ABNORMAL UTERINE BLEEDING

(AUB)

DR.ANAS A
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 Outline

•Brief overview of normal menstrual cycle

•Terminology of AUB
•Scope of the problem
•FIGO nomenclature & PALM-COEIN classification of AUB
•Causes & Diagnosis
•Principle of management

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 Normal menstrual cycle
Menstruation is a cyclic physiological phenomena
starting at the age of Menarche (11-14years) till
establishment of Menopause (45-55 years).
It is regulated by hypothalmo-pituitary- ovarian
hormones secreted in pulsatile and cyclic pattern

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 Endometrial Changes During The
Menstrual Cycle
1-Basal layer of the endometrium
-Adjacent to the myometrium
-Unresponsive to hormonal stimulation
-Remains intact throughout the menstrual cycle
2-Functional layer of the endometrium
Composed of two layers:
-zona compacta -----superficial
-Spongiosum layer
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 Endometrial Changes During The
Menstrual Cycle
1-Follicular /proliferative phase
Estrogen -----mitotic activity in the glands & stroma 
Increases endometrial thickness from 2 to 8 mm
2-Luteal /secretory phase
Progestrone - Mitotic activity is severely restricted
-Endometrial glands produce then secrete glycogen rich
vacoules
-Stromal edema
-Stromal cells enlargement
-Spiral arterioles develop, lengthen & coil
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 Menstruation
Periodic desquamation of the endometrium
• The external hallmark of the menstrual cycle
• Just before menses the endometrium is infiltrated with
leucocytes
• Prostaglandins are maximal in the endometrium just before
menses
• Prostaglandins constriction of the spiral arterioles
ischemia & desquamation
Followed by arteriolar relaxation, bleeding & tissue breakdown

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 Hypothalamic Role in the Menstrual
Cycle
The hypothalamus secretes GnRH in a pulsatile fashion
• GnRH activity is first evident at puberty
• Loss of pulsatility -----down regulation of pituitary
receptors secretion of gonadotropins
• Release of GnRH is modulated by –ve feedback by:
Steroids
gonadotropins
• Release of GnRH is modulated by external neural
signals

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 Estimation of MB Loss
25 % Of Women With Normal Periods Considered their
Blood Loss Excessive

40 % With Excessive Bleeding ( > 8 0 ML ) Described

their Periods As Light Or Moderate.

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 Abnormal uterine bleeding
AUB:-is defined as any variation from the normal
menstrual cycle which includes changes in regularity
and frequency of menses, duration of flow, or
amount of blood loss (non-pregnant women).

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Abnormal Uterine Bleeding
Women normally menstruate every 28 ± 7 days. The average
duration is 5 days, and menstrual blood loss volume does not
normally exceed 80 mL.
 Mense are ideally categorized by four qualities-volume,
duration, frequency, and regularity
1. Heavy menstrual bleeding (HMB), which was formerly called
menorrhagia-describe menstruation with excessive flow.
2. Prolonged bleeding lasting >8 days per menstrual period.
3. frequent bleeding describe menses with <24 days intervening.
Cont…..
Infrequent bleeding previously called oligomenorrhea.
is defined by menses with >38 days intervening.
4. Regularity-If cycle lengths vary from cycle to cycle
by >=10 days, they are considered irregular.
Intermenstrual bleeding defines bleeding, usually brief.
That occurs between fairly normal menses.

