ABNORMAL UTERINE BLEEDING

(AUB)
BY OKE ANUOLUWAPO ENIOLA - 18/MHS01/262
OUTLINE
 Introduction
 Normal uterine bleeding
 Forms of AUB
 Epidemiology of AUB
 Pathophysiology
 Classification
 Diagnostic approach and Investigations
 Management
 Complications
 Differential diagnosis
INTRODUCTION
Abnormal uterine bleeding (AUB) is defined as bleeding outside of normal
physiologic menstruation, or outside the normal parameters of the menstrual cycle
(volume, duration, or interval).
AUB can occur:
 As spotting or bleeding between periods
 After sex
 For longer days than normal
 Heavier than normal
 After menopause
NORMAL UTERINE BLEEDING
 Menstruation is the visible manifestation of cyclical physiologic uterine bleeding,
caused by the shedding of the functional layer of the endometrium following an
interplay of hormones, mainly through the hypothalami-pituitary-ovarian (HPO)
axis
 The duration of menses is about 2-7days (5 days on average) and the amount of
blood loss is estimated to be 20 to 80 mL with an average of 35 mL.
 Variations in any of these parameters constitute abnormal uterine
bleeding.
ACCEPTED TERMINOLOGIES FOR
COMMON TYPES OF AUB
Abnormal uterine bleeding (AUB) may display several patterns, and descriptive
terms have been updated to standardize nomenclature
 Heavy menstrual bleeding (HMB) – Also known as “Menorrhagia”, is
defined as cyclic bleeding at normal intervals in which the bleeding is either
excessive in amount (>80mL) or with a duration > 7days or the combination of
both
 Inter-menstrual bleeding (IMB) – Also known as “Metrorrhagia” can be
defined as an Irregular acyclic bleeding from the uterus that occurs in between
menstrual periods.
ACCEPTED TERMINOLOGIES FOR
COMMON TYPES OF AUB
 Postcoital bleeding (PCB) – Bleeding from the vagina after sexual
intercourse.
 Postmenopausal bleeding (PMB) - Bleeding or spotting that occurs
more than 1 year after cessation of periods
 Bleeding of endometrial origin’ (BOE); This a diagnosis of
exclusion, could be referred to as ‘dysfunctional uterine bleeding’
(DUB). It is a state of abnormal uterine bleeding without any clinically
detectable structural, systemic and iatrogenic cause
EPIDEMIOLOGY

 AUB is a common and frequently debilitating condition for women

worldwide. It is one of the most common gynecological complaints.
 The prevalence of AUB in the reproductive years is high; it is
estimated that it affects 30% of all women at some time in their lives.
Up to 30% of all visits to gynecologists are for an AUB symptom
PATHOPHYSIOLOGY OF AUB
 The uterine and ovarian arteries supply blood to the uterus. These
arteries become the arcuate arteries; then, the arcuate arteries send
off radial branches which supply blood to the two layers of the
endometrium, the functionality and basalis layers.
 Progesterone levels fall at the end of the menstrual cycle, leading to
enzymatic breakdown of the functionalis layer of the endometrium.
This breakdown leads to blood loss and sloughing, which makes up
menstruation.
PATHOPHYSIOLOGY OF AUB
 Functioning platelets, thrombin, and vasoconstriction of the arteries
supplying the endometrium act to control blood loss.
 Any derangement in the structure of the uterus (such as leiomyoma,
polyps, adenomyosis, malignancy, or hyperplasia), derangements to the
clotting pathways (coagulopathies or iatrogenically), or disruption of
the hypothalamic-pituitary-ovarian axis (through ovulatory/endocrine
disorders or iatrogenically) can affect menstruation and lead to
abnormal uterine bleeding
ETIOLOGIC CLASSIFICATION OF AUB
The International Federation of Gynecology and Obstetrics (FIGO) developed a
classification system – PALM COEIN – to help categorize both structural and non-
structural causes of abnormal uterine bleeding (AUB). When diagnosing AUB these
potential underlying causes should be investigated.
PALM - visually objective structural criteria:
 Polyps (AUB-P)
 Adenomyosis (AUB-A)
 Leiomyoma (AUB-L)
 Malignancy (AUB-M)
ETIOLOGIC CLASSIFICATION OF AUB

COEIN - causes unrelated to structural anomalies:

