ABNORMAL UTERINE

BLEEDING

CHAIR PERSON: DR. POORNIMA. M

PRESENTERS: DR. LAKSHMI MOUNIKA
DR. KRISHNA VENI
OVERVIEW
• EPIDEMIOLOGY
• NORMAL AND ABNORMAL MENSTRUAL BLEED
• PATHOPHYSIOLOGY
• PALM COEIN CLASSIFICATION
• DIFFERERENTIAL DIAGNOSIS
• COMPLICATIONS
• DIAGNOSTIC APPROACH
• MANAGEMENT
Epidemiology
• About 10 -25% of women experience episodes of abnormal uterine
bleeding at sometime during the reproductive years of their lives.
• About 55.7% of adolescents experience abnormal menstrual
bleeding in the first year or so after the onset of menarche
• AUB is reported to occur in 9 to 14% women between menarche and
menopause . The prevalence varies in each country. In India, the
reported prevalence of AUB is around 17.9%
Definition
• FIGO : AUB is the term used to describe any departure from normal
menstruation or from a normal menstrual cycle pattern.

• ACOG: Bleeding from the uterine corpus that is abnormal in regularity,

volume, frequency or duration and occurs in the absence of
pregnancy.

• NICE: when a women experiences a change in her menstrual loss or

degree of loss or vaginal bleeding pattern differs from that
experienced by the age matched general female population.
Acute vs Chronic
Chronic nongestational AUB in the reproductive years is defined as
bleeding from the uterine corpus that is abnormal in regularity,
frequency, volume or duration 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
Normal Menstrual blood flow
• Mean duration of the menstrual
cycle is 24 - 38 days
• Average menstrual blood loss (MBL)
is 35mL(normal range: 10-80ml)
• Average number of days of menses:
4 days (normal : </= 8 days)
Abnormal uterine bleeding (AUB)

Bleeding is abnormal if:

• It occurs at intervals of less than 24
days or more than 38 days;
• Lasts longer than 8 days;
• MBL of 80 mL or greater
• The term Dysfunctional uterine
bleeding (DUB) is no longer used
Heavy menstrual bleeding
• Heavy menstrual bleeding is
defined as excessive menstrual
blood loss which interfere with
the woman’s physical, social ,
emotional and /or material
quality of life
Assessment of HMB
• Hemoglobin and hematocrit
evaluation: normal level, however, does not exclude HMB, as
many women with clinically significant bleeding have normal values.

• Alkaline hematin technique: technique to extract

hemoglobin from sanitary napkins using sodium hydroxide. Hemoglobin
is then converted to hematin and measured spectrophotometrically.

• Pictorial blood assessment chart

(PBAC) : Using a scoring sheet, patients are asked to record daily
the number of sanitary products that are lightly, moderately, or
completely saturated. Scores are assigned as follows: 1 point for each
lightly stained tampon, 5 if moderately saturated, and 10 if completely
soaked. Pads are similarly given ascending scores of 1, 5, and 20,
respectively. Presence of small, 2-cm-diameter clots score 1 point,
whereas 3-cm clots score 5. Points are then tallied for each day. Totals >
100 points per menstrual cycle correlate with > 80 mL.

• Menstrual cup: a more direct method of measure

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. At the
endometrium-myometrium junction, the
radial arteries bifurcate to create the basal
and spiral arteries. The basal arteries serve
the basalis layer of the endometrium and are
relatively insensitive to hormonal changes.
The spiral arteries stretch to supply the
functionalis layer.
• In human menstruation, progesterone plays a critical role. Two
progesterone receptors (PR) are found in the endometrium, PRA and
PRB.
• In the secretary phase, PRB levels decline in the stromal and
glandular epithelial cells of the functionalis layer. However, PRA
expression in this layer persists in the stromal cells, which thus remain
responsive to progesterone and to its withdrawal.
• 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.
 ABSENCE OF PREGNANCY
CORPUS LUTEUM REGRESSES PROGESTERONE PRODUCTION

CYTOKINE LEVELS IN ENDOMETRIUM

RELEASE LYTIC ENZYMES (MATRIX
INFLUX OF LEUKOCYTES
METALLOPROTEINASES)