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 Prevalence

AUB affects up to 30% of women throughout their reproductive

lifetime

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 Repercussions of abnormal uterine bleeding
on different aspects

Influence
on social Anaem Pain/
aspects ia Dysmenorrho
ea

Influence on
Limitation
psychological AUB for activities
aspects

Worsening Absenteeism
of quality Surgical (Work or
of life procedures School) 13
 Abnormal uterine bleeding
Etiologies:-
1.Reproductive tract diseases
2.Systemic illnesses
3.Iatrogenic causes

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 Abnormal uterine bleeding
1.Reproductive Tract Diseases:-
 Benign conditions:- fibroids, adenomyosis, polyps,
hyperplasia
Malignant:- cervical, endometrial, vaginal or ovarian
ca; granulosa/theca cell tumors
Infections:-cervicitis(chlamydia,
Gonorrhea),endometritis(TB),PID

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 Abnormal uterine bleeding
2.Systemic illnesses:-
Coagulation disorders
Hypothyroidism
Hepatic disorders
Adrenal disorders
Renal dysfunction
Polycystic ovarian syndrome
Hyperprolactinemia, SLE

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 Abnormal uterine bleeding
3. Iatrogenic causes:-
Medications: IUD, oral &injectable steroids, Hormonal
replacement therapy, anticoagulants, corticosteroids
Trauma(rape, accidents)
Foreign body
Life style(substance abuse:heroin,marijuana,cigarette
smoking)
Stress
Excessive exercise
Obesity,undernutrition,anorexia 17
 classification of AUB

Acute AUB: require immediate intervention to prevent

further loss
Chronic AUB: has been present for the majority of the
last 6 months.
Intermenstrual bleeding: episodes of bleeding that
occur between normally timed menstrual periods.

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 Proposed classification system by FIGO
AUB-P; Polyps

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 AUB-P; Polyps

-Endocervical or endometrial polys

scored as Present or Absent
-Present with HMB, IMB, or PCB
Symptoms do NOT correlate with number, diameter &
site
-Incidence of CA varies between 0–4.8%

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 AUB-P; Polyps
-increases with age
Diagnosis:
- TVUS,
- SIS,
- hysteroscopy
- Biopsy

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 AUB-A; Adenomyosis
-Ectopic endometrial glands & stroma within the
myometrium
-Hypertrophy & hyperplasia of surrounding myometrium
Usual presentation:
-HMB, uterine enlargement, & dysmenorrhea
chronic pelvic pain, painful sexual intercoursee
-Diagnosis
ultrasound
MRI
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 AUB-L; Leiomyoma
-Smooth muscle tumours of the uterus
-Generally benign -(<1%) malignant transformations
Leiomyosarcoma
-Submucosal leiomyomas are more often associated with
AUB

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 AUB-M; Malignancy & Hyperplasia
-Endometrial cancer and hyperplesia
-Uterine sarcoma
Common presentation - PMB
•Endometrial cancer- Relatively uncommon in reproductive age
women
•Increasing obesity and rising prevalence of the metabolic
syndrome.
•( Risks --- Age, obesity, PCOS, Nullip, DM, HNPCC)
•Up to 40% of patients with a biopsy _hyperplasia with atypia
concomitant endometrial adenocarcinoma present
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 Non-structural Abnormalities
C – Coagulopathy
O – Ovulatory Dysfunction
E – Endometrial
I – Iatrogenic
N – Not yet classified

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 AUB-C – Coagulopathy
Prevalence: 13% of women presenting with HMB
Etiologies:
1. Clotting factor deficiency or defect- Liver
disease Congenital (Von Willebrands Disease-10%)
2. Platelet deficiency (thrombocytopenia) with
platelet count <20,000/mm3
-Idiopathic thrombocytopenic purpura (ITP)
-Aplastic anemia Platelet function defects

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 AUB-C – Coagulopathy
3. Platelet function defect
4. Anticoagulants
Supra-therapeutic anticoagulation: heavy menstrual
bleeding
**Therapeutic levels should not cause bleeding
problems**

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 AUB-C – Coagulopathy
HMB since menarche
• One of the following: Surgical related bleeding
Bleeding associated with dental work
•Two or more of the following:
Bruising 1-2 times/month
Epistaxis 1-2 times/ month
Frequent gum bleeding
Family history of bleeding problems

