Abnormal Uterine

Bleeding
JI DUCUT, Clare
Abnormal Uterine Bleeding
● Infrequent episodes, to excessive flow, or prolonged duration of
menses and intermenstrual bleeding
● One of the most common health concerns of women
● Oligomenorrhea
○ Infrequent uterine bleeding
○ Intervals between episodes vary from 3 days to 6 months
● Amenorrhea
○ No menses for at least 6 months
Normal Menstrual Blood Flow
● Mean duration of the menstrual cycle: 24-38 days (CPG); mean
interval 28 days ±7 days (Lobo)
● Average menstrual blood loss (MBL): 35mL (normal range: 10-
80mL)
● Average number of days of menses: 4 days (normal: ≤ 8 days)
Abnormal Uterine Bleeding
● Abnormal if:
○ Intervals of less than 24 days, or more than 38 days
○ Lasts longer than 8 days
○ MBL of 80 mL or greater
Normal and Abnormal Menses
Heavy Menstrual Bleeding

Excessive menstrual blood loss which interfere with

the woman’s physical, social, emotional and/or
material quality of life (FIGO 2018 update)
Acute vs Chronic AUB
Chronic nongestational AUB
● Bleeding from the uterine corpus -> abnormal duration, volume,
frequency, and/or regularity
● Has been present for the majority of the preceding 6 months
Acute AUB
● Episode of heavy bleeding that, is of sufficient quantity to require
immediate intervention or prevent future blood loss
Acute HMB
● May present in the context of existing chronic AUB or can occur
in the absence of such background history
Objective Method to Measure Blood Loss
Pictorial Bleeding Assessment
Chart (PBAC)
● Validated tool used to diagnose HMB
● Score of ≥150pts
● PBAC score of 150 correlates with
>80mL BL
● Check how soaked the napkin is ->
corresponds to a point on the chart
Objective Method to Measure Blood Loss
Alkaline Hematic Method
● Gold standard but more applicable in
research setting
● Chemical measurement of the blood
content of used sanitary napkin
○ Measures hematin
 02
Classification
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FIGO - AUB System 1
Revision of terminologies and definitions of symptoms of abnormal uterine
bleeding
FIGO - AUB System 2
PALM-COEIN classification of causes of AUB

Anatomic causes
Non-anatomic causes
Diagnosis Notation
● Acronym AUB is followed by the letters PALM-COEIN + subscript 0
or 1
● Example:
○ A patient with abnormal bleeding due to a Polyp:

AUB-P₁A₀L₀M₀-C₀O₀E₀I₀N₀
or

AUB - P
 03
Pathophysiology
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PALM
 PALM
ENDOMETRIAL
POLYPS
 AUB-P
● Localized overgrowths of endometrial tissue
○ Glands
○ Stroma
○ Blood vessels
● Most commonly found in reproductive aged
women
● Estrogen stimulation -> key role in development
● Usually benign
● Can be treated safely and effectively with
operative hysteroscopy
 PALM
ADENOMYOSIS
AUB-A
● Presence of endometrial glands and
stroma in the uterine myometrium ->
Ectopic endometrial tissue ->
hypertrophy of the surrounding
myometrium
● Risk Factors:
○ Multiparity
○ D&C
○ CS delivery
○ Spontaneous abortion
AUB-A
● Enlarged, asymmetric uterus on
ultrasound
● MRI: demonstrate thickening of
junctional zone equal ≥12mm
● Result of altered uterine
contractility and associated with
profound dysmenorrhea
AUB - A Diagnostic Criteria
 PALM
LEIOMYOMA
AUB-L
● AKA fibroids -> benign tumors of the uterine myometrium
● Pathogenesis:
○ myometrial injury -> proliferation, decreased apoptosis, increased
production of extracellular matrix, and overexpression of
transforming growth factor beta -> fibrosis of these tumors
● Mechanisms causing AUB: depend on size, location and number
○ Intracavitary
○ Intramural fibroids
○ Subserous
● Management: medical or surgical
AUB-L
AUB-L
 PALM
MALIGNANCY
 AUB-M
● Vulvar, vaginal, cervical, endometrial,
uterine, and adnexal (ovarian or fallopian
tube) cancers
● Bleeding from cervical malignancy
classically presents as coital bleeding or
intermenstrual bleeding
● Endometrial cancer is mostly secondary to
prolonged exposure to hyperestrogenic
state (chronic anovulation, PCOS, obesity,
nulligravidity, etc)
 AUB-M
● Conditions that lead to increased circulating levels of estrogen are
risk factors
○ Obesity associated with increased estrone levels
○ Primary source -> ovary
○ Impaired ovulation and absence of progesterone withdrawal can
result in sustained exposure of the endometrium to estrogen
 AUB-M
● Lynch syndrome, or hereditary nonpolyposis colorectal cancer,
○ an autosomal dominant disease caused by a disruption in the
mismatch repair (MMR) genesà carries a 40% to 50% lifetime risk of
endometrial cancer (mostly before the age of 45.)
● Estrogen-producing ovarian tumors (ex. Granulosa theca cell tumors)
COEIN
 COEIN
COAGULOPATH
Y
 AUB-C
● Disorders of blood coagulation such as von
Willebrand disease prothrombin deficiency,
hemophilia, leukemia, severe sepsis
○ Adolescents- prolonged heavy menses
beginning at menarche
○ Adults- clinical signs such as bleeding
gums, epistaxis, or ecchymosis.
AUB-C

