Nepalese Army Institute of Health Science

College of Nursing
Affiliated to Tribhuvan University, IOM
Sanobharyang, Bhandarkhal,
Kathmandu

CASE STUDY ON ABNORMAL UTERINE

BLEEDING
In
SHREE BIRENDRA HOSPITAL

Submitted to: Submitted by:

Prof. Subhadra Shrestha Pradhan Goma Syangtan

NAIHS, CON MN 1st Year

6th Batch, NAIHS, CON

ACKNOWLEDGEMENTS

I would like express my sincere thanks to Brigadier General Sumitra Mulepati. Principal of
Nepalese Army Institute of Health Science (NAIHS). Sanobharyang. Kathmandu for providing
me an opportunity of advanced learning in Women’s Health and Development.

I pay my deep sense of gratitude to Professor Dr. Sushila Bhandari, Program Coordinator of
NAIHS Professor Subhadra Pradhan Shresth, Clinical Coordinator for providing clinical learning
opportunity in Shree Birendra Hospital. Chhauni, Kathmandu. I feel to acknowledge and deep
sense of gratitude to my respected teachers Prof. Subhadra Pradhan Shrestha whose expertise
was invaluable and the guidance and kind supervision given to me throughout the course has
shaped the present work.

I am thankful to sister in charge Bhawani and all the staffs of Postnatal Gynae Ward of Shree
Birendra Hospital for their cooperation and support during my clinical practice. My special
thanks go to Ms. Tara kumari Giri Bista and her family for their wonderful support during my
case study period, despite of hospitalization stress, without whom this case study will not be
possible.
OBJECTIVES OF THE CASE STUDY

GENERAL OBJECTIVE

The general objective of doing this case study is to obtain detail information on AUB (abnormal uterine
bleeding) identifying its causes, sign and symptoms, complications, nursing management and also
provide holistic nursing care.

SPECIFIC OBJECTIVES

 To fulfills the partial requirement of course or curriculum.

 To collect information regarding the bio demography and present/past history of the patient.
 To obtain detail knowledge about disease condition; including signs and symptoms cause
complications, medical and nursing management.
 To gain knowledge upon various diagnostic procedures performed regarding the disease.
 To identify the normal growth and development of middle adulthood according their age as per
specific normal developmental tasks.
 To provide holistic care to the patient by using nursing process and suitable nursing theory.
 To gain detail knowledge on drugs used in my case.
 To observe client progress and management of case.
 To give informal health teaching to patient and families.
 To collaborate with the patient, family members and health team members in discharge
planning for continuing and home- based care.
 To share experience and knowledge to friends and supervisors.
 To get feedback from the friends and supervisors for further improvement.

BACKGROUND

 As a Master of Nursing curriculum and under practicum of Women health development in Shree
Birendra Hospital we have to perform one case study on Gyane Ward. Therefore, I had chosen a
case of Abnormal Uterine Bleeding (AUB) with severe anemia.
 I had performed the complete case study of the patient and her disease. For this I had consulted
many books and website and compared it with the patients. Thus, case study includes the
demographic data, pertinent findings on physical examination, disease condition (etiology, sign
and symptom, pathophysiology, its management).
 It is designed to gain comprehensive knowledge about the disease, acquire knowledge and
attitude relevant to the professional roles.
RATIONAL OF CASE SELECTION

