Aub Updated-1 PDF
Aub Updated-1 PDF
Aub Updated-1 PDF
A TE
D A
U P
Abnormal Uterine Bleeding (AUB)
with 2018 FIGO updates
INA S. IRABON, MD, FPOGS, FPSRM, FPSGE
Obstetrics and Gynecology
Reproductive Endocrinology and Infertility
Reference:
Munro MG, Critchley HO, Fraser I, FIGO Menstrual Disorders Committee. 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
Int J Gynaecol Obstet. 2018 Dec;143(3):393-408. doi: 10.1002/ijgo.12666. Epub 2018
Oct 10
Updated definitions: Acute vs chronic
´ Chronic nongestational AUB in the reproductive years 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.
´ 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.
´ Acute heavy menstrual bleeding may present in the
context of existing chronic AUB or can occur in the absence
of such a background history.
Munro, 2018
FIGO-AUB system 1
Revision of terminologies and definitions of symptoms of
abnormal uterine bleeding
FIGO-AUB system 2
PALM-COIEN classification of causes of AUB
Anatomic Non-anatomic
causes causes
Munro MG, Critchley HO, Fraser I, FIGO Menstrual Disorders Committee. 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
Int J Gynaecol Obstet. 2018 Dec;143(3):393-408. doi: 10.1002/ijgo.12666. Epub 2018 Oct 10
Diagnosis Notation
AUB-P1A0L0M0-C0O0E0I0N0
AUB-P1A0L0M0-C0O0E0I0N0
or
AUB - P
AUB – M;-O
Ryntz T, Lobo R. Chapter 26. Abnormal Uterine Bleeding;
In Comprehensive Gynecology 7th edition, 2017;Lobo RA,
Gershenson DM, Lentz GM, Valea FA editors; pp 621-633.
FIGO AUB system 2 diagnostic matrix
Pathophysiology
ENDOMETRIAL POLYPS (AUB-P)
´ localized overgrowths of endometrial
P tissue, containing glands, stroma, and
blood vessels, covered with epithelium.
A
´ Most commonly found in reproductive-
L age women
A. Asymmetrical myometrial
thickening
B. myometrial cysts
C. hyperechoic islands
D. fan shaped shadowing
E. echogenic subendometrial
lines and buds
F. translesional vascularity
where present
G. irregular junctional zone
H. interrupted junctional zone
FIGURE 3 Adenomyosis diagnostic criteria. Graphical depictions of the eight TVUS criteria proposed by the MUSA group are presented.
Munro 2018
These include asymmetrical myometrial thickening (A); myometrial cysts (B); hyperechoic islands (C); fan shaped shadowing (D); echogenic
LEIOMYOMA (AUB-L)
´ Also called fibroids, are benign tumors of the uterine
P myometrium.
´ pathogenesis : myometrial injury leading to cellular
A proliferation, decreased apoptosis, increased production
of extracellular matrix, and overexpression of transforming
L growth factor beta that leads to fibrosis of these tumors.
O ´ intramural fibroids
´ Subserous fibroids
I ´ Management:
E ´ Medical management
Ryntz T, Lobo R. Chapter 26. Abnormal Uterine Bleeding;
´ Surgical : hysterectomy, myomectomy
N In Comprehensive Gynecology 7th edition, 2017;Lobo RA,
Gershenson DM, Lentz GM, Valea FA editors; pp 621-633.
FIGO Leiomyoma subclassification
system
|
398 Munro ET AL.
F I G U R E 4 FIGO leiomyoma subclassification system. System 2 classification system including the FIGO leiomyoma subclassification system.
MALIGNANCY (AUB-M)
P
A
5 L
M Testing
100
C
al blood loss (mL)
1000
O
n ratio of endogenous concentra-
d prostaglandin E and menstrual Figure 26.6 Diagnostic approach to adults with abnormal uterine
I The synthesis
endometrium; persistent endo-
H, Kelly RW, et al.
bleeding due to coagulopathy. (Data from Kouides PA, Conard J,
Peyvandi F, et al. Hemostasis and menstruation: appropriate investi-
proliferative endometrium. J Clin gation for underlying disorders of hemostasis in women with exces-
-289.) E sive menstrual bleeding. Fertil Steril. 2005;84[5]:1345-1351.)