BREAKDOWN STROMA AND VASCULAR ARCHITECTURE IN FUNCTIONALIS LAYER

BLEEDING AND SLOUGHING MENSTRUATION

• 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
 PALM-COIEN classification of
causes of AUB
• The basic system comprises four
categories that are defined by visually
objective structural criteria (PALM:
Polyp; Adenomyosis; Leiomyoma; and
Malignancy and hyperplasia), four that
are unrelated to structural anomalies
(COEIN: Coagulopathy; Ovulatory
dysfunction; Endometrial disorders;
Iatrogenic causes), and one reserved for
entities categorized as “Not otherwise
classified”. The leiomyoma category (L)
is subdivided into patients with at least
one submucous myoma (LSM) and
those with myomas that do not impact
the endometrial cavity (Lo).
ENDOMETRIAL POLYPS (AUB-P)
• Localized overgrowths of endometrial tissue,
containing glands, stroma and blood vessels,
covered with epithelium.
• single or multiple
• sessile or pedunculated
• Most commonly found in reproductive age
women
• Estrogen stimulation is thought to play a key
role in their development.
• Risk factors: Hormone replacement therapy,
tamoxifen therapy, diabetes, hypertension,
obesity and increased patient age
Intermenstrual bleeding, HMB, prolonged bleeding, infertility
Per speculum, it looks reddish in color, usually attached with a slender pedicle
TVS with applied color Doppler, SIS, and Hysteroscopy
Hysteroscopic polypectomy: most effective for symptomatic women or those with
risk factors for malignant transformation.
ADENOMYOSIS (AUB-A)
• Adenomyosis is characterized by
uterine enlargement caused by
ectopic rests of endometrium-both
glands and stroma-located deep
within the myometrium.
• Diffuse or focal
• Most widely held theory: downward
invagination of the endometrial
basalis layer into the myometrium
• Parity and age are significant risk
factors
• Regresses after menopause
• HMB, dysmenorrhea,
dyspareunia
• On gross examination, the uterus
is often globally enlarged, but
this rarely exceeds 12-week size.
The uterine surface is usually
smooth, regular, reddish, and
soft
• MRI =/> TVS > TAS
Adenomyosis diagnostic criteria
(Graphical depictions of 8 TVUS criteria)

