ABNORMAL UTERINE BLEEDING

NORMAL MENSTRUAL CYCLE

NORMAL MENSTRUAL CYCLE

• Flow of 4-7 days

• Cycle length of 24-38 days
• Amount of blood loss less
than 80ml
ABNORMAL UTERINE BLEEDING
A broad term that describes irregularities in the menstrual cycle involving frequency,
regularity, duration, and volume of flow outside of pregnancy.
- International Federation of Obstetrics and Gynecology (FIGO) 2018

Abnormal uterine bleeding is a common condition, with a prevalence of 10% to 30%

among women of reproductive age

Abnormal bleeding is considered chronic when it has occurred for most of the
previous six months, or acute when an episode of heavy bleeding warrants immediate
intervention.
In premenopausal women, AUB is diagnosed when there is a substantial change in frequency,
duration, or amount of bleeding during or between periods.
In postmenopausal women, any vaginal bleeding 1 year after cessation of menses is
considered abnormal and requires evaluation.
 AETIOLOGY
STRUCTURAL NON-STRUCTURAL

Polyps Coagulopathy
Adenomyosis Ovulatory dysfunction
Leiomyoma Endometrial causes
Malignancy and Hyperplasia Iatrogenic
Not otherwise classified
POLYP(ENDOMETRIAL)
Definition: Discrete outgrowths of the endometrium that contain a variable amount of
gland stroma and blood vessels
The lifetime prevalence of endometrial polyps ranges from 8% to 35%, and their
incidence increases with age.
Intermenstrual bleeding is the most common presenting symptom, but many polyps
are asymptomatic.
Physical examination findings are typically unremarkable, except for cases in which
the polyps prolapse through the cervix.
Although they can develop into malignancy, approximately 95% of symptomatic
polyps are benign, and the risk of malignancy is even lower in premenopausal
women.
DIAGNOSIS
 Transvaginal ultrasonography (TVUS)
 Appear as hyperechogenic lesion with regular contour.
 Seen as a focal mass or nonspecific thickening.
 These findings, however, are not specific to polyps as fibroids
(submucosal) may have the same features.
 Imaging is best on the 10th day of the menstrual cycle when the
endometrium is the thinnest – to minimize false positive and
false negative results.

 Colour-flow Doppler
 Improve the diagnostic capability of TVUS
 May demonstrate the single vessel pattern
 As opposed to multiple vessel pattern seen in hyperplasia
and malignant lesions.
TREATMENT

