Abnormal Uterine Bleeding: - Rou'a Eyad - Rahaf Eyad

Abnormal Uterine Bleeding
- Rou’a Eyad
- Rahaf Eyad
Outlines
Normal uterine bleeding.
 AUB “ Definition & terminology”
 AUB Causes “ FIGO classification”
 DUB
What is a normal uterine bleeding ?
Menstruation
The menstrual cycle:
1-Regular:
Duration (3-7 days )
Frequency (21-35 day)
Amount : 50 - 80 ml ( not more than 80 ml )
2.In reproductive age ( from puberty to menopause(

Abnormal Uterine bleeding(AUB)
- Is a broad term that describes Vaginal bleeding from the uterus
- Disorders of menstrual bleeding related to changes in one of these:
* Age: before menarche / after menopause
* Frequency
* Regularity
* Duration : short/long
* Volume: change in hemodynamic status
Terminology related to menstrual disorder:
• Disorder of ovulation:
-Oligoovulation: Cycles of more than 35 days / less than 8 cycles a year.
- Anovulation: Absence of ovulation.
• Disturbances of regularity:
- Irregular Menstrual Bleeding: Abnormal variations in the length of
menstrual cycle
- Absent Menstrual Bleeding(Amenorrhea):No menstruation in a 90 day period.
• Disorder of length of cycle (frequency):
- Polymenorrhea: Menstruation occurring less than 21 days (frequent menses)
- Oligomenorrhea: Menstruation occurring more than 35 days (infrequent menses)
• Disorder of amount of flow:
-Menorrhagia: ↑in amount flow to 90 ml or more per cycle
- Hypomenorrhea: ↓ in amount of flow to less than 30 ml per cycle
• Disorder of duration of flow:

-Metrorrhagia: Bleeding in the intermenstrual period ( more than 7 days )
-Menometrorrhagia: Menorrhagia + Metrorrhagia
AUB Causes
Pregnancy test
If pregnancy test is POSITIVE: Pregnancy
- In a patient who has abnormal bleeding during the reproductive -
age group, pregnancy or a complication must first be considered.
- Complications of early pregnancy that are associated with

bleeding include: incomplete abortion, threatened abortion,
ectopic pregnancy, and hydatidiform mole.
- Diagnosis:
Urine or serum β-hCG test is required to confirm pregnancy.
If pregnancy is identified vaginal ultrasound will help sort out which
pregnancy complication is operative.
If pregnancy test is NIGATIVE:
FIGO classification of AUB: PALM-COEIN
PALM COIN
structural causes
PALM
Structural/ Anatomic lesion:
The classic history is that of unpredictable bleeding (without cramping) occurring
between normal, predictable menstrual periods (with cramping).
A variety of lower and upper reproductive tract factors can cause bleeding:
o Vaginal lesions: lacerations, varicosities or tumors.
o Cervical lesions: polyps, cervicitis or tumors.
o Endometrial lesions: submucous leiomyomas, polyps, hyperplasia or cancer.
o Myometrial lesions: adenomyosis.
P A L M
Palm- Polyps
• localized overgrowths of endometrial tissue ,containing
glands, stroma , and blood vessels , covered with epithelium .
• Most commonly found in reproductive age women
• key role in their development : estrogen stimulation
• Usually benign .
• Treatment for women with symptomatic polyps: operative
hysteroscopy
P A L M
pAlm- ADENOMYOSIS
• presence of endometrial glands and stroma in the
uterine myometrium . → ectopic endometrial tissue
leads to hypertrophy of the surrounding myometrium .
• RF: Multiparity and any process that allows for

penetration of endometrial glands and stroma past
the basalis layer (e.g. D&C, CS, spontaneous abortion )
• Enlarged , asymmetric uterus on ultrasound

P A L M
palm- LEIOMYOMA
• A.k.A fibroids
• Benign tumors of the uterine myometrium
• Mechanisms by which fibroids cause abnormal bleeding
are varied and depend on size , location , and number :
- Intracavitary / submucous fibroids
- intramural fibroids
- Subserous fibroids Medical
• management Surgical : hysterectomy , myomectomy
P A L M
palM: Malignancy
• In any part of genital tract
• Bleeding from cervical malignancy classically presents
as coital bleeding or intermenstrual bleeding
• mostly secondary to prolonged exposure to
hyperestrogenic state (chronic anovulation , PCOS ,
obesity , nulligravidity)
• Lynch syndrome ,carries a 40 % to 50 % lifetime risk of
endometrial cancer ( mostly before the age of 45. )
• Diagnosis:
A number of tests can be used to for anatomic diagnosis.
• Lower genital tract: pelvic and speculum exam
• Upper genital tract: saline sonogram, endometrial biopsy,
or hysteroscopy
• Management:
Varies according to the individual diagnosis.
NON structural causes
COEIN
Coein- coagulopathy
 Up to 15% of patients with AUB (especially in the adolescent age group)
have coagulopathies.
 positive for other bleeding symptoms including epistaxis, gingival bleeding,
and ecchymosis.
 can be due to: vessel wall disorders, platelet disorders, coagulation disorders, and
fibrinolytic disorders
 Von Willebrand disease
- the most common hereditary coagulation abnormality.
- arises from a deficiency of von Willebrand factor (vWF), a protein required
for platelet adhesion.
Diagnosis.
- Positive family history
- review of systems
- Lab tests include CBC with platelet count, PT, and PTT.
- vWF antigen.(Von Willebrand disease).
Management.
Consultation with a hematology specialist
COein- Ovulatory dysfunction
 Common cause of bleeding in pubertal girl and perimenopausal women .
 Disorder of hypothalamic-pituitary-gonadal axis ,PCOS, Obesity.
 Oligomenorrhea followed by heavy bleeding.
CoEin- Endometrial causes
 imbalance of PGs.
 endometritis /continuous release of PGs
CoeIn-Iatrogenic
 most common are hormonal preparations
 Oral contraceptives, progesterone, IUD implant-related bleeding, GnRH
agonist and antagonist, SERM, SPRM.
 Cigarette smoking: reduce the level of steroid because of enhanced hepatic
metabolism .
 Interactions between oral contraceptives and other medications , such as
antibiotics and anticonvulsants may alter circulating levels of steroids ,
allowing follicular recruitment and increased endogenous levels of estrogen .
 Drugs that interfere with dopamine metabolism such serotonin intake
inhibitor
 Use of anticoagulant drug
CoeiN-Not yet claciffied
 not classified in previous categories.