Coagulopathy (AUB-C)
Ovulatory disorders (AUB-O)
Endometrial (AUB-E)
Iatrogenic (AUB-I)
Not classified causes. (AUB-N)
UTERINE POLYPS (AUB-P)
 A uterine polyp (AUB-P) is an abnormal growth containing glands,
stroma and blood vessels projecting from the endometrial layer of the
uterus.
 Estrogen stimulation is thought to play a key role in their development
and they are usually benign.
 Abnormal uterine bleeding, is the most common symptom of endometrial
or endocervical polyps. They can cause irregular menstrual bleeding,
bleeding after menopause, very heavy menstrual flow or bleeding
between periods.
ADENOMYOSIS (AUB-A)
 Defined as the presence of endometrial glands and stroma in the uterine
myometrium. It can be described as an "ectopic endometrium"
 This ectopic endometrial tissue is responsive to the usual hormonal changes in
the menstrual cycle, resulting in bleeding within the myometrium.
 Leading to an increasingly severe secondary dysmenorrhoea (pain throughout
menses), uterine enlargement and heavy menstrual bleeding (HMB)
LEIOMYOMA (AUB-L)
 Also called fibroids, are benign smooth muscle tumours arising from
the myometrium of the uterus. Mechanisms by which leiomyomas cause
abnormal bleeding are varied and largely depends on the location of the growth.
 Intramural or submucosal fibroids distort the uterine cavity and can interfere with
the normal uterine blood supply and contractility. This can lead to bleeding
anomalies like menometrorrhagia - excessive and prolonged uterine bleeding that
occurs more frequently and at irregular intervals.
MALIGNANCY (AUB-M)

 Abnormal vaginal bleeding is one of the most frequent symptoms

experienced by women with gynecologic cancers such as cervical
cancer, and endometrial cancer.
 About 90% of women with endometrial cancer have abnormal
uterine leeding. This might be in form of HMB, bleeding between
periods, or bleeding after menopause.
 COAGULOPATHY (AUB-C)
 A spectrum of systemic disorders of hemostasis that’s associated with abnormal
uterine bleeding. This includes such as Von Willebrand disease(most common),
prothrombin deficiency, hemophilia, leukemia, severe sepsis, idiopathic
thrombocytopenic purpura, and hypersplenism
 In women with known inherited bleeding disorders, HMB is the most
common complaint. In adolescents, it could present as prolonged heavy
menses that begins at menarche.
 It’s usually associated with other clinical signs such as bleeding gums, epistaxis, or
ecchymosis.
OVULATORY DYSFUNCTION (AUB-O)

AUB due to ovulatory dysfunction is the most common type of nonstructural AUB and the most common cause overall.
AUB-O can result from any disorder or condition that causes anovulation or oligo-ovulation (irregular or infrequent
ovulation). Anovulatory Dysfunctional uterine bleeding (DUB) is included in this category
Causes of ovulatory dysfunction include
 polycystic ovarian syndrome
 Hyperprolactinemia
 Hypothyroidism
 Perimenarche or perimenopause
 Primary ovarian insufficiency
 Idiopathic
 ENDOMETRIAL (AUB-E)
 This includes abnormal uterine bleeding caused by a primary disorder of the
endometrium. The term “ovulatory dysfunctional uterine bleeding (DUB)” is usually
included in this category
 DUB is defined as an abnormal uterine bleeding in a woman with a structurally normal
uterus, regular ovulatory cycles and no evidence of coagulopathy or other systemic
disease. It is mainly a diagnosis of exclusion.
 Prolonged and heavy bleeding can occur with abnormalities of the platelet plug
formation or inadequate uterine levels of prostaglandin F2a, E2 and thromboxane A2,
which are responsible for uterine contraction, coupled with an increased local
production of prostacyclins that promote vasodilation.
IATROGENIC (AUB-I)
Abnormal uterine bleeding can be caused by various medications and
devices that act directly on the endometrium or affect the hormonal
interplay of the menstrual cycle.
This includes intrauterine devices (IUDs), hormonal contraception,
tamoxifen, tricyclic antidepressants, and some antipsychotics.
NOT YET CLASSIFIED (AUB-N)