1) Conservative
2) Polypectomy if symptomatic: Diagnostic and
therapeutic
 ADENOMYOSIS
 The presence of endometrial tissue in the myometrium of the uterus is known as
adenomyosis.
 Its prevalence ranges from 5% to 70%.
 One in three patients with adenomyosis is asymptomatic, but the rest may present
with heavy menstrual bleeding, pelvic pain, or infertility.
 Heavy menstrual bleeding is the most common symptom.
 Adenomyosis is distinct from endometriosis (the presence of endometrial glands
outside of the uterus), but the two conditions often occur simultaneously.
 Risk factors for developing adenomyosis include increasing age, parity, and history
of uterine procedures.
• Diagnosis of adenomyosis begins with clinical
suspicion and is confirmed with transvaginal
ultrasonography and pelvic magnetic
resonance imaging.
• Examination may reveal a dense, enlarged
uterus.
TREATMENT
Symptomatic treatment:
Dysmenorrhea – NSAIDs Mefenamic acid 500mg TDS
Menorrhagia – Tranexamic acid 1g TDS or QID
Suppression of menstruation – hormonal therapy
** any medical treatment that induces amenorrhea is helpful to relieve pain but
symptoms rapidly return after stopping treatment.
Patients with adenomyosis not desiring pregnancy can use a levonorgestrel-
releasing intrauterine system (Mirena) to help reduce heavy menstrual bleeding
and pain.
Hysterectomy is definitive treatment of adenomyosis for women who are past
childbearing age if other therapies are not effective.
LEIOMYOMA
Leiomyomas (also called fibroids) are benign tumors arising from the uterine
myometrium.
Their prevalence increases with age; they are eventually found in up to 80% of all
women.
Many are discovered incidentally on clinical examination or imaging in asymptomatic
women.
Most leiomyomas are asymptomatic, but bleeding is a common presenting symptom
and typically involves heavy or prolonged menses.
Larger leiomyomas are more likely to be associated with abnormal uterine bleeding.
Patients may report pelvic pain or pressure, and on examination the uterus may be
enlarged or irregularly contoured.
• Expectant management is recommended
for asymptomatic patients because most
fibroids decrease in size during menopause.
Clinical Features
 Asymptomatic (50%)
 Heavy menstrual bleeding (30%)
 Secondary dysmenorrhea
 Palpable mass +/- pressure symptoms (20-50%)
 Bladder: frequency, urgency, urinary retention
 Bowel: constipation, tenesmus
 Ureter: hydroureter / hydronephrosis
 Lower limb: varicose vein, edema
 Pelvic pain – acute due to torsion of pedunculated fibroid, or red
degeneration of fibroid during pregnancy
MALIGNANCY AND HYPERPLASIA
Endometrial cancer is the most common gynecologic malignancy.
It is the fourth most common cancer in women after breast, lung, and colorectal
cancers.
The mean age of patients at the time of diagnosis is 63 years, with 90% of cases
occurring in women older than 50 years. Only 20% of patients with endometrial
cancer receive a diagnosis before menopause.
The most common presentation for endometrial cancer is postmenopausal
bleeding.
Women with abnormal uterine bleeding should be evaluated for endometrial cancer
if they are older than 45 years or if they have a history of unopposed estrogen
exposure.
e.g. granulosa-theca cell tumors
In postmenopausal women, the endometrial thickness on transvaginal
ultrasonography should be less than 5 mm. With thickness above this level, biopsy
should be considered to rule out endometrial hyperplasia or cancer.
Protective factors include prior use of combined oral contraceptives for one or
more years and grand multiparity.
Management of risk factors such as obesity, diabetes, and hypertension could play a
role in the prevention of endometrial cancer. For women on hormone therapy, the
addition of progesterone has been shown to decrease the risk of endometrial cancer.
HISTOPATHOLOGY

Endometrial cancer is generally classified into two types.

Type I is the most common form, representing more than 70% of cases.
Type I tumors are associated with unopposed estrogen stimulation and are known as
endometrioid adenocarcinoma. These tumors are generally low grade.
Type II tumors are more likely to be high grade and of papillary serous or clear cell
histologic type. They are not linked to excess estrogen. They carry a poor prognosis
and have a high risk of relapse and metastasis.
Endometrial hyperplasia represents a precursor lesion to endometrial cancer.
Hyperplasia carries a 1% to 3% risk of progression to cancer.
DIAGNOSTIC STUDIES

1) TRANSVAGINAL ULTRASONOGRAPHY - Postmenopausal patients with endometrial

thickness greater than 5 mm should be evaluated with a tissue sample.
2) ENDOMETRIAL SAMPLING – To get the definitive diagnosis. Curettage has been
considered the preferred method, but the newer Pipelle method offers an alternative. When
an adequate sample is obtained, the Pipelle method has high diagnostic accuracy, with a
positive predictive value of 81.7% and a negative predictive value of 99.1%.
If an adequate sample cannot be obtained by pipelle method, patient will need hospital
admission for dilation and curettage.
3) SALINE INFUSION SONOHYSTEROGRAPHY - This study technique uses saline infused
into the endometrial cavity, followed by ultrasonography to allow better visualization of
structural changes, particularly when patients have focal irregularities such as polyps,
submucosal fibroids, or endometrial hyperplasia
4) HYSTEROSCOPY - direct visualization of the endometrial cavity. Hysteroscopy can
be performed in conjunction with a focal biopsy or curettage.
5) MAGNETIC RESONANCE IMAGING
COAGULOPATHY
COAGULOPATHY
Approximately 20% of patients with heavy menstrual bleeding have a bleeding disorder.
Von Willebrand disease and platelet dysfunction are the most common coagulopathies
associated with abnormal uterine bleeding.
The likelihood of a bleeding disorder increases if any of the following historical clues are
present:
Ø heavy menstrual bleeding since menarche;
Ø history of postpartum hemorrhage, surgical bleeding, or bleeding with dental procedures;
Øor two or more of the following: frequent gum bleeding, bruising > 5 cm at least monthly,
epistaxis at least monthly, or family history of abnormal bleeding
OVULATORY DYSFUNCTION
Non-cyclic uterine bleeding characterized by irregular, prolonged, and often
heavy menstruation.
It represents one of the identified causes of abnormal uterine bleeding (AUB),
a frequently encountered chief complaint in the primary care setting affecting
up to one-third of women of child-bearing age.
Though commonly observed during menarche and perimenopause, it can
present at any stage of reproductive life.
It is a diagnosis of exclusion
Causes of Anovulation – disturbance in the hypothalamic- pituitary ovarian axis