• Asymmetrical myometrial thickening

• Myometrial cysts
• Hyperechoic islands
• Fan shaped shadowing
• Echogenic subendometrial lines and
buds
• Translesional vascularity
• Irregular junctional zone
• Interrupted junctional zone
• At least, the presence of two or more
of these criteria are highly associated
with a diagnosis of adenomyosis.
LEIOMYOMA (AUB-L)
• Also called fibroids, are benign tumors of the
uterine myometrium
• Commonest benign tumor of the uterus and also
the commonest benign solid tumor in female.
• Histologically, this tumor is composed of smooth
muscle and fibrous connective tissue, so named
as uterine leiomyoma, myoma or fibromyoma
• Predominantly an estrogen-dependent tumor.
• Increased risk : • Nulliparity • Obesity •
Hyperestrogenic state
• Reduced risk: • Multiparity • Smoking
• Symptoms: Asymptomatic—majority (75%), HMB, Dysmenorrhea,
Dyspareunia, Infertility, Pressure symptoms, Recurrent pregnancy loss
(miscarriage, preterm labor), Lower abdominal or pelvic pain,
Abdominal enlargement.
• Complications: Degeneration, Atrophy, Necrosis, Infection,
Sarcomatous change, Torsion of subserous pedunculated fibroid,
Hemorrhage – Intracapsular, intraperitoneal
• Management:
• ´ Medical management
• ´ Surgical : hysterectomy, myomectomy
MALIGNANCY (AUB-M)
• Endometrial hyperplasia: irregular proliferation of the endometrial glands
with an increase in the gland to stroma ratio when compared with the
proliferative endometrium
• Endometrial cancer is mostly secondary to prolonged exposure to
hyperestrogenic state (chronic anovulation, PCOS, obesity, nulligravida, etc)
• Bleeding from cervical malignancy classically presents as coital bleeding or
intermenstrual bleeding
• Lynch syndrome, or hereditary nonpolyposis colorectal cancer, is an
autosomal dominant disease caused by a disruption in the mismatch repair
(MMR) genes carries a 40% to 50% lifetime risk of endometrial cancer
(mostly before the age of 45.)
• Estrogen-producing ovarian tumors (ex. Granulosa theca cell tumors)
COAGULOPATHY (AUB-C)
• Disorders of blood coagulation such as von Willebrand disease (most
common Inherited disorder), prothrombin deficiency, hemophilia,
leukemia, severe sepsis, idiopathic thrombocytopenic purpura, and
hypersplenism
• Routine screening mainly indicated for the adolescent who has
prolonged heavy menses beginning at menarche.
• In adults, screening for these disorders indicated by clinical signs such as
bleeding gums, epistaxis, or ecchymosis.
• Chronic anticoagulation as a result of heparin, low-molecular weight
heparin, direct thrombin inhibitors, and direct factor Xa inhibitors ARE
NO LONGER UNDER THIS CATEGORY
 OVULATORY DYSFUNCTION
(AUB-O)
• What are the causes of anovulation?
1. extremes of reproductive life
2. polycystic ovary syndrome (PCOS)
3. hypothalamic dysfunction (related to weight loss, severe exercise,
stress, or drug use)
4. abnormalities of other nonreproductive hormone (thyroid
hormone, prolactin)
• Anovulatory bleeding is most common during the extremes of
reproductive life:
First few years after menarche
Perimenopause.
In the adolescent: anovulation is due to an immaturity of the
hypothalamopituitary- ovarian (HPO) axis and failure of positive
feedback of estradiol to cause a luteinizing hormone (LH) surge.
In the perimenopausal woman: lack of synchronization between the
components of the HPO axis occurs as the woman approaches ovarian
decline at menopause.
• The predominant cause of ovulatory dysfunction postmenarchal and
premenopausal women is secondary to alterations in
neuroendocrine function.
• There is continuous estradiol production without corpus luteum
formation and progesterone production continuously
proliferating endometrium, which may outgrow its blood supply
necrosis excessive uterine bleeding
• The patterns of anovulatory bleeding may be oligomenorrhea,
intermenstrual bleeding, or heavy menstrual bleeding.
• Mostly painless
• Ruleout endometrial hyperplasia and malignancy.
ENDOMETRIAL (AUB-E)
• Heavy menstrual bleeding in the absence of any definable cause with
cyclical menstrual bleeding typical of ovulatory cycles.
• Primary disorder of the endometrium
• In the past, this category has been called “ovulatory dysfunctional
uterine bleeding.”
• The primary line of defense to excessive bleeding during normal
menses is the formation of the platelet plug, followed by uterine
contractility, largely mediated by prostaglandin F2α (PGF2α).
• Thus prolonged and heavy bleeding can occur with abnormalities of
the platelet plug or inadequate uterine levels of PGF2α
• In some women with heavy menstrual bleeding, there is excessive
uterine production of prostacyclin, a vasodilatory prostaglandin that
opposes platelet adhesion and may also interfere with uterine
contractility.
• Deficiency of uterine PGF2α or excessive production of PGE
(vasodilatory prostaglandin) may also explain ovulatory DUB
• Low PGF2α/PGE increase menstrual blood loss
IATROGENIC(AUB-I)
• Abnormal bleeding resulting from medications
• Most common of these are hormonal preparations, including
selective estrogen receptor modulators, and gonadotropic releasing
hormone agonists and antagonists.
• Hyperprolactinemia can result from central nervous system dopamine
antagonism of certain antipsychotic drugs (eg : risperidone)
• Combined and progesterone-only oral contraceptives may result in
breakthrough bleeding (BTB).
• 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
• Chronic anticoagulation as a result of heparin, low-molecularweight
heparin, direct thrombin inhibitors, and direct factor Xa inhibitors
NOT OTHERWISE CLASSIFIED
(AUB-N)
• Abnormal bleeding not classified in the previous categories is
considered AUB-N.
• Examples of such conditions may include foreign bodies or trauma.
Treatment is tailored to the specific cause
• AVM
Diagnosis Notation
• The acronym AUB is followed by the letters PALM-COEIN and a
subscript 0 or 1 associated with each letter to indicate the absence or
presence.
• Example #1: A patient with abnormal bleeding that is both irregular
and heavy may have endometrial hyperplasia due to anovulation.
• AUB- P0A0L0M1- C0O1E0I0N0
or
• AUB – M;-O
ADOLESCENT AUB:
ETIOLOGY:
• AUB-O: Most common cause, immature HPO axis.
• AUB-C
• PCOD
• HYPOTHYROIDISM
• OVARIAN TUMORS: GRANULOSA AND THECA CELL
• 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.
REPRODUCTIVE AGE GROUP:
• PREGNANCY AND RELATED EVENTS: to be ruled out
• PALM COEIN
PERIMENOPAUSAL AUB:
• AUB O: Most common cause, anovulatory cycles
low-dose (20-μg) combined oral contraceptives
Cyclic Progestogens
• AUB M: Chances of malignancy and hyperplasia increase with age,
hence, to be ruled out
• Other structural causes
POSTMENOPAUSAL
• AUB M
• ATROPHIC VAGINITIS
Differential Diagnosis

