ABNORMAL UTERINE
Julie Ann
M. Valencia, MD
BLEEDING
Normal Hemostatic Mechanism
Localized vasoconstriction
Platelet adhesion
Formation of platelet plug
Reinforcement of the platelet plug with fibrin
Removal of the coagulated material by
fibrinolytic mechanisms
Abnormal Uterine Bleeding
Any
significant deviation from
normal:
Frequency
Regularity
Amount
Duration
Clinical Practice Guidelines on Abnormal Uterine Bleeding
Normal Menstrual Flow
Interval:
28 +/- 7 days
Duration: 4-7 days
Amount: 35 mL
Comprehensive Gynecology, 6th edition
Definition of Terms
MENOMETRORRHA
GIA
NORMAL
Interval:
28 +/- 7
days
Duration: 4-7
days
Amount: 35 mL
Irregular
Prolonged
Definition of Terms
NORMAL
Interval:
MENORRHAGIA
28 +/- 7
days
Duration: 4-7
days
Amount: 35 mL
Regular
Prolonged (> 7
days)
Excessive (>80 mL)
Definition of Terms
NORMAL
Interval:
METRORRHAGIA
28 +/- 7
days
Duration: 4-7
days
Amount: 35 mL
Irregular
but
frequent
Variable
amount
Definition of Terms
INTERMENSTRUAL
BLEEDING
NORMAL
Interval:
28 +/- 7
days
Duration: 4-7
days
Amount: 35 mL
Bleeding
of
variable amounts
in between
regular periods
Definition of Terms
NORMAL
Interval:
POLYMENORRHEA
28 +/- 7
days
Duration: 4-7
days
Amount: 35 mL
Regular
intervals
of < 21 days
Definition of Terms
Acute
Heavy Menstrual Bleeding
HMB that is of sufficient quantity to
require immediate intervention
Chronic
Heavy Menstrual Bleeding
AUB that has been present for 6 months
or more
NORMAL LIMITS FOR MENSTRUAL
PARAMETERS IN THE MID-REPRODUCTIVE
YEARS
Clinical Dimensions
of Menstruation
and Menstrual
Cycle
Frequency of
menses (days)
Descriptive Terms
Frequent
Normal
Infrequent
Regularity of
Absent
menses (cycle to
Regular
cycle variation over
12 months; in days) Irregular
Normal Limits
(5th 95th )
percentiles
<24
24-38
>38
Variation of 2 to 20
days
Variation >20 days
Duration of flow
(days)
Prolonged
Normal
Shortened
>8.0
4.5 8.0
<4.5
Volume of monthly
blood loss (mL)
Heavy
Normal
Light
>80
5-80
<5
Epidemiology
12-month cumulative incidence of HMB
Metrorrhagia 29%
Menorrhagia 25%
Intermenstrual bleeding 17%
Oligomenorrhea 15%
Postcoital bleeding 6%
POGS Clinical Practice Guidelines on AUB
Epidemiology
Predominant cause of admission for
adolescent menorrhagia:
Anovulation (46%)
Hematological disease (33%)
Scotland: 30-35%, 25-44 years old
Sweden: 37%, mean age of 16.7
Nepal: 6.2%, 11-17 years old
POGS Clinical Practice Guidelines on AUB
ABNORMAL UTERINE
BLEEDING
ORGANIC CAUSES
SYSTEMIC
DISEASES
REPRODUCTIVE
TRACT DISEASE
IATROGENIC
DYSFUNCTIONAL
UTERINE BLEEEDING
ANOVULATOR
Y
OVULATORY
ABNORMAL UTERINE
BLEEDING
ORGANIC CAUSES
SYSTEMIC DISEASES
REPRODUCTIVE
TRACT DISEASE
PREGNANCYRELATED
NONPREGNAN
CY RELATED
IATROGENIC
SYSTEMIC DISEASE
Disorders
of blood coagulation (von
Willebrand disease and prothrombin
deficiency)
Chronic
systemic diseases
Endocrine
prolactin)
Disorders (thyroid,