 One of the most common gynecological complaints worldwide is the occurrence of abnormal
uterine bleeding (AUB), With a prevalence of 10-30% among women of reproductive age, it can
negatively affect the quality of life and is associated with financial losses, reduced productivity,
inadequate health status and greater use of health services.
 Anemia is one of the most common problems in clinical practice that affects millions of people
worldwide.
 Non-pregnant women account for 30% of all anemia cases in the world, and approximately 60%
of them have ID.
 A descriptive cross-sectional study conducted in the Out-patient Department (OPD) of the
Department of Obstetrics and Gynecology of Lumbini Medical College and Teaching Hospital of a
tertiary care hospital (LMCTH), Palpa, Nepal. The data were collected over a period of nine
months from August 1, 2020 to April 23, 2021. Among 2680 women visiting the gynecology
outpatient department, the prevalence of abnormal uterine bleeding was 240 (8.9%) (7.82-9.98
at 95% Confidence Interval).
 An analytical study of abnormal uterine bleeding in women of child bearing age group was done
by Department of OBGY, AMC MET Medical College, L. G. Hospital, Maninagar, Ahmedabad,
Gujarat, India. 200 cases of AUB fitting the selection criteria were taken from OPD and
gynecology ward between September 2020 to June 2021. Results: AUB was more common in
the age group 41-45 years, that is, perimenopausal age group, more in multiparous women and
women with previous surgeries on uterus and adnexa. Heavy menstrual bleeding was the most
common complaint. Endometrial hyperplasia was the most common finding on ultrasound
examination. Medical therapy was beneficial in some patients, rest had to undergo surgical
intervention later.
 A Descriptive observational study conducted in the department of Obstetrics and Gynecology,
Malla Reddy Teaching Tertiary Care Hospital from August 2023 to January 2024. There were 153
cases in the study. Details of each patient were recorded and analyzed with respect to age,
parity, patterns, AUB according to PALM-COEIN, symptoms, treatment options and Patients
were evaluated with menstrual history, physical examination, laboratory tests, pre and post iron
supplementation for 4 weeks. and Patients were followed up from 1 to 2 months. The study
shows that the age range of 41-45 years old has the highest prevalence of AUB (44%), AUB and
anaemia are significantly correlated (by 60%) moderate anaemia patients are more , 25% of
patients had mild anaemia. Iron Supplementation Efficacy is beneficial in controlling
hematologic issues caused by AUB, as evidenced by the 80% of cases in which anaemia was
successfully corrected. So AUB is a widespread problem that impacts millions of women globally.
The prevalence varies between age groups, classification of AUB as per PALM-COEIN, patterns
are identified by symptoms of the patient.
HISTORY TAKING

A. BIO-DEMOGRAPHIC DATA:

 Name :Tara Kumari Giri Bista

 Age/Sex :49yrs/ Female
 Educational status : 10 class
 Occupation : House Maker
 Religion : Hindu
 Marital status : Married
 Address : Nawalparasi
 Ward : Gynae Ward
 Inpatient number : SBHF82292
 Date of admission :081-04-31
 Date of Interview :081-05-2
 Final diagnosis : AUB with severe Anemia
 Consultant’s name : Col. Dr. Roshani Malla
 Informant : Her Son and patient herself

CHIEF COMPLAINTS

Excessive PV bleeding during mensuration by 3 years.

HISTORY OF PRESENTING ILLNESS

My patient was apparently well 3 years back when she developed excessive PV bleeding during minses
which was insidious on onset, requiring about 10-12 fully soaked pads. There was no exacerbation and
relieving factors, associated with lower abdominal pain, dysmenorrhea, burning micturition and urinary
urgency. No history of PV discharge, epigastric pain and fever

OBSTETRIC HISTORY

She reported that she had 2 children 18 year old son and 14 years old son and she delivered both
normal vaginal delivery at hospital. According to her there were no any complication arise during
pregnancy delivery and in postnatal period.

CONTRACEPTIVE HISTORY
She reported that she used to take oral pills for 14 years back for 2 months but she left due to excessive
irregular bleeding and now she does not use any device except natural methods .

MENSTRUAL HISTORY

• Age of menarche : 12 years.

• Menstrual cycle : Irregular
• Amount of blood flow : Excessive (10-12 pads) with clots
• Duration of bleeding : 10-15days
• Dysmenorrhea : present
• LMP :2081/04/10

Gynecological history: Known case of AUB, type II DM with Fibroid uterus.

Past medical history: She did not have any significant medical history

Past surgical history: She did not have any significant surgical history.

Personal History

Habits: The patient is a non-smoker, non-alcohol. Her bladder and bowel habit is normal.

Diet: Patient is a non-vegetarian, consumes mixed diet and no known food allergies.

Rest and Sleep Pattern: normal sleep awake cycle.

Activities of daily living: patient can care of herself and perform daily activities such as eating,
grooming, dressing, elimination walking, food preparation, shopping, transportation, laundry etc.