Ryntz T, Lobo R. Chapter 26. Abnormal Uterine Bleeding;Comprehensive

Gynecology 7th edition, 2017;Lobo RA;; pp 621-633
 COEIN
OVULATORY
DYSFUNCTION
 AUB-O
● Anovulatory bleeding is most
common during the extremes of
reproductive life: in the first few
years after menarche and during
perimenopause.
AUB-O
ADOLESCENT PERIMENOPAUSAL
WOMAN
anovulation is due to an lack of synchronization
immaturity of the between the components of the
hypothalamic- pituitary- HPO axis occurs as the woman
ovarian (HPO) axis and failure approaches ovarian decline at
of positive feedback of estradiol menopause
to cause a luteinizing hormone
(LH) surge.
 AUB-O
● the patterns of anovulatory bleeding may be oligomenorrhea,
intermenstrual bleeding, or heavy menstrual bleeding.
● What are the causes of anovulation?

○ extremes of reproductive life

○ polycystic ovary syndrome (PCOS)
○ hypothalamic dysfunction
○ abnormalities of other nonreproductive hormone
 COEIN
ENDOMETRIAL
 AUB-E
● Heavy menstrual bleeding in the
absence of other abnormalities

● The primary line of defense to

excessive bleeding during normal
menses is the formation of the platelet
plug, followed by uterine contractility,
largely mediated by prostaglandin
F2α (PGF2α) and endothelin-1
 COEIN
IATROGENIC
 AUB-I
● Usually manifest with irregular
bleeding→"breakthrough" bleeding
● Hormonal preparations- most
common
● Examples of iatrogenic causes include
contraceptive hormones, intrauterine
devices (IUD), steroids, tranquilizers,
digitalis, dilantin, rifampicin, and
griseofulvin.
 COEIN
NOT
OTHERWISE
CLASSIFIED
 AUB-N
● Abnormal bleeding not classified in the
previous categories is considered AUB-
N.

● ́ Examples of such conditions may

include foreign bodies or trauma.
● Other uterine entities such as chronic
endometritis, arteriovenous
malformations, and myometrial
hypertrophy, may cause AUB.
 04
Diagnosis
 MEDICAL HISTORY
● Menstrual history: frequency,
duration, and amount of
bleeding

● Describe the menstrual

abnormality as oligomenorrhea,
polymenorrhea, heavy
menstrual bleeding, or
intermenstrual bleeding.
 PHYSICAL EXAM
● The presence of tachycardia, pallor, or
a heart murmur suggests anemia
● Palpation of the thyroid gland for
enlargement or other abnormalities.
● Sexual maturity rating of the breasts
and assessment for galactorrhea.
● ́ Palpation of the abdomen
(pregnancy, uterine/ovarian mass).
PHYSICAL EXAM
● Bimanual inspection of the
genitalia is sufficient for
diagnosis in most patients.
● A sexually active patient
may warrant a complete
pelvic examination
(speculum and bimanual
exams).
LABORATORY EVALUATION
Pregnancy test
Possible causes of pregnancy-
related bleeding include
● Abortion
● Ectopic pregnancy
● Placenta previa
● Abruptio placenta
● Trophoblastic disease.
LABORATORY EVALUATION
● von Willebrand studies (factor
VIII, von Willebrand factor
antigen (VWF:Ag)
● CBC with platelets
● Partial and thromboplastin
 05
Management
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MANAGEMENT
OF ACUTE
UTERINE
BLEEDING
 MANAGEMENT
● The management of AUB depends on:
○ Assessment of whether or not the patient is hemodynamically stable
○ Medical management based on etiology and the severity of anemia
○ Determination of the underlying cause
■ Requires an accurate diagnosis.
■ Anatomic or physiologic
● In the absence of an organic cause for excessive uterine
bleeding, it is preferable to use medical instead of surgical
treatment
THERAPEUTIC GOALS