• 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
Complications
• Chronic AUB: anemia, infertility, and endometrial cancer
• Acute AUB: severe anemia, hypotension, shock, and even death may
result if prompt treatment and supportive care are not initiated.
Diagnostic approach
History, Physical examination, and
Laboratory tests
Medical History
• Menstrual history: frequency, duration, and amount of bleeding
• Enquire whether and when the menstrual pattern changed
• Use of steroidal contraceptive or IUCD insertion to be enquired.
• Symptoms present for the majority of the preceding 6 months are
considered chronic
Screen for coagulopathies
• History of heavy bleeding starting at menarche
• One of the following:
Postpartum haemorrhage
Surgery-related bleeding
Bleeding associated with dental work
• At least two of the following symptoms:
At least one episode of bruising per month
At least one episode of epistaxis per month
Frequent gum bleeding
Family history of bleeding symptoms
• Family history –bleeding disorders, menstrual disorders, diabetes and
thyroid
• Past medical history – systemic illness, including hematologic or renal
disease, and current or recent medications
• Examination: Including assessment of weight, pallor, thyroid, breasts,
acne, hirsutism scoring (if present), abdominal, P/S and P/V
examination.
Physical Examination
• The presence of tachycardia,
pallor, or a heart murmur
suggests anemia
• Tachycardia and hypotension
may indicate acute
hemodynamic instability and the
need for rapid intervention
• 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.
• Palpation of the thyroid gland for
enlargement or other abnormalities.
• Sexual maturity rating of the breasts
and assessment for galactorrhea.
• Palpation of the abdomen (pregnancy,
uterine/ovarian mass).
• Speculum and bimanual examination
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
• TSH
• Pelvic ultrasound
Patients with a history of
amenorrhea or irregular bleeding
prior to the onset of heavy bleeding
should have:
• FSH and LH
• Total and free testosterone levels
• Dehydroepiandrosterone
• Prolactin level
Imaging
• Ultrasonography is mandatory in AUB to evaluate uterus, adnexa and
endometrial thickness
• Doppler ultrasonography: In suspected arteriovenous malformation,
malignancy cases and to differentiate between fibroid and
adenomyomas
• 3D-USG:For evaluating intra myometrial lesion in selected patients for
fibroid mapping
• SIS: If intracavitary lesion is suspected and hysteroscopy is not
available
• Hysteroscopy: For diagnosis and characterization of intrauterine
abnormalities
• MRI: To differentiate between fibroids and adenomyomas and for
mapping exact location of fibroids while planning conservative
surgery and prior to therapeutic embolization for fibroids
Endometrial Histopathology
(HPE)
Endometrial histopathology is recommended in AUB
• In women > 40 years
• In women < 40 years who have high risk factors for carcinoma
endometrium such as irregular bleeding, obesity associated with
hypertension, PCOS, diabetes, ET > 12 mm, family history of
malignancy of ovary/breast/endometrium/colon, HNPCC, use of
tamoxifen for HRT or breast cancer, late menopause, AUB
unresponsive to medical treatment
• Endometrial aspiration should be the preferred procedure for
obtaining endometrial sample for histopathology. If endometrium is
thick on imaging, but where HPE is inadequate or atrophic,
hysteroscopy should be performed to rule out polyps
• Dilatation and curettage is not the preferred procedure of choice for
endometrial assessment
MANAGEMENT
Management
The management of AUB depends on:
• assessment of whether or not the patient is hemodynamically stable
• determination of the underlying cause
Goals of treatment:
• Establish and/or maintain hemodynamic stability
• Correct acute or chronic anemia
• Return to a pattern of normal menstrual cycles
• Prevention of recurrence
• Prevent long-term consequences of anovulation (eg, anemia, infertility,
endometrial cancer)
Medical treatment
• The goal of medical therapy is to stabilize the endometrium with
estrogen that will provide initial hemostasis, followed by progestins
for endometrial stability.
• Typically, this is achieved with combined oral contraceptive pills
(OCPs) taken continuously for several months until hemodynamically
stable, as withdrawal of either hormone will cause recurrent bleeding.
