy
thrombocytopenic purpura, and hypersplenism
● May presented with epistaxis, bleeding gum or
ecchymosis
● Treat according to symptoms and causes
● Referral to hematologists
 Ovulatory dysfunction
● Alteration in neuroendocrine function
● Continuous estradiol production without corpus
luteum formation and progesterone production
thus causing excessive proliferation of
endometrium lead to necrosis
● Anovulatory bleeding commons in early years
after menarche due to immaturity of HPO axis
and perimenopausal woman due to lack of
synchronization of HPO
● Anovulation causes by
● Extremes of reproductive life
● PCOS
● Hypothalamic dysfunction
● Abnormalities of other hormones(thyroid, prolactin,
and cortisol)
 Iatrogenic
● Abnormal uterine bleeding from medication
● Hyperprolactinemia from CNS dopamine
antagonism of drugs like risperidone
● COC and POP can cause breakthrough
bleeding
● Common meds like
● Selective estrogen receptor modulators(Tamoxifen)
● Gonadotropin releasing hormone agonists and
antagonists
 Endometrial
● Previously known as dysfunctional uterine
bleeding (DUB)
● Abnormal uterine bleeding not attributable to
any systemic cause or organic lesion in genital
tract
● Diagnosis of exclusion
● Classified into cyclic and acyclic
● Dysfunctional polymenorrhea due to short
proliferative or secretory phase
● Dysfunctional menorrhagia due to irregular ripening
or regular shedding
 Not Otherwise Specified
● Abnormal bleeding not in other classification
● Examples like foreign bodies or trauma
● Treatments are according to causes
 History
● Menstrual history like frequency, duration and
amount of bleeding
● Pattern of menstruation
● Menstrual calendar to properly characterize
type of bleeding
● Ask about menarche, cycle length, menstrual
product, first day of LMP, contraceptives and
dysmenorrhea
● Inquire the bleeding of other systems like
epistaxis and gum bleeding
 Physical Examination
● General
● Pallor
● Obesity, acne, hirsutism
● Petechiae or bruises
● Vital sign(tachycardia,hypotension)
● Auscultate for murmur

● Local
● Palpation of abdomen
● Speculum and bimanual exams
 Laboratory
● UPT
● FBC – hb level and platelet
● Iron studies
● Coagulation profile
● Thyroid function test
● Specific test
● For blood diseases (von Willebrand studies, factor
antigen)
● FSH and LH
● Total and free testosterone levels
● Prolactin levels
● HPE
● Pap smear and endometrial sampling
● Tumor markers
● CA 125, CEA, AFP, BHCG
 Imaging
● Pelvic ultrasonography
● Hysteroscopy
● Colposcopy
● Laparoscopy
● CT scan
● MRI
 Management
● General management by ABCD
● Correct anemia either by medication or blood
transfusion
● Maintain hemodynamic stability
● Correct the menstruation
● Prevent recurrence
● Prevent long term damage in anovulation
● Anemia, infertility, cancer
 Medical therapy
● High dose estrogen(temporary measure to stop
bleeding)
● Androgen(Danazol)
● Mirena(levonorgestrel intrauterine system)
● Progestin therapy
● Tranexamic acid
● NSAIDs
● COCP
 Reference
● Abnormal Uterine Bleeding in Comprehensive
Gynecology, 7th edition
● Zagazig Textbook of Gynecology
● Obstetrics and Gynecology Malaysian Protocol
THANK YOU