1. Treat underlying cause

2. Establish and/or maintain hemodynamic stability
a. Correct acute or chronic anemia
3. Return to a pattern of normal menstrual cycles
4. Prevent of recurrence
5. Prevent long-term consequences of anovulation (eg, anemia, infertility,
endometrial cancer)
 MEDICAL MANAGEMENT
● Medical options treat the underlying pathology and manage the symptoms in
patients with:
○ ovulatory dysfunction and endometrial causes
● May be initiated in patients with adenomyosis or leiomyoma not
severe enough to require surgery
● Medical management methods
○ Treatment of AUB-O and AUB-E.
■ Estrogens, progestogen (systemic or local)
■ Gonadotropin-releasing hormone (GnRH) agonists
■ Nonsteroidal anti-inflammatory drugs (NSAIDs) and
Antifibrinolytic agents
 MANAGEMENT OF AUB-O

● Adolescents:
○ Rule out coagulation disorders
○ Main direction of therapy is to temporize to
allow the maturation of the HPO axis
■ Cyclic progesterone
● Medroxyprogesterone acetate (MPA) -
10 mg for 10 days each month
○ May last for a few months to 6
months
■ Oral Contraceptives
● > 6 months
 MANAGEMENT OF AUB-O

● Perimenopausal woman:
○ Low-dose (20-μg) combined oral contraceptives
○ Cyclic Progestogens

● Reproductive-aged women:
○ Chronic anovulatory bleeding is primarily caused
by hypothalamic dysfunction or PCOS.
○ Combined oral contraceptives
○ Cyclic progestogens
 MANAGEMENT OF AUB-E
● Heavy menstrual bleeding with no known anatomical cause
● Aim of therapy is to reduce the amount of excessive
bleeding
○ Progestogens
■ Prolonged regimen of (3 weeks each month)
■ Medroxyprogesterone acetate (MPA) 10 mg daily
○ Levonorgestrel intrauterine system (IUS)
■ Every 5 years
 Gonadotropin-Releasing Hormone Agonists
● Inhibit ovarian steroid production
○ Limited to women with severe MBL who fail to
respond to other methods of medical management
and wish to retain their childbearing capacity.
○ Effective means of bridging patients to surgical
treatment
■ Correction of anemia.
 NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
● Mode of action
○ Block the action of prostaglandins by interfering
directly at their receptor sites.
○ Block the formation of both thromboxane and the
prostacyclin pathway.
○ NSAIDs have been shown to reduce MBL
● Examples:
○ Mefenamic acid (500 mg, three times daily)
○ Ibuprofen (400 mg, three times daily),
○ Naproxen sodium (275 mg, every 6 hours after a
loading dose of 550 mg)
 Anti-fibrinolytic Agents
● Potent inhibitors of fibrinolysis
○ ε-Aminocaproic acid (EACA), tranexamic acid
(AMCA), and para-aminomethyl benzoic acid (PAMBA)
○ Limited by side effects mainly Gl side effects
■ Reduce the dose and limiting therapy to the first 3 to
5 days of bleeding.
○ Increased risks of thrombosis and myocardial infarction
■ Should not be combined with oral contraceptives.
MANAGEMENT
OF ACUTE
BLEEDING
 ACUTE BLEEDING
● Women who are bleeding heavily and are
hemodynamically unstable
○ Quickest way to stop acute bleeding is with curettage.
■ Curettage is the preferred approach
● Older women
● Medical risk factors for whom high- dose
hormonal therapy may pose a great risk.
● May also be managed medically (pharmacologic agents)
 PHARMACOLOGIC AGENTS FOR ACUTE
BLEEDING
● To stop acute bleeding that does not require curettage,
the most effective regimen involves high-dose estrogen.