REPRODUCTIVE TRACT DISEASE
Pregnancy-related
Threatened,
incomplete, missed
miscarriage
Ectopic pregnancy
Trophoblastic disease
Placenta previa
Abruptio placenta
REPRODUCTIVE TRACT DISEASE
Nonpregnancy-related
Myomas
Endometrial
carcinoma, polyps,
or hyperplasia
Endometriosis
Adenomyosis
Chronic cervicitis
Cervical polyps and
carcinomas
Arteriovenous
malformations
Vaginal carcinoma
Functional ovarian
cysts or
neoplasms
Foreign bodies
Infections
IATROGENIC
OCPs
Steroids
Anticoagulants
IUD
Other
medications
ABNORMAL UTERINE
BLEEDING
DYSFUNCTIONAL
UTERINE BLEEEDING
ANOVULATO
RY
OVULATORY
ANOVULATORY
Most
frequent in adolescents and
perimenopause
Continuous
estradiol production
without progesterone production
OVULATORY
PGE
Vasodilatation
PGF2
Vasoconstriction
Uterine
contractility
EVALUATION OF
ABNORMAL UTERINE BLEEDING
DIAGNOSTIC STEP
HISTORY
PERTINENT SIGNS &
SXS
CONDITIONS
Pelvic pain
Miscarriage, ectopic
pregnancy, trauma, PID,
sexual abuse
Nausea, weight gain,
urinary frequency,
fatigue
Pregnancy
Weight gain, cold
intolerance, fatigue
Hypothyroidism
Weight loss, sweating,
palpitations
Hyperthyroidism
Easy bruising, tendency
to bleed
Coagulopathy
Jaundice, hx of hepatitis
Liver disease
Hirsutism, acne, obesity
PCOS
Postcoital bleeding
Cervical dysplasia,
endocervical polyps
Galactorrhea, headache,
visual-field disturbance
Pituitary adenoma
Weight loss, stress,
excessive exercise
Hypothalamic
suppression
DIAGNOSTIC STEP
PHYSICAL
EXAMINATIO
N
PERTINENT SIGNS &
SXS
CONDITIONS
Thyromegaly, weight
gain, edema
Hypothyroidism
Thyroid tenderness,
tachycardia, weight loss
Hyperthyroidism
Bruising, jaundice,
hepatomegaly
Liver disease
Enlarged uterus
Pregnancy, myoma,
uterine cancer
Firm, fixed uterus
Uterine cancer
Adnexal mass
Ovarian tumor, ectopic
pregnancy, cyst
Uterine tenderness,
cervical motion
tenderness
PID, endometritis
DIAGNOSTIC STEP
PERTINENT SIGNS &
SXS
bHCG
CONDITIONS
Pregnancy
CBC with platelet
Coagulopathy
count and coagulation
studies
LABORATOR
Y TESTS
Liver function tests,
prothrombin time
Liver disease
TSH
Thyroid disease
Prolactin
Pituitary adenoma
Blood glucose
Diabetes mellitus
DHEA-S, free
testosterone, 17hydroxyprogesterone
Ovarian or adrenal
tumor
Pap smear
Cervical dysplasia
Cervical testing for
infection
Cervicitis, PID
DIAGNOSTIC
STEP
IMAGING
AND
TISSUE
SAMPLING
PERTINENT
SIGNS & SXS
CONDITIONS
Endometrial
biopsy or D&C
Hyperplasia,
atypia, or
adenocarcinoma
Transvaginal
Ultrasound
Pregnancy,
ovarian, or uterine
tumors
Saline Infusion
Intracavitary
Sonohysterograph lesions, polyps,
y
submucous
fibroids
Hysteroscopy
Intracavitary
lesions, polyps,
submucous
fibroids
Points to Remember
A
complete blood count should be
obtained from all women with AUB.
Pregnancy
test should be done in
women of reproductive age group.
Ultrasound
is the first-line diagnostic
tool for identifying structural
abnormalities.