Physiologic
• Pre-adolescence – hypothalamic-pituitary- ovarian axis not yet mature
• Near menopause – precocious maturation of the follicle
Pathologic
• Hyperandrogenism (e.g., PCOS, congenital adrenal hyperplasia, androgen-
producing tumors)
• Hypothalamic dysfunction
• Anorexia
• Thyroid disease
• Primary pituitary dysfunction
ENDOMETRIAL CAUSES
Endometriosis:
 inflammatory condition caused by the presence of endometrial tissue in extra-uterine
locations and can involve bowel, bladder, and all peritoneal structures.
 Presentation of endometriosis can vary widely, from infertility in asymptomatic people to
debilitating pelvic pain, dysmenorrhea, and period-related gastrointestinal or urinary
symptoms
 ENDOMETRIOSIS
Clinical history
• Triad
• Dysmenorrhea
• Dyspareunia
• Subfertility
• Others
• Menorrhagia
• Premenstrual spotting
• Chronic pelvic pain

Physical examination
• Pelvic mass (Endometrioma)
• Tenderness on bimanual or rectovaginal examination (during
menses)
ENDOMETRIOSIS - DIAGNOSIS
• Diagnosis of endometriosis in the primary care setting is clinical and often challenging, frequently
resulting in delayed diagnosis and treatment
• Direct visualization via laparoscopy *GOLD STANDARD*
• Allows diagnosis and treatment. Laparoscopy with biopsy remains the definitive method for diagnosis
• Imaging studies
• Ultrasound scan – TVS
• MRI
Although transvaginal ultrasonography is used to evaluate endometriosis of deep pelvic sites to rule out
other causes of pelvic pain, magnetic resonance imaging is preferred if deep infiltrating endometriosis is
suspected.
 ENDOMETRIOSIS (MANAGEMENT)
Ovulation suppression can treat endometriosis-related pain; however, there is no evidence
that it improves conception compared with placebo if used up to six months before
attempted conception for patients who wish to conceive.
First-line treatment of symptoms of endometriosis is combined hormonal contraceptives +/-
NSAIDs.
 Improves symptoms in up to 80%

Second-line treatments: include gonadotropin-releasing hormone (GnRH) receptor agonists

with add-back therapy, GnRH receptor antagonists, and danazol
 Side effects: hot flashes, vaginal dryness, insomnia, bone loss, irritability
IATROGENIC •
•
Hormonal contraceptive use
Hormonal replacement
therapy
A variety of medical treatments can provoke abnormal uterine bleeding.
Hormonal contraception is the most common cause of iatrogenic uterine bleeding (i.e.,
breakthrough bleeding).
Other causative agents include
1. Non contraceptive hormone therapy,
2. Drugs that interfere with sex steroid hormone function or synthesis (e.g., tamoxifen),
3. Anticoagulants, and
4. Dopamine antagonists (e.g., tricyclic antidepressants, some antipsychotics).
 • PID