● High-dose estrogen is aimed at stopping acute bleeding,

and is merely a temporary measure.
ESTROGENS
● Estrogen in pharmacologic doses causes rapid growth
of the endometrium.
○ A rapid growth of endometrial tissue occurs over
the denuded and raw epithelial surfaces
○ Large doses of estrogen may alter platelet activity
■ Promoting platelet adhesiveness.
 ESTROGENS
● 1. oral conjugated equine estrogen (CEE) 10 mg/day, in
four divided doses
● 2. IV conjugated estrogen: 25 mg q4-6h until the bleeding
stops. (No more than six doses should be administered)
● 3. combination oral contraceptive (both estrogen and
progestin), Four tablets of an oral contraceptive containing
30 to 35 ug of estrogen taken every 24 hours in divided
doses.
 PROGESTOGENS
● For patients with contraindication to estrogen
○ Prior thrombosis, certain rheumatologic diseases, estrogen-
responsive cancer
● Progestogens inhibit endometrial growth
○ Support and organize the endometrium
■ Organized slough occurs after withdrawal.
● Rapid cessation of bleeding.
● Stimulate arachidonic acid formation in the endometrium
○ Increasing the PGF2α/PGE2 ratio
 PROGESTOGENS
● Medroxyprogesterone acetate (MPA) at a dose of
60 mg daily (20 mg three times daily) for 7 days
followed by 20 mg per day for 3 weeks
● Depo-MPA 150 mg intramuscularly followed by
oral MPA 60 mg (20 mg three times daily) for 3
days
● Norethindrone acetate (30 mg per day)
 ANDROGENS
● Danazol is a synthetic androgen
○ Doses of 200 mg daily for the treatment of
heavy menstrual bleeding
● May be used for progestin resistant cases
● Limited use because of the side effects
○ Weight gain
○ Skin problems
SURGICAL
MANAGEMENT
OF ACUTE
BLEEDING
 DILATATION AND CURETTAGE (D&C)
● For the immediate management of severe bleeding.
○ Diagnostic and is therapeutic
■ Diagnostic
● AUB
● Infertility
● Severe menstrual pain
● Abnormal cervical cells
■ Therapeutic
● Excessive bleeding after birth
● Cervical and uterine polyps
● Fibroid tumors
● Incomplete abortion
 DILATATION AND CURETTAGE (D&C)
● For women with markedly excessive uterine bleeding who
may be hypovolemic
○ D&C is the quickest way to stop acute bleeding
■ Treatment of choice in hypovolemic women
● D&C may be preferred as an approach to stop an acute
bleeding episode in women > 35 when the incidence of
pathologic findings increases
 DILATATION AND CURETTAGE (D&C)
● D&C is only indicated for women with acute bleeding resulting in
hypovolemia and for older women who are at higher risk of having
endometrial neoplasia.
● Not proved useful for the treatment of women who ovulate and have heavy
menstrual bleeding
● All other women, after having an endometrial biopsy, sonohysterography, or
diagnostic hysteroscopy to rule out organic disease, are best treated with
medical therapy, without D&C.
DILATATION AND CURETTAGE (D&C)
 HYSTERECTOMY
● DEFINITIVE DIAGNOSIS
● Surgical removal of the uterus.
● Reserved for the woman with other indications for hysterectomy
○ Leiomyoma
○ Uterine prolapse.
● Usually offered to women with completed family size
● Treat persistent abnormal uterine bleeding after all medical
therapy has failed
HYSTERECTOMY
HYSTERECTOMY
 ENDOMETRIAL ABLATION (EA)
● Abnormal bleeding may be treated by
endometrial ablation (EA) if medical
therapy is not effective or is
contraindicated.
● Exceptions are women who have very large
uteri caused by fibroids or abnormal
pathology, such as endometrial hyperplasia
or cancer.
● These methods are an alternative to
hysterectomy or to the use of the
levonorgestrel IUS
MANAGEMENT (POGS 2009)
 Thanks
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References
● Clinical Practice Guidelines on AUB 2017
● Comprehensive Gynecology 7th Edition
● Williams Gynecology 4th Edition