Treatment
• In the absence of an organic cause for excessive uterine bleeding, it is
preferable to use medical instead of surgical treatment, especially if
the woman desires to retain her uterus for future childbearing or will
be undergoing natural menopause within a short time.
• The type of treatment depends on whether it is used to stop an acute
heavy bleeding (acute AUB) episode or is given to reduce the amount
of MBL in subsequent menstrual cycles (Chronic AUB).
NONSTEROIDAL ANTI-
INFLAMMATORY
DRUGS
• Prostaglandin synthetase inhibitors that inhibit the biosynthesis of the
cyclic endoperoxides, which convert arachidonic acid to prostaglandins.
• Block the action of prostaglandins by interfering directly at their receptor
sites.
• All NSAIDs are cyclooxygenase inhibitors and thus block the formation of
both thromboxane and the prostacyclin pathway.
• Examples:
Mefenamic acid (500 mg, three times daily)
Ibuprofen (400 mg, three times daily)
Given in the first 3 days of menses or whole duration of bleeding
Anti-fibrinolytic Agents
• ε-Aminocaproic acid (EACA), tranexamic acid (AMCA), and para-
aminomethyl benzoic acid (PAMBA) are potent inhibitors of
fibrinolysis.
• Mainly GI side effects: minimized by reducing the dose and limiting
therapy to the first 3 to 5 days of bleeding.
• Due to the increased risks of thrombosis and myocardial infarction,
antifibrinolytic agents should not be combined with oral
contraceptives
Progestogens
• Commonest prescription for women with unexplained menorrhagia.
• Progestogens not only stop endometrial growth but also support and
organize the endometrium so that an organized slough occurs after
their withdrawal.
• Progestogens stimulate arachidonic acid formation in the
endometrium, increasing the PGF2α/PGE ratio.
• Routes: oral, intramuscular, IUD
• Medroxyprogesterone acetate (MPA) at a dose of 60 mg daily (20 mg
three times daily) for 7 days followed by 20 mg per day for 3 weeks
• Norethindrone acetate (30 mg per day)
• Ovulatory:5-25 day
• Anovulatory:15-25 day
• Hyperplasia:high dose ,prolonged
• Injectable progestogens: Depo-MPA 150 mg intramuscularly followed
by oral MPA 60 mg (20 mg three times daily) for 3 days
LNG-IUS
• MIRENA: Delivers 20mcg of LNG over 24hours for about 5
years
• PROGESTASERT: releases approximately 65mcg of
progesterone over 24hours for about 16 months
• Apart from lowering menstrual blood loss, LNG IUS may
alleviate symptoms of dysmenorrhea and reduce incidence
of PID.
• Less morbidity and more cost effective than surgery,
preserves fertility, provides contraception, can be
discontinued when patient becomes menopausal, can be
continued as HRT.
Estrogens
• Estrogen in pharmacologic doses causes rapid growth of the endometrium.
• A rapid growth of endometrial tissue occurs over the denuded and raw
epithelial surfaces
• Large doses of estrogen may alter platelet activity, thus promoting platelet
adhesiveness.
1. Oral conjugated equine estrogen (CEE) 10 mg/day, in four divided doses
2. IV conjugated estrogen: 25 mg q4-6h until the bleeding stops. (No more
than six doses should be administered)
3. Combination oral contraceptive (both estrogen and progestin). Four
tablets of an oral contraceptive containing 30 to 35 μg of estrogen taken
every 24 hours in divided doses.
Gonadotropin-Releasing
Hormone Agonists
• GnRH agonists may be used to inhibit ovarian steroid production, as
estrogen production is necessary for endometrial proliferation.
• Because of the expense and menopausal side effects of these agents,
their use is limited to women with severe MBL who fail to respond to
other methods of medical management and wish to retain their
childbearing capacity.
• More commonly, GnRH agonists are an effective means of bridging
patients to surgical treatment, allowing for correction of anemia.
• Use of an estrogen or progestogen (add-back therapy) together with
the agonist will help prevent bone loss.
ORMELOXIFENE
• SERM
• Potent anti estrogenic to endometrium
and breast
• Weak estrogenic : beneficial effects on
bone, CVS
• Contraceptive
• Dose: 60mg twice weekly for 3 months &
weekly for next 3 months
ANDROGENS
• Danazol is a synthetic androgen used in doses of 200 mg daily for the
treatment of heavy menstrual bleeding
• Limited use because of the side effects of weight gain and skin
problems
SURGICAL MANAGEMENT