FAMILY HISTORY

She lives in with her husband and 2 sons

 No significant similar illness in family

 HTN in father
 The patient is from middle class family.
 Her family member has positive attitude towards her illness.
 Type of Family- Nuclear
 Number of family member-4
FAMILY TREE

P
aternal side Maternal side
SOCIOECONOMIC STATUS:

Economic status is adequate

• Type of housing : - Cemented house

• Number of Rooms : - 8 rooms
• Fuel : - Gas
• Kitchen : - Separate
• Type of toilet : - Bore hole latrine
• Source of water : -Tap water
• Water purification : - Filtration
• Refuse disposal method: - Municipality tanker

DEVELOPMENTAL TASK

As my patient is of 41years, she belongs to middle aged Adulthood (30 to 60 years) Developmental Tasks
Comparison with patient.
According to book According to patient
Maintaining healthy living patterns comfortable She is partially maintaining healthy living patterns
home environment and comfortable home environment

Establishing and maintaining an economic She has maintained an economic standard of

standard of living. living.
Assisting teen-age children to become She is assisting ten age children to become
responsible and happy adults. responsible and happy adults
Developing adult leisure, time activities She uses her leisure time talking with other
people and family

Accepting and adjusting to the physiological She has accepted and adjusting to the
changes of middle age physiological changes
Adjusting to ageing parents She has adjusted to ageing parents
PHYSICAL EXAMINATION

Head to toe examination was done. The techniques used for physical examination are inspection,
palpation, percussion, auscultation and neurological measurement.

The complete head to toe physical examination of the patient was performed on 2080/05/03.

General Assessment:

 State of consciousness and alertness: The client is fully awake and alert. The client is well
oriented to time, place, and person.
 Gait: Normal balanced.
 Posture: normal.
 Limb movements are bilaterally.
 General build: Average
 Facial expression: Eyes are alert and in contact.
 Hygiene state: Hair, skin, and clothing are clean, well-groomed, and appropriate for the
occasion.
 Speech is normal.
 Capillary refill time: less than 2 second.

Measurement:

 Height: 5.5 fit

 Weight: 64kg
 Body Temperature: 98.20 F
 Pulse: 78/min
 Respiration: 22/min
 Blood Pressure: 90/70mmHg
 Spo2: 98% in room air
 Nutritional status: BMI: 27.94kg/m2,

Integumentary system

Inspection of skin for

  Color: uniform fair skin color all over the body.
 Skin is intact
 Pallor but no cyanosis, redness.

 No any lesions or any patches

 Moisture: No excessive sweating or dehydration
 Hair distribution was evenly distributed
 Edema: Not present
 No scar, injury or wound

Palpation of skin for

 Temperature: warm and uniform

 Skin turgor: Normal skin elasticity (skin recoil immediately after pinching)

Examination of Nail:

Inspection

 Fingernails and toenails: Nails were pink color, no any discoloration

 Plate shape: no clubbing of finger nails

Examination of head, face and neck:

Inspection of hair and scalp

Hair for:

 Color, texture, growth, distribution: Black fine texture, evenly distributed and clean.
 Pediculosis: Not present
 No any abrasions/ injuries, scar on scalp
 Amount of body hair: Normal

Skull

 Inspection :Head is symmetrical, and erect in the midline.

 Palpation: Smooth uniform consistency, absence of masses or nodules, swelling, depressions,
lumps or tenderness.
Face

 Inspection : anxious facial expression

 Symmetric facial structures, symmetric nasolabial folds, some fine wrinkles on forehead
 Symmetric facial movements
 No Involuntary movement
 No any edema, masses/ nodules

EYE

 No deviation and abnormal alignment, any discharge or excessive tearing or dryness in both
eyes.
 Eyebrows and eyelashes: Equal distribution in both sides, no scaliness.
 Eyelid: No edema, redness lesions and any deviation
 Patient can read newspaper without difficulty, no blurring of vision.

Ear:

Inspection

 Location of ears, shape, size and symmetry: The imaginary line drawn from the outer canthus of
eyes cross the top of the pinnae, symmetrical,
 No any ear discharge, redness, bleeding, mass, foreign body noted and slight cerumen (wax)
present, patent

Palpation

 Auricles for texture, elasticity and areas of tenderness: Mobile, firm and non -tender. Pinna
recoils after it is folded.
 Pre-auricular and post auricular lymph node for tenderness: Tenderness not noted

Auditory function

 Voice test: The client repeats each word correctly after whispering slowly two syllable word at
30 - 60 cm distance from client's ear.