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 AUB-O; Ovulatory
-Mainly due to anovulatory bleeding
-Age-related: peri-menarche, perimenopause
-Estrogenic: unopposed exogenous or endogenous
Estrogen
-Androgenic: PCOS; CAH, acute stress
-Systemic: Renal disease, liver disease Hyperthyroidism
or hypothyroidism Luteal Phase Defect (LPD)

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 AUB –O (ovulatory dysfunction)

physiologic pathologic

Adolescence Hyper-androgenic anovulation (PCOS,

Peri-menopause CAH)
Lactation Hypothalamic dysfunction
Pregnancy Hyper-prolactinemia
Thyroid disease
Primary pituitary disease
Premature ovarian failure
Iatrogenic (eg secondary to chemo)
Medications
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 Anovulatory Bleeding
In the absence of ovulation

Continued Fragile
Ovary does
endometrial endometrium
not make
proliferation bleeds
progesterone
erratically

Irregular
bleeding
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 AUB-E; Endometrial
Etiology: diagnosed by exclusion
Deficiencies of local production of vasoconstrictors
• Endothelin-1
• Prostaglandin F2a
Excessive production of plasminogen activators
Increased local production of vasodilators
•Prostaglandin E2
•Prostacyclin I2
Disorders of endometrial repair (inflammation)
• Chlamydia

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 AUB-I; Iatrogenic
Etiology: Breakthrough bleeding (BTB) using
gonadal steroids is the major component of AUB-
I:
Oral contraceptives
Continuous or cyclic progesterone
IUD or implant related bleeding
Cigarette smoking : reduces the level of steroids
because of enhanced hepatic metabolism
Systemic agents that interfere with dopamine
metabolism : Serotonin uptake inhibitors
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 AUB-I; Iatrogenic
Tricyclic antidepressants (e.g. amitriptyline and
nortriptyline) and phenothiazines
impact dopamine metabolism by ↓serotonin
uptake → ↓ed inhibition of prolactin release
→disruption in the HPO axis and→anovulation

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 AUB-N; Not Yet Classified
Disorders that would be identified or defined only
by biochemical or molecular biology assays
• Arterio-venous malformations
• Myometrial hypertrophy
• Category for new etiologies
• Pathological conditions of lower genital tract ??

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 Diagnosis of AUB
Targeted history

Structured Examination

Relevant Investigations

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 Diagnosis: History Symptoms
Impact on suggestive of
social and systemic
sexual causes of
functioning bleeding
and quality Sympto
of life Establish ms of
pattern of Anaemia
AUB ?
Associated
Sexual and symptoms_
reproductive vaginal discharge
history or odour, pelvic
pain or pressure 39
 Physical assessment
General assessment
Gynecological examination
Vital signs Inspection: vagina, cervix,
anal canal
Weight/BMI Bimanual examination:
uterus and adnexa
Thyroid exam Per rectal examination
Skin exam Testing: Pap smear,culture
Abdominal exam
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 Uterine Evaluation
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 Imaging
Imaging studies in cases of AUB may be indicated
when:
• examination suggests structural causes for bleeding,
• conservative management has failed, or
• there is a risk of malignancy
Types: transabdominal
transvaginal
Saline infusion sonography
Hysteroscopy
MRI
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 Management
Conservative medical management
Surgical management

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 Management
Treat the underlying problem
- If structural lesion causing AUB, remove it
- If evidence of coagulopathy, correct it
- If thyroid function is abnormal, address it
Utilize therapies known to decrease bleeding
- Hormonal treatment (combined hormonal
contraception or progestin-only methods including
levonorgestrel IUS)
-Non-hormonal treatment (NSAIDs or tranexamic acid)
-Specialized GYN procedures (uterine artery
embolization, endometrial ablation, or hysterectomy) 45
 Medical management

Hormonal
Nonhormonal
Combined hormonal contraceptives
NSAID
LNG-IUS
Antifibrinolytics
Oral progestins
Depot-medroxyprogesterone acetate
Danazol------Estrogen
GnRH-agonists
Ormilexifene 46
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END

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