MANAGEMENT
CHRONI
C HMB
ACUTE
HMB
SURGER
Y
MANAGEMENT
Acute Heavy Menstrual Bleeding
High
dose estrogen
High
dose combined OCPs
Progestins
Tranexamic
Acid
Acute Heavy Menstrual Bleeding
CONJUGATED HIGH DOSE EQUINE ESTROGEN
Conjugated Equine Estrogen 25mg/IV
Every 4 hours for 24 hours
Conjugated Equine Estrogen 2.5 mg/tab
1 tablet every 6 hours for 24 hours
Acute Heavy Menstrual Bleeding
COMBINED OCPS
Ethinyl estradiol 35 ug +
Ethinyl estradiol 30 ug
Norethisterone 1 mg
+ Norgestrel 0.3 mg
1 tablet 3x a day for 1 week then
once a day for 3 weeks
1 tablet 4x a day for 4 days then
3x a day for 3 days then
2x a day for 2 days, then
once daily for 3 weeks
Acute Heavy Menstrual Bleeding
ORAL PROGESTOGENS
Medroxyprogesterone acetate
60-100mg/tab for the 1st day, then
20 mg/tab for 10 days
Norethisterone acetate 5-15 mg/tab per
day until cessation of bleeding for 2
days, then
5-10mg/day for 3-6 weeks
Acute Heavy Menstrual Bleeding
Tranexamic acid 1g/tab every 6 hours for 3
days
CHRONI
C HMB
ACUTE
HMB
SURGER
Y
MANAGEMENT
Chronic Heavy Menstrual
Bleeding
Levonorgestrel-releasing IUS
Antifibrinolytic agents
NSAIDs
Combined OCPs
Cyclic Progestogen
Danazol
Chronic Heavy Menstrual
Bleeding
Levonorgestrel-releasing
intrauterine
system (LNG-IUS)
Once every 5 years
Effective
Reversible
Reduces endometrial thickness and
vascularity
Chronic Heavy Menstrual
Bleeding
ANOVULATORY
Medroxyprogesterone 10 mg/tab once a
day for 10 days on
days 16-25 of cycle
OVULATORY
Medroxyprogesterone 10 mg/tab once a
day for 10 days on
days 5-26 of cycle
Chronic Heavy Menstrual
Bleeding
ANOVULATORY
Norethisterone acetate 5 mg/tab 3x a
day for 10 days on days 16-25 of
cycle
OVULATORY
Norethisterone acetate 5 mg/tab 3x a
day for 10 days on
days 5-26 of cycle
Chronic Heavy Menstrual
Bleeding
Tranexamic acid 1g/tab every 6 hours for 3 days
Mefenamic Acid 500 mg/tab every 8 hours for 3 days
Naproxen 550 mg/tab loading dose then 275 mg/tab
2x a day for 3 days
Ibuprofen 200 mg/tab 3x a day for 3 days
Danazol 200mg/tab once a day for 3 months
CHRONI
C HMB
ACUTE
HMB
SURGER
Y
MANAGEMENT
Surgical Management
Dilatation
and curettage
Endometrial
ablation
Hysterectomy
Dilatation & Curettage
Not
be used as a therapeutic
treatment
May
be performed for acute HMB
unresponsive to initial management
Endometrial Ablation
May
be offered as an initial
management for HMB
Normal
uterus or
< 10 weeks size
Fibroids
< 3 cm
Endometrial ablation
Transcervical Resection of Endometrium
(TRCE)
Microwave endometrial ablation (MEA)
Thermal Balloon Endometrial Ablation
(TBEA)
Rollerball Endometrial Ablation (REA)
Hysterectomy
Should not be used as first-line treatment
for HMB
Indicated when HMB is causing anemia
Requirements:
Investigate for causes of HMB
Failed medical management
Full information must be given
THANK YOU!
MANAGEMENT OF
ACUTE BLEEDING
PHARMACOLOGIC AGENTS
Estrogens
Rapid growth of the endometrium
Oral conjugated equine estrogen (CEE),
10mg/day, in 4 divided doses
Progestin (MPA), 10mg/tab OD x 7 to 10 days
after bleeding stops along with oral estrogen
PHARMACOLOGIC AGENTS
Progestogens
Stop endometrial growth
Organize the endometrium
Stimulate arachidonic acid in the
endometrium increasing the PGF2/PGE ratio
Opposing the effects of estrogen in
anovulatory women
OVULATORY
Platelet plug