Nose and sinuses

Inspection
  External nose: No any deviation and flaring.
 Nasal canal: Dark pink mucous membrane. Redness, swellings, discharge, bleeding or foreign
bodies not present, polyp not present

Palpation

 External nose: No any tenderness, masses, lesion and displacements of bone and cartilage.na
sinuse tenderness.

Mouth and throat

Inspection

 Lips color and moisture: Pinkish, moist & intact skin. No any lumps, ulcers and cracking
 Oral mucosa and gums: Dry mucous membrane, pink color in both oral mucosa and gums.
Ulcers, swelling, bleeding not present
 Teeth: No any missing, discolored, dental carries, loosened, misshapen or abnormally positioned
teeth.
 Tongue: Central position; Pink, moist, papillae and midline fissure present and symmetrical.
Smooth lateral margins; no lesion, freely; no tenderness
 palate, anterior and posterior pillars, uvula, tonsils, and pharynx: pink/ symmetry. Exudates,
swelling, ulceration or tonsillar enlargement and tenderness not present

Palpation

 Sub-mental and sub-mandibular lymph node: Not palpable

Neck:

Inspection

 Mobility, Stiffness (ROM): No tilting of head, full and smooth range of movement, no stiffness or
tenderness, no jugular vein distended.
 Thyroid gland for contour and symmetry: Not visible on inspection, gland ascends (upward
movement) during swallowing but is not visible

Palpation

 Carotid pulse: palpable, normal volume and strength, bilaterally uniform

 Neck for enlarged lymph nodes in Superficial anterior cervical, Posterior cervical, Deep cervical,
Supraclavicular: Not palpable
 Trachea: no lateral deviation.
  Thyroid gland for smoothness, enlargement, masses or nodules: Nodules not palpable.
 No pain and tenderness; and rises freely with swallowing.

Examination of Chest:

Inspection

 Size and shape: Transverse diameter is greater than anterio-posterior diameter

 Symmetry, location of sternum: Symmetrical shape, sternum is located at the midline.
 Spinal alignment: Spine vertically aligned.
 Equal movement of chest during breathing (chest expansion and chest retraction) noted
 Difficulty in breathing: Not Present
 Cough reflex: Present

Breast

 Both breast are equal in shape and size.

 On palpation: no abnormal mass or nodules are present, no milk secretion

Palpation

 Chest wall intact, No tenderness, lumps or depression

 Tactile (vocal) fremitus: Bilateral symmetry of vocal fremitus

Percussion

 Percussion notes resonant, except over scapula- flatness, percussion on ribs elicits dullness

Auscultation

 Chest for breathing sounds: Normal vesicular breathing sound, bronchial breathing sound,
broncho-vesicular sound (tracheal sound), bilateral equal air entry
 Adventitious breath sound crackles, wheezing, rhonchi: Not present
 Heart sound in all 4 valve areas: Mitral, Tricuspid, Aortic, Pulmonic
 Clear and heart rate between 78 beats/min.
 Murmur sound present, S3, S4 not present

Examination of abdomen

Inspection
  Size/ Shape: rounded abdominal contour. No swelling and visible blood vessels, abdominal
mass, distension absent.

Auscultation

 Bowel sounds in all 4 quadrants: Bowel sound present in all areas (irregular gurgling noises
occurring about every 5 to 20 second

Percussion

Abdomen for dull or tympanic sounds: Tympany due to presence of gas within the stomach, small
bowel, colon and dullness in solid areas Rt Hypochondrium, Lt. Hypochondrium

Palpation

 Abdominal guarding Absent. Liver was not palpable and tender.

 Spleen was non palpable and tender.
 Kidneys not palpable and tender

Examination of limbs and back

Inspection

 Shape and size: bilateral equal

 No bone or joint deformities, no redness or swelling of joints.
 Spine for its placement: Spine is in the midline,

Palpation

 Normal movement of lower side joint freely

Genital

 No itching, no foul smelling, no PV discharge and save pads.