• Uterine curettage
• Endometrial Ablation (thermal balloon, Novasure, Microwave)
• Transcervical resection of endometrium(TCRE)
• Uterine artery embolization
• Hysterectomy (Abdominal, vaginal, laproscopic, robotic)
FOGSI Management
guidelines
AUB-P (Polyps)
• 1. Hysteroscopic polypectomy is recommended for younger women
who wish to preserve fertility.
• 2. In women multiple endometrial polyps and not desirous of
continued fertility, it is suggested to perform hysteroscopic
polypectomy followed by LNG- IUS insertion after confirmation of
benign lesion on histopathology.
• 3. Polyp should be sent for histopathology. If histopathology suggests
malignancy, further management should be as AUB-M.
AUB-A (Adenomyosis)
• 1. For managing adenomyosis-A, it is suggested to consider the age,
symptomology (AUB, pain and infertility) and association with other
conditions (leiomyomas, polyps and endometriosis).
• 2. In women with AUB-A, desirous of preserving fertility but unwilling
for immediate conception, progestogens especially LNG-IUS is
recommended as first-line therapy.
• 3. In patients with AUB-A, desirous of preserving fertility and resistant
to LNG-IUS/ unwilling to use LNG-IUS, gonadotropin releasing
hormone (GnRH) agonists with add-back therapy is recommended as
second-line therapy
• 4. In patients with AUB-A, and not desirous of preserving fertility,
medical management using long-term GnRH agonists and add-back
therapy can be initiated.
• 5. Combined oral contraceptives, danazol, NSAIDs, and progestogens
can be offered for symptomatic relief where LNG-IUS and GnRH
agonists cannot be indicated.
• 6. In case of failure/refusal for medical management, vaginal or
laparoscopic hysterectomy is indicated.
AUB-L (Leiomyoma)
• Treatment for AUB-L should be individualized because many variables
such as age, parity, symptoms, fertility desires may affect the treatment
preference. Various options can be generalized as follows:
• 1. Women with intramural or subserosal myomas, desirous of
preserving fertility, can be managed with tranexamic acid or combined
oral contraceptives (COCs) or NSAIDs as second-line therapy.
• 2. Women with intramural or subserosal myomas (grade2-6) and
desirous of preserving fertility can be medically managed with LNG-IUS
if other medical treatment fails and patient is not trying to conceive for
at least 1 year.
3. If treatment fails, or if myoma is causing infertility, myomectomy is
recommended by abdominal (open or laparoscopic)/ hysteroscopic
route depending on myoma location
4. For sub-mucosal myomas Grade 0-1, hysteroscopic resection (for 4
cm diameter) is the recommended treatment.
5. In women above 40 years of age, not desirous of continued fertility,
hysterectomy is the definitive treatment; however medical
management including LNG-IUS may be tried in small fibroids.
6. For short-term management (up to 6 months), GnRH agonists with
add-back therapy is an option in peri-menopausal women, prior to
myomectomy or for improving general condition.
7. For long-term management of leiyomyomas, it is recommended to
use LNG-IUS (except in AUB-L 0 and 1 grade, may be tried in selected
cases of AUB-L 2) as first-line management. Newer promising options
are progesterone receptor modulators such as ulipristal acetate and
low dose mifepristone., though these are presently not available in
India.
AUB-M
• 1.In AUB-M with endometrial malignancy, standard protocol for
management of malignancy should be followed.
• 2. In AUB-M with endometrial hyperplasia with atypia, hysterectomy
is the standard treatment.
• 3. In AUB-M with endometrial hyperplasia without atypia, LNG-IUS
can be considered as first-line therapy; oral progestins can be used if
LNG-IUS is contraindicated or if patient is unwilling for LNG-IUS.
AUB-C (Coagulopathy)
• 1. In patients with AUB-C, non-hormonal treatment with tranexamic
acid as primary option and hormonal treatment with COCs/LNG-IUS
