ABNORMAL

UTERINE
BLEEDING - PAL
Group 5 - Subgroup 1
ESPECTATO, CRUZ, DULAY, PITAGAN,
BASKARAN, GASTARDO, VISPERAS, CARAMBAS,
NAVALTA, THANAPAL
 Table of contents
01
Introduction

02 03 04
Polyps Adenomyosis Leiomyoma
 01
INTRODUCTION
ABNORMAL UTERINE BLEEDING
Infrequent episodes

Prolonged duration Intermenstrual

bleeding

Excessive flow
 REVIEW: NORMAL MENSTRUAL BLOOD FLOW
○ Mean duration of the menstrual cycle is 28 ‡ 7 days.
○ Average menstrual blood loss (MBL) is 35 mL. (normal value: 10-80ml)
○ Average number of days of menses: 4 days (normal range: 2-7 days)
ABNORMAL UTERINE BLEEDING(AUB)
• Bleeding is abnormal/heavy if:
• it occurs at intervals of 21 days or less, or 35 days or more;
• Lasts longer than 7 days;
• MBL of 80 mL or greater

- the term dysfunctional uterine bleeding (DUB) is no longer

favored and should be discarded.
NORMAL LIMITS FOR MENSTRUAL PARAMETERS IN
THE MID- REPRODUCTIVE YEARS (CPG ON AUB, 2017)
Clinical Dimensions of
Descriptive Normal Limits
Menstruation and Menstrual
Terms (5th- 95th percentile)
Cycle

Frequent <24
Frequency of Menses
Normal 24- 38
(days)
Infrequent >38

Regularity of menses Absent -

(cycle to cycle variation Regular +/-2 to 20 days
over 12 months) Irregular >20 days

Prolonged >8.0
Duration of flow (days) Normal 4.5- 8.0
Shortened <4.5

Heavy > 80
Volume of monthly blood
Normal 5- 80
loss (ml)
Light <5
 PATHOPHYSIOLOGY
NORMAL MENSTRUATION
Hemostasis in a normal menstruation is
influenced by several factors:
● Higher thromboxane (PGF2) level in
relation to prostacyclin (PGE2)
● Formation of a fibrin clot
● Maintenance of a stable platelet plug
● Heavy or profuse menstrual flow
resulting from the absence of any, or all of
these factors
 PATHOPHYSIOLOGY
ABNORMAL UTERINE BLEEDING
Aberrant hemostasis in menstruation
causing alterations in the pattern or
volume of blood flow of menses.

● STRUCTURAL (PALM)
○ (Polyp-Adenomyosis-
Leiomyoma-Malignancy &
Hyperplasia)
● NONSTRUCTURAL (COEIN)
○ (Coagulopathy-Ovulatory
dysfunction-Endometrial-Iatrogenic-
Not yet classified)
FIGO CLASSIFICATION OF AUB - PALM COEIN

Submucosal
Other
Example #1. Patient with abnormal bleeding due to polyp
Example #2.patient with abnormal bleeding that is both irregular and heavy may
have endometrial hyperplasia due to anovulation
 ABNORMAL UTERINE BLEEDING

INTERVAL - 28 days (±7 days)

Normal Menstrual Flow DURATION - 4 days (±2 days)

Oligomennorhea Interval of 35 days to 6 months

Amennorhea No menses for at least 6 months

 02
AUB - Polyps
POLYPS
● localized overgrowths of
endometrial tissue, containing
glands, stroma, and blood vessels,
covered with epithelium
● reproductive-age women
● estrogen stimulation
● Can be sessile or pedunculated
● majority are benign
 Signs and
Symptoms
● Asymptomatic
● Abnormal bleeding patterns
○ Menorrhagia or
intermenstrual bleeding
○ Postcoital bleeding
● Infertility
 TRANSVAGINAL
ULTRASOUND
- main diagnostic tool
● detects asymptomatic polyps in up to 12% of
women undergoing routine gynecologic
examination
 HISTOLOGIC FEATURES
3 components
1. Endometrial glands
2. Endometrial stroma
3. Central vascular channels

may be dense and cellular, elongated shape, vascular pedicle glands lined by proliferative
resembling normal (arrow head), cystic glands type endometrium
proliferative endometrium
 GROSS FEATURES