Nervous system

Inspection

 Muscle strength: 5/5, equal strength in both hands and rt. Feet but 2/5 on left leg.
 Sensation: touch, pain, taste, smell: Intact (Feels light brush of the cotton equally on both sides
of his body)

Reflexes (deep tendon and superficial)

  Bicep reflex (C5-C6): Intact contraction of the biceps muscle and flexion of the forearm)
 Triceps reflex (C7-C8): Intact (extension of the forearm)
 Brachioradialis reflex (C3-C6): Intact (flexion and supination of the forearm)
 Knee jerk or patellar reflex (L2-L4): Intact (extension of the lower leg)
 Achilles or ankle jerk reflex (S1-S2): intact (is the foot planter flexes against examiner’s hand)
 Planter reflex (L4-S1): Intact (planter flexion of all the toes and inversion and flexion of the
forefoot)

Summary of physical examination

A complete physical examination from head to toe was performed in the patient at bedside using basic
techniques of inspection, palpation, auscultation and measurement. Patient was conscious, alert,
oriented to time, place and person.
Abnormal Uterine Bleeding (AUB)

Abnormal uterine bleeding is a broad term that describes irregularities in the menstrual cycle
involving frequency, regularity, duration, and volume of flow outside of pregnancy.
Up to one-third of women will experience abnormal uterine bleeding in their life, with
irregularities most commonly occurring at menarche and perimenopause.
A normal menstrual cycle has a frequency of 24 to 38 days and lasts 2 to 7, with 5 to 80
milliliters of blood loss. Variations in any of these 4 parameters constitute abnormal uterine
bleeding. This activity reviews abnormal uterine bleeding diagnosis and treatment and explains
the importance of an interprofessional approach to evaluating and treating abnormal uterine
bleeding.
Revisions to the terminology were first published in 2007, followed by updates from the
International Federation of Obstetrics and Gynecology (FIGO) in 2011 and 2018. The FIGO
systems first define abnormal uterine bleeding, then give an acronym for common etiologies.
These descriptions apply to chronic, nongestational AUB.
Abnormal uterine bleeding can also be divided into acute versus chronic. Acute AUB is excessive
bleeding that requires immediate intervention to prevent further blood loss. Acute AUB can
occur on its own or superimposed on chronic AUB, which refers to irregularities in menstrual
bleeding for most of the previous 6 months.[2]
Abnormal uterine bleeding is one of the common health concern affecting women of
reproductive age leading to large demand in the Gynaecology department(1) .
Abnormal uterine bleeding refers to the bleeding from the uterus that can be present in ways
from
infrequent episodes, to excessive flow or prolonged duration. The etiology varies with age, parity
and
may be attributed to both structural and non-structural causes(PALM COEIN)according to FIGO
classification(2) .It is a very frequent complaint that negatively affects the quality of life, hence,
investigation for IDA is mandatory in these patients. Anaemia, characterized by a deficiency of
red
blood cells or hemoglobin, is a prevalent health concern affecting women worldwide in
association with
abnormal uterine bleeding. The document includes a comprehensive summary of the most recent
research on the diagnosis, symptoms, investigations, causes, and management of AUB. The
purpose of
the recommendations, which include a list of side effects and indications for large blood loss, is
to
address the need to improve the lives of women. The objectives of education are supported by
the

evaluated literature from many sources(

Etiology

PALM-COEIN is a useful acronym provided by the International Federation of Obstetrics and

Gynecology (FIGO) to classify the underlying etiologies of abnormal uterine bleeding. The first
 portion, PALM, describes structural issues. The second portion, COEI, describes non-structural
issues. The N stands for "not otherwise classified."

P: Polyp

A: Adenomyosis

L: Leiomyoma

M: Malignancy and hyperplasia

C: Coagulopathy

O: Ovulatory dysfunction

E: Endometrial disorders

I: Iatrogenic

N: Not otherwise classified

One or more of the problems listed above can contribute to a patient's abnormal uterine bleeding.
Some structural entities, such as endocervical polyps, endometrial polyps, or leiomyomas, may be
asymptomatic and not the primary cause of a patient's AUB.

In the 2018 FIGO system, AUB secondary to anticoagulants was moved from the coagulopathy category
to the iatrogenic category.

Conditions to be included in the not otherwise classified category include pelvic inflammatory disease,
chronic liver disease, and cervicitis.