N
Ryntz T, Lobo R. Chapter 26. Abnormal Uterine Bleeding;
In Comprehensive Gynecology 7th edition, 2017;Lobo RA,
Gershenson DM, Lentz GM, Valea FA editors; pp 621-633.
OVULATORY DYSFUNCTION (AUB-O)
P ´ the patterns of anovulatory bleeding may be
A oligomenorrhea, intermenstrual bleeding, or heavy
menstrual bleeding.
L
´ What are the causes of anovulation?
M 1. extremes of reproductive life
C 2. polycystic ovary syndrome (PCOS)
3. hypothalamic dysfunction (related to weight loss, severe exercise,
O stress, or drug use
I 4. abnormalities of other nonreproductive hormone (thyroid
hormone, prolactin, and cortisol)
E
N Ryntz T, Lobo R. Chapter 26. Abnormal Uterine Bleeding;
In Comprehensive Gynecology 7th edition, 2017;Lobo RA,
Gershenson DM, Lentz GM, Valea FA editors; pp 621-633.
IATROGENIC(AUB-I)
P ´ abnormal bleeding resulting from medications
L
M
C
O Munro 2018
I
E
N
ENDOMETRIAL (AUB-E)
P ´ heavy menstrual bleeding in the
A absence of other abnormalities are
thought to have underlying disorders of
L the endometrium or are otherwise
unclassified.
M
´ In the past, this category has been
C called “ovulatory dysfunctional uterine
bleeding.”
O
´ the primary line of defense to excessive
I bleeding during normal menses is the
formation of the platelet plug, followed
E by uterine contractility, largely mediated
N by prostaglandin F2α (PGF2α). Ryntz T, Lobo R. Chapter 26. Abnormal Uterine Bleeding;
In Comprehensive Gynecology 7th edition, 2017;Lobo RA,
Gershenson DM, Lentz GM, Valea FA editors; pp 621-633.
ENDOMETRIAL (AUB-E)
´ thus prolonged and heavy bleeding can
P occur with abnormalities of the platelet plug
A or inadequate uterine levels of PGF2α.
´ In some women with heavy menstrual
L bleeding, there is excessive uterine
M production of prostacyclin, a vasodilatory
prostaglandin that opposes platelet
C adhesion and may also interfere with
uterine contractility.
O ´ Deficiency of uterine PGF2α or excessive
I production of PGE (vasodilatory
prostaglandin) may also explain ovulatory
E DUB
N ´ Low PGF2α/PGE à increase menstrual Ryntz T, Lobo R. Chapter 26. Abnormal Uterine Bleeding;
In Comprehensive Gynecology 7th edition, 2017;Lobo RA,
blood loss Gershenson DM, Lentz GM, Valea FA editors; pp 621-633.
NOT OTHERWISE CLASSIFIED (AUB-N)
P ´ Abnormal bleeding not classified in the previous
A categories is considered AUB-N.
´ Examples of such conditions may include foreign bodies
L or trauma. Treatment is tailored to the specific cause.
M ´ New example: niche or isthmocoele associated with
C previous CS
O
I
E
N Ryntz T, Lobo R. Chapter 26. Abnormal Uterine Bleeding;
In Comprehensive Gynecology 7th edition, 2017;Lobo RA,
Gershenson DM, Lentz GM, Valea FA editors; pp 621-633.
Examples of the use of a matrix to guide FIGO-
based
|
evaluation
402
of patients with chronic AUB.
Munro ET AL.
(A)
(B)
Examples of the use of a matrix to guide FIGO-
based evaluation of patients with chronic AUB.
(B)
Examples of the use of a matrix to guide FIGO-
based evaluation of patients with chronic AUB.
Munro ET AL. |
403
(C)
Examples of the use of a matrix to guide FIGO-
based evaluation of patients with chronicAUB.
(D)
Diagnostic approach
History, Physical examination, and Laboratory exams
1. Medical History
T A B L E 3 Screening instrument for coagulopathies in women with not use MRI if it is deemed
the symptom of heavy menstrual bleeding.a,b used to categorize leiomyom
or location and extent of ade
Initial screening for an underlying disorder of hemostasis in patients
with excessive menstrual bleeding should be by a structured history.