● single or multiple,
● few millimeters to several centimeters
● sessile or pedunculated
 MANAGEMENT
ASYMPTOMATIC SYMPTOMATIC
● Observation ● operative hysteroscopy
○ Small endometrial polyps (polypectomy)
smaller than 1 cm appear to
regress spontaneously.
 03
Adenomyosis
 ADENOMYOSIS
(AUB - A)
● derived from aberrant glands of the basalis layer of the endometrium
● referred to as Endometriosis Interna
 ADENOMYOSIS
AUB - A

● Endometrial glands & Stroma

-> myometrium

● Ectopic endometrial tissue

-> hypertrophy of myometrium

● *Profound Dysmenorrhea
 ADENOMYOSIS
AUB - A

RISK FACTORS
● 5th decade of life

● Most significant risk factor

-> Multiparity

● Other risk factors

-> any process that allows for
penetration of endometrial glands
and stroma past the basalis layer
PATHOPHYSIOLOGY
PATHOPHYSIOLOGY
 PATHOPHYSIOLOGY

● Several hypothesis regarding adenomyosis and its

association with AUB:
○ Increased endometrial surface
○ Altered PGE/PGF2a balance
○ Hampered myometrial contractility
○ Abnormal myometrial angiogenesis
SIGNS AND SYMPTOMS
HISTORY
○ Increase in dysmenorrhea and
menstrual bleeding
○ 50%: asymptomatic
○ Symptomatic: 35-50 years old
○ Classic symptoms
■ secondary dysmenorrhea
■ Menorrhagia
○ dyspareunia
SIGNS AND SYMPTOMS
Physical Examination
○ UTERUS
➢ Diffusely enlarged two to
three times the normal
size
➢ Globular and tender
before and during
menstruation
GROSS FEATURES
GROSS FEATURES
HISTOLOGIC FEATURES
DIAGNOSTICS:

Transvaginal sonography of uterus with adenomyosis

A: heterogeneous and hypoechogenic, B: increased echotexture of the
poorly described areas in the myometrium with an indistinct
myometrium with characteristic anechoic endomyometrial junction
lacunae, and linear striations radiating out
from the endometrium into the
myometrium
Magnetic Resonance Imaging
(MRI)
Magnetic Resonance Imaging
(MRI)

● more sensitive and specific than

ultrasound
● will demonstrate thickening of the
junctional zone, the area between the
endometrium and the myometrium,
equal to or greater than 12 mm
CLINICAL DIAGNOSIS
● Over 50% are asymptomatic
● CLASSIC SYMPTOMS
○ Secondary dysmenorrhea
○ Menorrhagia
● Diagnosis is confirmed usually following histologic examination
● Ultrasound and MRI are both useful to differentiate between
adenomyosis and uterine myoma
 MANAGEMENT
● Factors to consider:
○ Age
○ Parity
○ Plans for future reproduction
● Approaches:
○ Medical
○ Surgical
 MANAGEMENT
MEDICAL
● HORMONAL THERAPY
○ GnRh agonist
○ Progestogen
○ Progesterone containing IUD
○ Cyclic hormones
● NONHORMONAL
○ Nonsteroidal anti-inflammatory drugs
○ Antifibrinolytic agents
● *Follow up after 3 months
 MANAGEMENT
MEDICAL
● HORMONAL THERAPY
○ Levonorgestrel-releasing intrauterine system once every 5 years
○ COC: daily pill for 21 days each month, or continuous
○ Medroxyprogesterone 10 mg PO once/day on cycle days 15-26
○ Norethisterone acetate 5 mg PO 1-3x/day on cycle days 5-26
○ Oral micronized progesterone 300 mg at bedtime x 14 days
○ Danazol 200 - 400 mg PO daily
○ GnRH IM/SQ monthly, 3-6 months; add back if more than 6
months
 MANAGEMENT
MEDICAL
● NON-HORMONAL THERAPY
○ Tranexamic acid 1 gram 3-4x/day PO during heavy bleeding for 3
days.
○ Ibuprofen 200 mg PO 3x/day for
○ Mefenamic acid 500 mg PO 3x/day
○ Naproxen 550 mg loading dose, then 275 mg PO 2x/day during
heavy bleeding for 3 days.
 MANAGEMENT
SURGICAL
● Definitive management: Hysterectomy
○ If it is appropriate for the age, parity, and plans for future
reproduction
04 LEIOMYOMA
 LEIOMYOMA
● “myomas”
● BENIGN tumors of uterine
myometrium (muscle cell origin)
● MOST COMMON benign neoplasms
of the uterus