AUB not otherwise classified contains rare etiologies and includes arteriovenous malformations (AVMs),
myometrial hyperplasia, and endometritis.[1]

Epidemiology

The prevalence of abnormal uterine bleeding among reproductive-aged women internationally is

estimated to be between 3% to 30%, with a higher incidence occurring around menarche and
perimenopause. Many studies are limited to heavy menstrual bleeding (HMB), but when irregular and
intermenstrual bleeding are considered, the prevalence rises to 35% or greater.[1] Many women do not
seek treatment for their symptoms, and some components of diagnosis are objective while others are
subjective, making exact prevalence difficult to determine.[3]

Pathophysiology

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. Functioning platelets, thrombin, and
vasoconstriction of the arteries to the endometrium 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.[4]

Evaluation

Laboratory testing can include but is not limited to a urine pregnancy test, complete blood count,
ferritin, coagulation panel, thyroid function tests, gonadotropins, and prolactin.

Imaging studies can include transvaginal ultrasound, MRI, and hysteroscopy. Transvaginal ultrasound
does not expose the patient to radiation and can show uterus size and shape, leiomyomas (fibroids),
adenomyosis, endometrial thickness, and ovarian anomalies. It is an important tool and should be
obtained early in the investigation of abnormal uterine bleeding. MRI provides detailed images that can
prove useful in surgical planning, but it is costly and not the first-line choice for imaging in patients with
AUB. Hysteroscopy and sonohysterography (transvaginal ultrasound with intrauterine contrast) are
helpful in situations where endometrial polyps are noted, images from transvaginal ultrasound are
inconclusive, or submucosal leiomyomas are seen. Hysteroscopy and sonohysterography are more
invasive but can often be performed in office settings.

Endometrial tissue sampling may not be necessary for all women with AUB but should be performed on
women at high risk for hyperplasia or malignancy. An endometrial biopsy is considered the first-line test
in women with AUB who are 45 years or older. Endometrial sampling should also be performed in
women younger than 45 with unopposed estrogen exposure, such as women with obesity and/or
polycystic ovarian syndrome (PCOS), as well as a failure of treatment or persistent bleeding.[2]
Treatment / Management

Treatment of abnormal uterine bleeding depends on multiple factors, such as the etiology of the AUB,
fertility desire, the clinical stability of the patient, and other medical comorbidities. Treatment should be
individualized based on these factors. In general, medical options are preferred as initial treatment for
AUB.

For acute abnormal uterine bleeding, hormonal methods are the first line in medical management.
Intravenous (IV) conjugated equine estrogen, combined oral contraceptive pills (OCPs), and oral
progestins are all options for treating acute AUB. Tranexamic acid prevents fibrin degradation and can
be used to treat acute AUB. Tamponade of uterine bleeding with a Foley bulb is a mechanical option for
the treatment of acute AUB. It is important to assess the patient's clinical stability and replace volume
with intravenous fluids and blood products while attempting to stop the acute abnormal uterine
bleeding. Desmopressin, administered intranasally, subcutaneously, or intravenously, can be given for
acute AUB secondary to the coagulopathy von Willebrand disease. Some patients may require dilation
and curettage.

Based on the PALM-COEIN acronym for etiologies of chronic AUB, specific treatment options for each
category are listed below:

Polyps are treated through surgical resection.

Adenomyosis is treated via hysterectomy. Less often, adenomyomectomy is performed.

Leiomyomas (fibroids) can be treated through medical or surgical management depending on the
patient's desire for fertility, medical comorbidities, pressure symptoms, and distortion of the uterine
cavity. Surgical options include uterine artery embolization, endometrial ablation, or hysterectomy.
Medical management options include a levonorgestrel-releasing intrauterine device (IUD), GnRH
agonists, systemic progestins, and tranexamic acid with non-steroidal anti-inflammatory drugs (NSAIDs).

Malignancy or hyperplasia can be treated through surgery, +/- adjuvant treatment depending on the
stage, progestins in high doses when surgery is not an option, or palliative therapy, such as
radiotherapy.
Coagulopathies leading to AUB can be treated with tranexamic acid or desmopressin (DDAVP).

Ovulatory dysfunction can be treated through lifestyle modification in women with obesity, PCOS, or
other conditions in which anovulatory cycles are suspected. Endocrine disorders should be corrected
using appropriate medications, such as cabergoline for hyperprolactinemia and levothyroxine for
hypothyroidism.

Endometrial disorders have no specific treatment, as mechanisms are not clearly understood.

Iatrogenic causes of AUB should be managed based on the offending drug and/or drugs. If a certain
contraception method is the suspected culprit for AUB, alternative methods can be considered, such as
the levonorgestrel-releasing IUD, combined oral contraceptive pills (in monthly or extended cycles), or
systemic progestins. If other medications are suspected and cannot be discontinued, the
aforementioned methods can also help control AUB. Individual therapy should be tailored based on a
patient's reproductive wishes and medical comorbidities.