A positive screening result comprises any of the following:c
8 | CONCLUSIO
1. Heavy menstrual bleeding since menarche
2. One of the following:
The present paper reports
a Postpartum hemorrhage
based on 6 years of ana
b Surgical related bleeding original publication. The
c Bleeding associated with dental work effective approaches to t
3. Two or more of the following symptoms: AUB (System 1), followed
a Bruising 1–2 times per month (PALM- COEIN) of underl
b Epistaxis 1–2 times per month ing in the reproductive y
c Frequent gum bleeding and refinements are integ
d Family history of bleeding symptoms in this manuscript.
a
Reproduced with permission.45
b
This structured history- based instrument is 90% sensitive for the pres-
AUT HO R CO NT R IBUT
The menstrual history
For all patients:
• Age at menarche
• Cycle length
• Duration of bleeding
• Perception of flow: heavy, medium or light
• Menstrual product use
• First day of LMP
• Dysmenorrhea
Holland-Hall C. Heavy menstrual bleeding in adolescents:Normal variant or a bleeding disorder.http://contemporaryobgyn.modernmedicine.com/
THE MENSTRUAL CALENDAR
The menstrual history
For patients reporting heavy menstrual bleeding:
De Silva N. Abnormal uterine bleeding in adolescents: Evaluation and approach to diagnosis. August 2016. www.uptodate.com
Physical Exam
´Vital signs
´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
Ryntz T, Lobo R. Chapter 26. Abnormal Uterine Bleeding;
In Comprehensive Gynecology 7th edition, 2017;Lobo RA,
Gershenson DM, Lentz GM, Valea FA editors; pp 621-633.
Physical Exam
´Petechiae or excessive
bruising: may suggest a
platelet defect or another
bleeding disorder.
´Obesity, acne, hirsutism, and
acanthosis nigricans : may be
present in a patient with PCOS.
Rydz N and Jamieson MA. Managing heavy menstrual bleeding in adolescents. 2013. http://contemporaryobgyn.modernmedicine.com/
Physical Exam
Rydz N and Jamieson MA. Managing heavy menstrual bleeding in adolescents. 2013. http://contemporaryobgyn.modernmedicine.com/
Laboratory evaluation
´ Pregnancy test
´ Complete blood count
including differential and
platelet count; blood typing
´ Measure of iron stores
´ prothrombin time and
activated partial
thromboplastin time
(A)
(B)
(B)
FIGURE 6 Investigative algorithms for patients with chronic AUB during the reproductive years. (A) Initial investigation comprises a structured
history, physical examination, and the use of appropriate ancillary investigations, in part based upon the history and physical assessment.
Evidence suggesting an ovulatory disorder prompts assessment for endocrinopathy, whereas a positive screening result for coagulopathy
TREATMENT
Management
Bennet AR and Gray SH. What to do when she’s bleeding through: the recognition, evaluation, and
management of abnormal uterine bleeding in adolescents. Curr Opin Pediatr 2014, 26:413–419
Treatment
A. Adolescents:
´ after ruling out coagulation disorders, the main direction
of therapy is to temporize because once the HPO axis
matures, the problem will be corrected.
´cyclic progestogen (medroxyprogesterone acetate,
10 mg for 10 days each month for a few months) to
produce reliable and controlled menstrual cycles.
´oral contraceptive (OC)may be an option if the
problem persist beyond 6 months.
Ryntz T, Lobo R. Chapter 26. Abnormal Uterine Bleeding;
In Comprehensive Gynecology 7th edition, 2017;Lobo RA,
Gershenson DM, Lentz GM, Valea FA editors; pp 621-633.
ABNORMAL UTERINE BLEEDING: OVULATORY
DYSFUNCTION
B. Perimenopausal woman:
´ low-dose (20-µg) combined oral contraceptives( in a
nonsmoking woman).
´ Cyclic Progestogens
C. Reproductive-aged women:
´ chronic anovulatory bleeding is primarily caused by
hypothalamic dysfunction or PCOS.
´ Combined oral contraceptives
Ryntz T, Lobo R. Chapter 26. Abnormal Uterine Bleeding;
´ cyclic progestogens In Comprehensive Gynecology 7th edition, 2017;Lobo RA,
Gershenson DM, Lentz GM, Valea FA editors; pp 621-633.
ABNORMAL UTERINE BLEEDING:
ENDOMETRIAL