PATHOGENESIS
Myometrial injury leading to:
- cellular proliferation
- decreased apoptosis
- increased production of extracellular
matrix.
CLASSIFICATION
 WHERE DID MYOMAS COME
FROM?
AT LEAST TWO DISTINCT COMPONENTS CONTRIBUTE TO
LEIOMYOMA DEVELOPMENT:

1. INITIATING EVENT

2. GROWTH PHASE
LEIOMYOMA DEVELOPMENT
 RISK FACTORS

1. Increasing Age
2. Early Menarche
3. Parity
4. Obesity
5. High fat Diet
6. Familial tendencies
 HOW DOES LEIOMYOMAS
CAUSE AUB?
● Mechanical Distortion leading to increase in
endometrial surface
● Bleeding from ulcerated endometrium overlying
submucous myoma
● Myomas interfering with normal uterine
hemostasis or compressing of the venous
drainage on any site
● Dilatation of venous plexuses draining the
endometrium
 SIGNS AND SYMPTOMS
SUBMUCOSAL SUBSEROSAL INTRAMURAL
Most troublesome “Knobby” uterus Pressure sympt
clinically
Abnormal uterine Pressure symptoms Abnormal uterine
bleeding bleeding
Distortion of the Infertility
uterine artery
Infertility of
miscarriage
“PRESSURE SYMPTOMS”
● Anteriorly on urethra- urinary
retention
● Posteriorly on rectum- sense of
incomplete defecation
● On pelvic veins - edema,
varicose veins
● On diaphragm - dyspnea
● On GIT - dyspepsia and distention
 REPRODUCTIVE
DYSFUNCTION
● SUBMUCOUS and
INTRAMURAL myomas
 PHYSICAL EXAMINATION
● Abdominopelvic exam
○ large, midline,
irregular-contoured,
mobile pelvic mass
which has hard feel or
solid quality

● Increasing abdominal
girth
DIAGNOSIS
Most common
imaging modality
 DIAGNOSIS

Hysteroscopy and
Sonohysterography or
Saline Infusion
Sonography
 Gross Features

lighter color than the

normal myometrium
glistening, pearl-white
appearance
smooth muscle arranged in
a trabeculated or whorled
configuration
 Histology

proliferation of mature
smooth muscle cells
nonstriated muscle fibers
are arranged in
interlacing bundles
variable amounts of
fibrous connective tissue
Management
Consider:
● Age
● Parity
● Future Reproductive plans

GOAL:
● Control bleeding

APPROACH
● Medical
● Surgical
 MEDICAL MANAGEMENT
SMALL,
Hormonal Nonhormonal
ASYMPTOMATIC
● Judicious COC Tranexamic acid
observation Progestogens NSAIDS
● Pelvic
examination LNG-IUS
every 6 months GnRH - alpha
SPRM
 SURGICAL MANAGEMENT
Myomectomy Hysterectomy
Uterus preserving Most definitive
For women who desire fertility Most common
preservation
Longer hospital stay >90% satisfaction rate
Causes more pelvic adhesions Higher rates of urinary tract
injuries
Approximately 80% resolution of
symptoms
 Thank
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