Not otherwise classified causes of AUB include entities such as endometritis and AVMs. Endometritis can
be treated with antibiotics and AVMs with embolization.[2][4][5]

Differential Diagnosis

Any bleeding from the genitourinary tract or gastrointestinal tract (GI tract) can mimic abnormal uterine
bleeding. Therefore, bleeding from other sources fits into the differential diagnosis and must be ruled
out.

The differential diagnosis for genital tract bleeding based on anatomic location or system:

Vulva: Benign growths or malignancy

Vagina: Benign growths, sexually transmitted infections, vaginitis, malignancy, trauma, foreign bodies

Cervix: Benign growths, sexually transmitted infections, malignancy

Fallopian tubes and ovaries: Pelvic inflammatory disease, malignancy

Urinary tract: Infections, malignancy

Gastrointestinal tract: Inflammatory bowel disease, Behçet syndrome

Pregnancy complications: Spontaneous abortion, ectopic pregnancy, placenta previa

Uterus: Etiologies of bleeding arising from the uterine corpus are listed in the acronym PALM-COEIN[1]
[2][6]

Go to:

Prognosis

The prognosis for abnormal uterine bleeding is favorable but also depends on the etiology. The main
goal of evaluating and treating chronic AUB is to rule out serious conditions such as malignancy and
improve the patient's quality of life, keeping in mind current and future fertility goals and other
comorbid medical conditions that may impact treatment or symptoms. Prognosis also differs based on
medical versus surgical treatment. Non-hormonal treatment with anti-fibrinolytic and non-steroidal anti-
inflammatory medications has been shown to reduce blood loss during menstruation by up to 50%.[5]
Oral contraceptive pills can be effective, but there is a lack of data from randomized trials. For women
with heavy menstrual bleeding as their primary symptom of AUB, the levonorgestrel-releasing IUD has
been proven to be more effective than other medical therapies and improves the patient's quality of life.
Injectable progestogens and GnRH agonists can produce amenorrhea in up to 50% and 90% of women,
respectively. However, injectable progestogens can produce the side effect of breakthrough bleeding,
and GnRH agonists are usually only used for a 6-month course due to their side effects in producing a
low estrogen state.[5]

With the surgical techniques, randomized clinical trials and reviews have shown that endometrial
ablation controlled bleeding more effectively at 4 months postoperatively, but at 5 years, there was no
difference compared to medical management. When trials have compared hysterectomy versus
levonorgestrel-releasing IUD, the hysterectomy group had better results at 1 year. There was no
difference in the quality of life seen at 5 and 10 years, but many women in the levonorgestrel-releasing
IUD group had undergone a hysterectomy by 10 years.[5]

Complications

Complications of chronic abnormal uterine bleeding can include anemia, infertility, and endometrial
cancer. Acute abnormal uterine bleeding, severe anemia, hypotension, shock, and even death may
result if prompt treatment and supportive care are not initiated.

Consultations
Consultations with obstetrics and gynecology should be initiated early on for proper evaluation and
treatment. Depending on the etiology of abnormal uterine bleeding, other specialties may need to
become involved in patient care. For coagulopathies, consultations with hematology/oncology are
warranted. If the patient wishes to undergo a uterine artery embolization, Interventional radiology will
need to be consulted. Malignancy may require both gynecologic oncology and hematology/oncology
specialties for proper treatment.

Deterrence and Patient Education

Worldwide, many women do not report abnormal uterine bleeding to their healthcare providers, so it is
important to foster an environment of open discussion on menstruation. Primary care physicians should
ask women about their last menstrual cycle, regularity, desire for fertility, contraception, and sexual
health. If abnormal uterine bleeding can be identified at the primary care level, then further history,
examination, and testing can be performed, and the proper consultations can be arranged.

Patients with abnormal uterine bleeding should be educated on any pertinent lifestyle changes,
treatment options, and when to seek emergency care.