 Eg: uterine arteriovenous malformation, CS scar defect,
 endometrial pseudoaneurysm.
Dysfunctional uterine
bleeding
DUB
 pregnancy test is negative.
 no anatomic causes for bleeding.
 coagulopathy is ruled out
the diagnosis of hormonal imbalance should be

considered.
DUB
 Classic history: bleeding that is unpredictable in amount,
duration, and frequency without cramping.
 Mechanism:
 - The most common cause of DUB is anovulation.
 - Anovulation results in unopposed estrogen.
 - With unopposed estrogen, there is continuous stimulation of
the endometrium with no secretory phase.
An estrogen dominant endometrium is structurally unstable as it increasingly thickens.

With
inadequate structural support, it eventually undergoes random, disorderly, and
unpredictable breakdown resulting in estrogen breakthrough bleeding.
DUB
 Diagnosis:
 - Anovulatory cycles: a history of irregular, unpredictable bleeding.
 Bleeding is usually without cramping since there is no PG release to cause
myometrial contractions.
 Cervical mucus will be clear, thin and watery reflecting the estrogen dominant
environment.
 Basal-body temperature (BBT) chart will not show a midcycle temperature rise
due to the absence of the thermogenic effect of progesterone.
 Endometrial biopsy will show a proliferative endometrium.
DUB
Basal-body temperature (BBT) chart
DUB
 Diagnosis:
 Progesterone trial
 administering progestin to:
stabilize the endometrium,
Stop the bleeding and prevent

A positive progesterone trial confirms a
clinical diagnosis of anovulation.
random breakdown ,
A negative progesterone trial rules out
anovulation.
 When the progestin is stopped,
spiral arteriolar spasm
 results in,
necrosis, and an orderly shedding of the
PG release
endometrium.
DUB
 Correctable causes of anovulation:
 - Anovulation can be secondary to other medical conditions.
 Hypothyroidism is a common cause of anovulation, diagnosed by a high TSH and
treated with thyroid replacement.
 Hyperprolactinemia, diagnosed by a serum prolactin test. An elevated prolactin
inhibits GnRH. Treatment depends on the cause of the elevated prolactin.
DUB
 Management:
 Progestin management:
o Treatment involves replacing the hormone which is lacking. These methods
help regulate the menstrual flow and prevent endometrial hyperplasia, but do
not re-establish normal ovulation
o Cyclic MPA (Medroxyprogesterone acetate): can be administered for the last
7 to 10 days of each cycle.
o Oral contraceptive pills (OCs): Estrogen-progestin oral contraceptives are
often used for convenience.
o Progestin intrauterine system (LNG-IUS): The levonorgestrel lUS (Mirena)
delivers the progestin directly to the endometrium.
DUB
 Management:
 Other managements:
 If progestin management is not successful in
controlling blood loss, the following generic methods have been
successful:
 Tranexamic acid: works by inhibiting fibrinolysis by plasmin. It is
contraindicated with history of DVT, PE or CVA, and not
recommended with E+P steroids.
 Endometrial ablation: procedure destroys the endometrium by
heat, cold or microwaves. It leads to iatrogenic Asherman syndrome
and minimal or no menstrual blood loss. Fertility will be affected.
 Hysterectomy: is a last resort and performed only after all other
therapies have been unsuccessful.

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Abnormal Uterine Bleeding

2.In reproductive age ( from puberty to menopause(

* Age: before menarche / after menopause

• Disorder of duration of flow:

- Complications of early pregnancy that are associated with

• RF: Multiparity and any process that allows for

• Enlarged , asymmetric uterus on ultrasound

 not classified in previous categories.

the diagnosis of hormonal imbalance should be

An estrogen dominant endometrium is structurally unstable as it increasingly thickens.

Stop the bleeding and prevent

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