as secondary option* are recommended in consultation with a
haematologist, with the following considerations.
• 2) a. For patients with uncontrolled uterine bleeding with above
medical management, specific factor replacement where possible or
desmopressin in refractory cases to be given
• B. When surgical interventions are indicated, for appropriate pre-,
intra- and post-operative management of bleeding
• *NSAIDs are contraindicated as they can alter platelet function and
interact with drugs that might affect liver function and production of
clotting factors.
• * Injectables (GnRH agonists) are contraindicated, except in mild
coagulation abnormalities. When administered, prolonged pressure
should be applied at injection site.
AUB-O (Ovulatory Dysfunction)
• 1. In women not desiring conception presently, COCs can be used as
first-line therapy for 6-12 months .
• 2. Cyclic luteal-phase progestins should not be used as a specific
treatment in women with AUB-O.
• 3. Norethisterone cyclically (for 21 days) is given as initial therapy in
acute episodes of bleeding for short-term management of 3 months.
• 4. It is suggested to assess response after 1 year of medical
management and judge to continue/discontinue existing therapy.
• 5. Surgical intervention is not recommended unless, there is evidence
of persistent AUB or failure of medical management to alleviate the
condition.
• 6. If COCs are contraindicated or patient is unwilling for COCs, LNG-
IUS is recommended if she wishes to use it for atleast 1 year.
• 7. In adolescents with AUB-O, both hormonal and non-hormonal
therapies can be prescribed
AUB-E (Endometrial)
Recommendations specific to AUB-E
• 1. Management of AUB-E can be similar to the management of AUB-O.
• AUB-I (Iatrogenic causes) Recommendations specific to AUB –I
• 1. Whenever possible, medications causing AUB should be changed to
other alternatives, if no alternatives are available, LNG-IUS is
recommended.
AUB-N (Not defined)
• 1. In patients with idiopathic AUB and desire effective contraception,
LNG-IUS is recommended as first-line therapy to reduce menstrual
bleeding.
• 2. In patients with AUB-N desirous of continued fertility, in whom,
LNG-IUS are contraindicated, use of COCs are recommended as
second line therapy.
• 3. For the management of abnormal uterine bleeding that are mainly
cyclic or predictable in timing, non-hormonal options such as NSAIDs
and tranexamic acid are recommended.
• 4. When medical or conservative surgical
treatments (such as ablation) have failed
or are contraindicated, and GnRH
agonists along with add-back hormone
therapy are recommended to reduce
idiopathic AUB, while hysterectomy is
suggested as last resort.
• 5. Uterine Artery embolization is
recommended for A-V malformation
AUB-COEIN: General management
guidelines: Recommendations of
AUB-COEIN
• 1. Tranexamic acid is first-line therapy. Other non-hormonal option is
NSAIDs.
• 2. In women desiring effective contraception, LNG-IUS is
recommended.
• 3. COCs are recommended as second line therapy in patients desiring
effective contraception, but unwilling or unsuitable for LNG-IUS.
• 4. Cyclic oral progestins (from day 5 to 26), are recommended if COCs
are contraindicated.
• 5. Centchroman is an option when steroidal hormones and other
medical options are not suitable.
• 6. Use of cyclic luteal-phase progestins are not recommended for AUB

• 7. GnRH agonists with add-back hormone therapy are recommended

as a last resort when medical or surgical treatments for AUB have
failed or are contraindicated.
• 8. Role of conservative surgery such as ablation has decreased a lot
due to availability of LNGIUS which works like medical ablation
CONTACT US
REFERENCES
• WILLIAMS TEXTBOOK OF GYNAECOLOGY
• DUTTA’S TEXTBOOK OF GYNAECOLOGY
• COMPREHENSIVE GYNAECOLOGY 7TH EDITION
• JEFFCOATE’S PRINCIPLES OF GYNAECOLOGY
• FOGSI GCPR GUIDELINES ON AUB