Pearls and Other Issues

Abnormal uterine bleeding is common among women worldwide. A detailed history is an important first
step in evaluating a woman who presents with AUB, and clinicians should be familiar with the normal
pattern of menstruation, including frequency, regularity, duration, and volume of flow. After a detailed
history is obtained and a physical exam is performed, further tests and imaging may be warranted
depending on the suspected etiology. PALM COEIN is a useful acronym for common etiologies of AUB,
with PALM representing structural causes (polyps, adenomyosis, leiomyomas, and malignancy or
hyperplasia) and COEIN representing non-structural causes (coagulopathies, ovulatory disorders,
endometrial disorders, iatrogenic causes, and not otherwise classified). Women older than 45 years of
age or women younger than 45 with risk factors for malignancy require endometrial sampling as part of
the evaluation for AUB. Treatment is based on etiology, desire for fertility, and medical comorbidities.

Enhancing Healthcare Team Outcomes

Health professionals should coordinate care in an interprofessional approach to evaluate and treat
women with abnormal uterine bleeding. Nurses and physicians in primary care, such as family medicine
and internal medicine, might be the first to discover AUB and should consult with obstetrics and
gynecology early on. Patients should be informed of all of their options for control of AUB based on
etiology. A detailed discussion concerning the desire for fertility, medical versus surgical management,
and prognosis should be conducted. Physicians and pharmacists should educate patients concerning any
possible side effects of medical management.

The American College of Obstetrics and Gynecology (ACOG) has published a summary of
recommendations and conclusions concerning abnormal uterine bleeding. [6]

Level A Recommendations (Level I evidence or consistent findings from multiple studies of levels II, III, or
IV):

Sonohysterography is superior to transvaginal ultrasound in detecting intracavitary lesions, such as

polyps or submucosal leiomyomas.

For all adolescents with heavy menstrual bleeding and adults with a positive screening history for a
bleeding disorder, lab tests should be performed, including a CBC with platelets, prothrombin time, and
partial thromboplastin time; bleeding time is neither sensitive nor specific and is not indicated.

Level B Recommendations (Levels II, III, IV evidence and findings are generally consistent):

Testing for Chlamydia trachomatis should be considered in patients at high risk of infection.

Hypothyroidism and hyperthyroidism are associated with AUB. Screening for thyroid disease with TSH in
women with AUB is reasonable and inexpensive.

Level C Recommendations (Levels II, III, or IV evidence, but findings are inconsistent):

Endometrial sampling should be performed in patients with AUB older than 45 years as a first-line test.

The ACOG supports adopting the PALM-COEIN nomenclature system developed by FIGO to standardize
the terminology used to describe AUB.

Some experts recommend transvaginal ultrasound as the initial screening test for AUB and MRI as
second-line options when the diagnosis is inconclusive. Further delineation would affect patient
management, or coexisting uterine myomas are suspected.

MRI may be useful to guide the treatment of myomas, particularly when the uterus is enlarged, contains
multiple myomas, or precise myoma mapping is clinically important. However, the benefits and costs
must be weighed when considering its use.
Persistent bleeding with a previous benign pathology, such as proliferative endometrium, usually
requires further testing to rule out nonfocal endometrial pathology or a structural pathology, such as a
polyp or leiomyoma.

ABSTRACT

Background: AUB (abnormal uterine bleeding) is defined as any variation from the normal menstrual
cycle including alteration in its frequency, regularity of menses, duration of flow and amount of blood
loss. In India, the reported prevalence of AUB is 17.9%. It can occur any time between menarche to
menopause. A good clinician tries to recognize and identify the causative factors responsible for the
disease, reverse the abnormality and induce or restore the cyclic predictable menses which should have
normal volume and duration.

Methods: 200 cases of AUB fitting the selection criteria were taken from OPD and gynecology ward
between September 2020 to June 2021.

Results: AUB was more common in the age group 41-45 years, that is, perimenopausal age group, more
in multiparous women and women with previous surgeries on uterus and adnexa. Heavy menstrual
bleeding was the most common complaint. Endometrial hyperplasia was the most common finding on
ultrasound examination. Medical therapy was beneficial in some patients, rest had to undergo surgical
intervention later.

Conclusions: Transvaginal sonography is very accurate in assessing the endometrium as well as uterus
and adnexa and diagnosing their abnormalities. Medical therapy is the first line of management in most
cases. Dilatation and curettage should be used along with hysteroscopy for better results. LNG-IUS gives
very good result in suitable cases. Hysterectomy is the final measure if everything else fails. Vaginal
hysterectomy is preferred wherever possible.