 A category of “not yet classified” was created to accommodate entities

that are rarely encountered or are ill-defined.
 Several uterine entities that might contribute to, or cause, AUB in a given
individual include conditions like chronic endometritis, uterine arterio-
venous malformations, myometrial hypertrophy, and endometrial
pseudoaneurysm.
 SIGNS AND SYMPTOMS
There is substantial overlap in the signs and symptoms based on the etiology,
but some common characteristics may be seen.
 AUB-P: The bleeding with endometrial polyps is typically intermenstrual and
light. Approximately one-third of polyps are asymptomatic.
 AUB-A: Classic symptoms of adenomyosis include heavy menses,
dysmenorrhea, and midline dyspareunia.
 AUB-L: The symptoms from leiomyomata (fibroids) depend on their size and
location. Submucosal and intramural fibroids tend to result in heavy bleeding.
This is because the fibroids increase the surface area of the endometrial cavity
so that there is more tissue to bleed from during menses.
 SIGNS AND SYMPTOMS
 AUB-M; The vast majority of patients with endometrial cancer (91%) will
have postmenopausal bleeding (PMB). There is no specific pattern of
abnormal bleeding in premenopausal women; the most common types are
heavy menses, intermenstrual bleeding, and heavy irregular bleeding
 AUB-C: AUB typically presents in adolescence with the most common
patterns of heavy menses and heavy menses beginning to at menarche .
Associated symptoms may include easy bruising, dental extraction bleeding,
post-surgical bleeding, and epistaxis
 SIGNS AND SYMPTOMS

 AUB-I; The use of a copper intrauterine device (IUD) may result in

predictable heavy menses, whereas the use of a progestin-secreting
intrauterine device results in hypomenorrhea and irregular cycles.
DIAGNOSTIC APPROACH – HISTORY TAKING
Menstrual history: frequency, duration, and amount of bleeding is important in
categorizing abnormal uterine bleeding;
 Age at menarche
 Cycle length
 Duration of bleeding
 Perception of flow: heavy, medium or light
 Associated symptoms such as fever, fatigue, bulk symptoms, tissue passage, or
pain can also direct evaluation.
 inquire whether and when the menstrual pattern changed.
 DIAGNOSTIC APPROACH – HISTORY TAKING
 Drug history; abnormal bleeding can accompany use of (NSAIDs), anticoagulants,
and agents associated with hyperprolactinemia
 Sexual history - Contraception and condom use, history of sexually transmitted
infections or current symptoms (eq, vaginal discharge, pelvic pain), previous
pregnancy or abortion, history of sexual abuse or assault
 Social history - Social stressors, substance use, exercise patterns, and athletic
competition.
 Family history - Bleeding disorders, menstrual disorders, thyroid disorders
 Past medical history - Systemic illness, including hematologic or renal disease, and
current or recent medications.
DIAGNOSTIC APPROACH – PHYSICAL EXAMINATION
 Vital signs should be assessed first – Tachycardia and hypotension may signal
acute hemodynamic instability and the need for rapid intervention. The
presence of tachycardia, pallor, or a heart murmur suggests anemia
 The presence of petechia or excessive bruising - may suggest a platelet defect
or another bleeding disorder.
 Examination of the thyroid gland for enlargement and other abnormalities
 Obesity, acne, hirsutism, and acanthosis nigricans: may be present in a patient
with PCOS
 Galactorrhea (bilateral milky nipple discharge) suggests the presence of
hyperprolactinemia
 DIAGNOSTIC APPROACH – PHYSICAL EXAMINATION

An abdominopelvic examination should be performed.

 Palpation of the abdomen – for pregnancy, uterine/ovarian masses
 A boggy, globular, tender uterus is typical of adenomyosis
 Uterine tenderness - pelvic inflammatory disease (PID)
 Examination of the genitalia for masses, lacerations, ulceration, friable area,
vaginal or cervical discharge, foreign body)
 A sexually active patient may warrant a complete pelvic/examination
(speculum and bimanual exams).
 INVESTIGATIONS - LABS
 Pregnancy test; Human chorionic gonadotropin (hCG) in all sexually
active reproductive age females
 CBC; Measure of iron stores- prothrombin time and activated partial
thromboplastin time
 Targeted screening for bleeding disorder (when indicated); Von
willebrand studies (factor VIII, \Willebrand factor antigen (VWF:Ag)
 Thyroid-stimulating hormone (TSH)
 Chlamydia trachomatis and Neisseria gonorrhea- in high risk patients
 FSH and LH, total and free testosterone levels, dehydroepiandrosterone,
prolactin levels
 INVESTIGATIONS - IMAGING
The optimal imaging study is dependent on the disease process.
 Trans vaginal ultra Sonography (TVUS) ; This technology is chosen by
many as a first line tool to assess AUB. Advantageously, it allows assessment
of both the myometrium and the endometrium.
 Sonohysterography: Also known as SIS, allows identification of common
masses associated with AUB such as endometrial polyps, submucous
leiomyomas, and intracavitary blood clots. These masses frequently create
non descript distortion or thickening of the endometrial lining when imaged
 INVESTIGATIONS - IMAGING

