ABNORMA

L UTERINE
BLEEDING

PRESENTED BY :
DR ARIEMAHFUSA
DR SITI NABILA
 • INTRODUCTION
• ETIOLOGY
• APPROACH TO
AUB – HISTORY
TAKING,
PHYSICAL
EXAMINATION,
IMAGING AND
TEST
MANAGEMENT
CONTENT
•

04/21/2024 S a m p l e F o o t e r Te x t 2
INTRODUCTION
• The prevalence of abnormal uterine bleeding among reproductive-aged women internationally is
estimated to be between 3% to 30%, with a higher incidence occurring around menarche and
perimenopause.

• AUB is defined as bleeding from the uterine corpus that is abnormal in regularity, volume,
frequency, or duration and occurs in the absence of pregnancy
• Acute AUB is defined as an episode of heavy bleeding that, in the opinion of the clinician, is of
sufficient quantity to require immediate intervention to minimize or prevent further blood loss

• Chronic AUB is defined as bleeding from the uterine corpus that is abnormal in duration, volume,
frequency, and/or regularity, and has been present for the majority of the preceding 6 months.
FIGO AUB SYSTEM 1

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• Terms such as menorrhagia, metrorrhagia, oligomenorrhea, and dysfunctional uterine
bleeding have been abandoned.
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
• HMB is a symptom rather than a diagnosis
• Referring to excessive menstrual blood loss, which interferes with a woman’s physical, social,
emotional and/or material quality of life
FIGO AUB SYSTEM 2

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CLASSIFICATION

Non
Structural
structural
04/21/2024 S a m p l e F o o t e r Te x t 15
APPROACH TO
PATIENT WITH AUB

04/21/2024 S a m p l e F o o t e r Te x t 16
HISTORY TAKING
• Menstrual history
• Menarche ?
• Last menstrual period ?
• Menses – frequency, regularity, duration of menses and volume
• Heavy menstrual bleeding/ irregular menses/ intermenstrual bleeding/ post coital bleeding
• Associated symptoms
• Symptoms of anemia – SOB/ palpitation/ presyncope or syncopal attack/ giddiness
• Dyspareunia
• Constitutional symptoms
• Abnormal PV discharge
• Urinary symptoms/ Bowel symptoms / Symptoms of metastasis ?
• Sexual and reproductive history
• Past pregnancies and mode of delivery
• Future fertility desire
• Subfertility
• Current contraceptive usage ?
• Pap smear history
• Past medical history
• Any bleeding tendencies to suggest coagulopathy ?
• PCOS ? Metabolic syndrome ?
• BMI
• Breast cancer – tamoxifen ?
• Drug history – anti platelet/ anti coagulant/ hormonal / HRT
• Family history of malignancy ? Bleeding disorder ?
• Management of acute abnormal uterine bleeding in non pregnant
reproductive age, ACOG 2013
• Social history :
• Impact of the illness – hospitalization/ absenteeism from school/ work ?
• Smoking
• Occupation
PHYSICAL EXAMINATION
• General inspection :
• Body built
• Signs of hypovolemia
• Anemia
• Signs of hyperandrogenism
• Bruising / petechiae
• Thyroid swelling / eye signs of hyperthyroidism
• Systemic approach
• Abdominal examination – mass palpable
• Per speculum/ vaginal examination / bimanual
• Per rectal examination
TEST AND IMAGING
• Blood investigations :
• Full blood count – types of anemia
• Anemic work up – iron profile/ full blood picture/ stool occult blood
• Evaluation of disorder of haemostasias : coagulation profile/ fibrinogen level/ von Willebrand factor assay / factor VIII
assay
• Thyroid function test
• Liver function test
• Urine pregnancy test
• Transabdominal/ transvaginal ultrasound
• Endometrial sampling
• Hysteroscopy
MANAGEMENT OF AUB

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 AIM treatment for AUB

• To control current episode of heavy menstrual bleeding (HMB)

• To reduce menstrual blood loss in subsequent cycle
AUB-O – MILD TO MODERATE BLEEDING
• Outpatient management
• Menstrual calendar
• Treatment of anemia
• Medical treatment: tranexamic acid and NSAID / hormonal treatment
• Follow up 3-6 monthly
SEVERE BLEEDING
• Inpatient management
• Treatment of anemia
• Evaluate the cause and treat the cause
• Medical treatment: IV Tranexamic Acid 1g tds/ qid for first 4 days
• Hormonal treatment:
• COCP – monophasic, TDS dosage for 1 week/ tapering method TDS for 3 days, BD for 2 week and
then OD
• Oral Progestogens – medroxyprogestrone acetate 20mg TDS for 7 days
CHRONIC ANOVULATORY BLEEDING/
HMB
• Risk of endometrial hyperplasia and increased risk of endometrial carcinoma
• Need to induce menses (withdrawal bleeding) at least every 3 months
• Hormonal treatment:
• COCP
• Oral Progestogens (for withdrawal bleeding)
• T Medroxyprogestrone Acetate
W O M E N W I T H N O I D E N T I F I E D PAT H O L O G Y,
FIBROIDS <3 CM AND NO SUSPECTED/DIAGNOSED
ADENOMYOSIS

• LNG-IUS
1 line
st

• Cyclical oral progesterone

2 line
nd • Combined hormonal contraception

• Hysteroscopic resection of submucosal fibroids

• Second generation endometrial ablation
3 line
rd • Hysterectomy (open/laparoscopic/vaginal and
total/subtotal)
WO ME N WIT H FIB R O ID S O F 3 C M O R MO R E IN
D IA MET E R

• Tranexamic acid
Non hormonal • NSAIDs

• LNG-IUS
Hormonal • Combined hormonal contraception
• Cyclical oral progestogens
• Myomectomy
Surgical • Hysterectomy (open/laparoscopic/vaginal
and total/subtotal)
 REFER
POLYPECTOM MEDICAL
Y

MEDICAL VS
SURGICAL TX
NON-HORMONAL
VS HORMONAL TX
MEDICAL VS
SURGICAL TX

REMOVE THE
CAUSE

REFER
GYNAEONCOLOGIST/
FOLLOW PATHWAY
MANAGING
HYPERPLASIA
THANK YOU.