NOT OTHERWISE SPECIFIED •

•
Cervical erosions, cervicitis
Vaginal trauma
• Foreign bodies
DIAGNOSTIC EVALUATION OF AUB
The approach to patients presenting with abnormal uterine bleeding includes:
Ø assessing for hemodynamic instability and anemia
Ø identifying the source of bleeding,
Ø pregnancy testing
Ø determining whether evaluation for endometrial carcinoma is indicated
The broad differential diagnosis necessitates a detailed history and physical examination.

q BLEEDING HISTORY
Heavy menstrual bleeding is defined as more than 80 mL of total blood loss, but quantitative
assessment is impractical in routine clinical practice. Historical clues such as passing blood clots or
changing pads/tampons at least hourly suggest heavy menstrual bleeding.
A history of postcoital bleeding may indicate cervicitis, ectropion, or, rarely, cervical cancer, whereas
abdominopelvic pain may suggest infection, structural lesions, or endometriosis
q PHYSICAL EXAMINATION
An examination of the pelvis, including speculum and bimanual examinations, is an
important aspect of the evaluation of abnormal uterine bleeding.
Examine all potential bleeding sites, including the urethra, perineum, and anus.
Cervical cancer screening should be performed if it is not up to date.
q LABORATORY TESTING
1) UPT
2) FBC – check for anaemia and thrombocytopenia.
3) Thyroid function test
4) Prolactin, androgens, estrogen - indicated only if history or examination findings
suggest a specific hormonal cause.
5) Coagulation profile
6) Endometrial sampling:
ØAll patients with abnormal uterine bleeding who are 45 years or older.
Ø Younger women should undergo sampling if they have a history of unopposed
estrogen exposure, if medical management fails, or if bleeding symptoms persist.
Øhysteroscopic dilation and curettage - should be performed if symptoms persist
despite normal biopsy results or inadequate sampling by pipelle method

q IMAGING
Ø1) Transvaginal ultrasonography
Ø2) Saline infusion sonohysterography (the infusion of sterile saline into the
endometrial cavity while transvaginal ultrasonography is performed)
Ø3) Magnetic resonance imaging
 TREATMENT OPTIONS FOR MEDICAL MANAGEMENT
OF ABNORMAL UTERINE BLEEDING
1) Tranexamic acid - the main mechanism of action is anti-fibrinolytic activity.
2) NSAIDs – Mefenamic Acid
Ø NSAIDs reduce prostaglandin levels, which are elevated in women with excessive
menstrual bleeding. It was suggested that they might help with heavy bleeding and
may have a beneficial effect on painful menstrual periods.
Ø The endometria of women with excessive menstrual bleeding have higher levels of
prostaglandin E2 and prostaglandin F2α when compared with women
with normal menses
3) Progestin – e.g. Dienogest (Visanne)
- it works by suppressing oestradiol production and preventing the growth
of the endometrium
- taken 1 tablet daily without any break, at the same time each day with some liquid
as needed.
- used especially for endometriosis-associated pelvic pain.
CASE DISCUSSION
A YOUNG GIRL WITH HEAVY MENSES
A 13-year-old, single, nulliparous girl complained of prolonged menses for 2 months.
Her menses lasted for 14 to 18 days each cycle. She was using 4 pads per day and
all pads are fully soaked with blood clots. She also complained of palpitation for 1
week which was associated with dizziness and lethargy. Her mother noticed that the
patient was pale after coming back from school hence brought the patient to
Emergency Department. Otherwise, no shortness of breath, no chest pain, no fever
and no other bleeding tendency. She attained her menarche at 13 years old.

At ED, o/e: alert, pale, not tacypnic Investigations:

Vital signs - BP: 136/42mmHg FBC: Hb 4.2g/dL / WBC: 12.7/ Platelet: 485
PR: 111/min ECG: sinus arrythmia
T: 36.8 TAS: Uterus anteverted 5x3cm
ET: 5mm
SPO2: 98% under RA
No free fluid
1) What further history would you like to asked?

2) What is your differential diagnosis?

3) How would you examined the patient?

4) What is the treatment and management for this patient?

THANK YOU! 