 Hysteroscopy; With this procedure, an endoscope, usually 3 to 5 mm in diameter, is

inserted into the endometrial cavity. The uterine cavity is then distended with saline
or another medium for visualization. In addition to inspection, biopsy samples can
also be taken and this allows for the histologic diagnosis of abnormal areas
 One advantage of hysteroscopy is that it permits simultaneous removal of many
lesions once identified
 Initial evaluation should begin with a TVUS scan or SIS. If specific lesions are
visualized, consideration should be given to hysteroscopy with site-directed biopsies
and/or curettage.
MANAGEMENT
 Medical management should be initial treatment for most patients
 Need for surgery (including type of surgery) is based on various factors:

- stability of patient
- severity of bleed
- contraindications to med management
- underlying cause
- desire for future fertility
 MANAGEMENT
Initial Approach
 Determine if AUB acute vs. chronic
 If acute AUB, are there signs of hypovolemia/hemodynamic instability?

If yes, resuscitate:
- IV access with 2 large bore cannulas.
- Crystalloids vs colloids
- Prepare for blood transfusion +/- clotting factor replacement
 Once stable, evaluate etiology (PALM-COEIN) and Determine Treatment
 MEDICAL MANAGEMENT
First line medical therapy for AUB (for patients not known with bleeding disorders)
Hormonal medical therapies;
 Progestin; works as an antiestrogen by minimizing the effects of estrogen on target cells,
thereby maintaining the endometrium in a state of down-regulation.
 Oral contraceptive pills; OCPs are generally considered effective in management of both
ovulatory and Anovulatory AUB.
 Levonorgestrel intrauterine device (L-IUD) – 20mcg daily for 5 years
 Gn-RH agonist; GnRH agonists are effective in reducing menstrual blood flow. They inhibit
pituitary release of FSH and LH, resulting in a hypoestrogenic state. These agents are used on a
short-term basis due to high costs and severe adverse effects
 Danazol; synthetic androgen with antioestrogenic & antiprogestagenic activity. It inhibits the
release of pituitary Gnt & has direct suppressive effect on the endometrium
MEDICAL MANAGEMENT
Non-hormonal medical therapies;
 Tranexamic acid; An antifibrinolytic agent. Works by inhibiting the activation of
plasminogen to plasmin. Thereby decreasing bleeding.
- Dose; Tranexamic acid 1g QID, for the first 4 days of the menstrual cycle
 Ethamsylate; maintain capillary integrity, inhibitory effect on PG

- Dose:500 mg qid, starting 5 days before the onset of cycle & continued for 10 days
 Prostaglandin synthetase inhibitors (PSI); Fenamates (Mefenamic acid). They
decrease abnormal prostaglandin concentrations and reduce prostacyclin tranexamic
ratio.
- Dose; Mefanamic acid 250-500mg 2-4xdaily,
 SURGICAL MANAGEMENT
 Endometrial ablation/resection;

Endometrial ablation is a procedure to remove a thin layer of tissue

(endometrium) that lines the uterus. It is done by using heat, cold or different
types of energy to destroy the lining of the uterus.
It is used to treat used to treat heavy menstrual bleeding
It is an alternative to hysterectomy
If indicated;
 Polypectomy - Surgical removal of a polyp.
 Myomectomy - Myomectomy is a surgical procedure to remove uterine
fibroids
SURGICAL MANAGEMENT
 Hysterectomy

- Surgical removal of the uterus. reserved for the woman with other
indications for hysterectomy, such uterine prolapse.
- Usually offered to women with completed family size (no longer
desirous of pregnancy)
- used to treat persistent abnormal uterine bleeding after all medical
and surgical therapy has failed, or when medical therapy is
contraindicated.
 COMPLICATIONS OF AUB
 Acute AUB
- Severe anemia
- hypotension
- Shock
- Death may result if prompt treatment and supportive care are not initiated.
 chronic AUB
- Infertility
- endometrial cancer (excessive estrogen exposure )
REFERENCES
 Gynecology 20th Edition by Ten Teachers
 Williams Gynecology 3rd Edition
 MEDSCAPE;
- https://emedicine.medscape.com/article/795587-overview#a2
- https://emedicine.medscape.com/article/255540-treatment
 Ryntz T, Lobo R. Chapter 26 AUB; comprehensive gynecology 7th edition.
 Committee Opinion no 557: management of acute abnormaluterine bleeding
in nonpregnant reproductive-aged women.Obstet Gynecol.