ABNORMAL UTERINE

BLEEDING
Dr Kipa Shrestha
MDGP EM 2nd year
2080/02/14

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CONTENTS
1. Definition
2. Etiology
3. Diagnosis
4. Pathophysiology
5. Management

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PATHOPHYSIOLOGY

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• Endometrium has two distinct zones, the functionalis layer and the
basalis layer.
• The basalis serves as a reservoir for regeneration of the functionalis
layer following menses.
• The functionalis layer lines the uterine cavity and undergoes dramatic
change throughout the menstrual cycle and ultimately sloughs during
menstruation.
• Histologically, the functionalis has a surface epithelium and
underlying subepithelial capillary plexus. Beneath these are stroma,
glands, and interspersed leukocytes
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• Blood reaches the uterus via the uterine and ovarian arteries.
• From these, the arcuate arteries arise to supply the myometrium.
• These branch into radial arteries, which extend toward the endometrium
at right angles from the arcuate arteries.
• At the endometrium-myometrium junction, the radial arteries bifurcate
to create the basal and spiral arteries.
• The basal arteries serve the basalis layer of the endometrium and are
relatively insensitive to hormonal changes.
• The spiral arteries stretch to supply the functionalis layer and end in a
subepithelial capillary plexus.
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• In human menstruation, progesterone plays a critical role.
• Two progesterone receptors {PR) are found in the endometrium, PRA
and PRB.
• In the secretory phase, PRB levels decline in the stromal and glandular
epithelial cells of the functionalls layer.
• However, PRA expression in this layer persists in the stromal cells,
which thus remain responsive to progesterone and to its withdrawal.

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• In the absence of pregnancy, the corpus luteum regresses and curtails
progesterone production.
• Progesterone acts as an antiinflammatory agent, and thus its
withdrawal raises cytokine levels in the endometrium.
• Elevated concentrations of cytokines prompt an influx of leukocytes,
which release lytic enzymes.
• These matrix metalloproteinases break down the stroma and vascular
architecture of the functionalis layer

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• Subsequent bleeding and sloughing of this layer constitute menstruation.
• Concurrently, endometrial levels of tissue factor and plasminogen activator
inhibitor-1 drop with progesterone withdrawal. These two proteins foster
hemostasis during the luteal phase, but their decline promotes an
environment conducive to bleeding and fibrinolysis (Lockwood, 2011).
• Last, progesterone withdrawal raises concentrations of cydooxygenase-2, a
necessary enzyme in prostaglandin PG synthesis. As a result, levels of
prostaglandin Fza (PGF2a) rise and cause intense spiral arteriole constriction.
• Explanations differ as to whether this vasoconstriction produces a hypoxia
needed to prompt endometrial sloughing or whether it serves to minimizes
menstrual blood loss
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• Hemostasis and cessation of menstruation are dependent on the endometrial
coagulation system.
• Initially, platelets aggregate and are activated in response to endothelial injury.
• This occurs by either platelet glycoprotein interaction with von Willebrand factor or
tissue factor generation of thrombin.
• Subsequently, fibrin is formed through the coagulation cascade to help form a stable clot
to seal bleeding vessels.
• In addition, the remaining endometrial arterioles constrict to limit further bleeding.
• During menses, augmented endometrial glucocorticoid production also helps to control
blood loss by dampening the inflammatory response.
• Dysregulation in any of the above events can lead to abnormal menstruation and greater
blood loss.

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DEFINITION
• Women normally menstruate every 28 ± 7 days.
• The average duration is 5 days, and
• menstrual blood loss volume does not normally exceed 80 mL.
• Variations in any of these norms constitute abnormal uterine bleeding
(AUB), which may be acute or chronic.
• Acute AUB is defined as bleeding sufficiently heavy to require
immediate intervention to prevent ongoing losses.
• Chronic AUB is defined as bleeding that has been present during most
of the prior 6 months.

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