Abnormal uterine bleeding
AUB
• Defined as bleeding from uterine corpus that is abnormal in
duration,volume,frequency and or regularity in a non pregnant
women.
Terminologies
• Amenorrhea-when menses are absent or a woman experiences no
bleeding.
• Frequent menstrual bleeding - when menses occur less than 24 days
apart
• Infrequent menses-when menses occur more than 38 days apart
• Prolonged menses is more than 8 days of bleeding
• Heavy menstrual bleeding-defined as excessive menstrual blood loss
that interferes with a women’s physical, social,emotional or material
quality of life
• Inter menstrual bleeding-bleeding between spontaneous ,predictable
menses and may occur randomly through the cycle or predictably
and cyclically in early,mid or late cycle
• Unscheduled bleeding-bleeding that may occur on hormone
medications such as contraceptive pills,patches,rings
PALM COEIN classification -
• Structural
• Polyps
• Adenomyosis
• Leiomyoma
• Malignacy
Non structural
• Coagulopathies
• Ovulatory disorders
• Endometrial disorders
• Iatrogenic
• Not otherwise classified
AUB
In reproductive age group
• First check for serum hCG and anemia,once these are excluded-
proceed systematically to address each components of PALM COEIN
Causes
Polyps(AUB -P)
• Endometrial and cervical polyps can cause AUB
• Usually benign
• Risk factors( endometrial )-age,tamoxifen use,obesity,increased
estrogen levels,lynch syndrome
Adenomyosis (AUB-A)
• Presence of heterotopic endometrial tissue in the myometrium
Leiomyoma( AUB -L)
• Fibroids are benign tumours of uterus
• Submucous fibroids- more likely to present with HMB
• Fibroids categorises from 0 to 8
• 0,1,2 are submucous type
• 3 shows both intramural and submucous characteristics.
Malignancy ( AUB -M)
• Atypical hyperplasia and malignancy of endometrium should be
considered in women of perimenopausal and reproductive age and
also in longstanding AUB- O
Coagulopathy ( AUB-C)
• Systemic disorders of hemostasis
• Most common -VWD,platelet disorders like Glanzmans
thrombasthenia,thrombocytopenia and clotting factor deficiency
Ovulatory disorders AUB-O
• Characterised by irregular cycles,short cycles,periods of amenorrhea
followed by prolonged and irregular bleeding
• M/C -PCOS
• Other causes-hyperprolactinemia,thyroid dysfunction,mental stress
Endometrial AUB -E
• Here HMB is predictable and cyclic and typical Ovulatory cycles.
• Deficiency of local production of PGF2 and endothelin 1
• Accelerated lysis of endometrial clots due to increased production of
plasminogen activator.
• Impaired endometrial repair ,mechanism
Iatrogenic
• Hormone intake,iuds,drugs interfering dopamine metabolism or
blood coagulation
• Break through bleeding -unscheduled bleeding during hormone
therapy-due to reduced circulating levels of estrogen and
progesterone
• Drugs like-griseofulvin,anticonvulsant,rifampicin also reduces steroid
levels
Not otherwise classified AUB -N
• Chronic endometritis,arteriovenous malformations,isthmocele
Diagnosis
History
• Heavy regular cyclical bleeding over several consecutive cycles-
suggests fibroids ,Adenomyosis and AUB E
• Inter menstrual bleeding( with or without HMB)-polyps and
submucous fibroids
• Post coital bleeding-cervical premalignancy or malignancy
• Associated dysmenorrhea and chronic pelvic pain-Adenomyosis
• Amenorrhea followed by bleeding -AUB-O
• Heavy bleeding since menarche,h/o PPH—>AUB-C
Clinical examination
• Pallor and signs of chronic anemia
• Evidence of bleeding diathesis-(AUB-C)
• Obesity and hirsutism-PCOS and AUB-O
• Abdominal mass -fibroids
• Speculum examination- cervical polyps
Investigations
• Assess anemia-hemoglobin,CBC,peripheral smear platelet
count ,serum ferritin
• Thyroid function test and prolactin
• Coagulation tests if clinical suspicion
• Transvaginal ultrasound(TVS)-asses uterine cavity and myometrium-
structural abnormalities
• Hysteroscopy-cavity and endometrium
• Endometrial sampling-endometrial aspiration with pippelle,D and C,
hysteroscopy and directed biopsy
Management
Non hormonal
• Anti fibrinolytic-tranexamic acid
• NSAIDs(prostaglandin synthetase inhibitors )-mefenamic acid &
combi. Of mefenamic and tranexamic acid (500 mg TID for 5 days)
• Ethamsylate-reduces endometrial capillary fragility and promotes
platelets aggregation (500 mg QID)
Hormonal
• Combined oral contraceptive pills- causing endometrial atrophy,so
reduced endometrial prostraglandin synthesis and fibrinolysis
• Progestins-cyclical progestins (10 to 14 days a month) can be given
for AUB-O to ensure withdrawal bleeding,once initial bleeding
stopped with high dose progestin
• LNG -IUS —Mirena-delivers 20 mcg of levonorgestrel every 24 hours,
• GnRH agonists-causes down regulation of pituitary and amenorrhe
eg:leuprolide acetate nd goserilin,—> hypoestrogenic side effects-
limited to 6 months
Other methods
• Hysterectomy
• Endometrial ablation-superficial layers of endometrium destroyed
using Hysteroscope-trans cervical resection of endometrium using
diathermy or using laser ablation
• Arterial embolisation-for arteriovenous malformations.
