Abnormal Uterine Bleeding

❶ Organic Lesions
❷ Dysfunctional Lesions
1ry DUB  d2 Disturbed HPO Axis
2ry DUB  d2 General Causes, Hormonal Contraception & IUD
 Abnormal Uterine bleeding [AUB]
Definition (AUB is symptom & not disease)

-Any bleeding from FGT other than Normal Uterine bleeding

-Quantitative or Qualitative disturbance in menstrual func. Excessive blood loss

Normal Uterine Bleeding

A) Menstruation: → Normal in all characters
B) Bleeding during 3rd stage of labor & during puerperium
C) Birth crisis. (???)
D) Ovulatory spotting. (???)

Causes of AUB

A) General causes:
1) Hematological diseases: → Thrombocytopenia, Hemophilia or leukemia.VWD (PLT dysfunc.)
2) Endocrinal diseases: → Hyperthyroidism or hypothyroidism. ??? Adrenal disorder???
3) Systemic diseases:
-HTN & congestive HF
-Renal diseases "1972"
-Liver diseases d2 impaired estrogen metabolism ‫ ↓↓ & االهم‬SHBG & (X, IX, VII, II) deficiency

4) Psychological disturbances.
5) Malnutrition.
6) Drugs: → Anticoagulants, aspirin (anti-PLT), psychotropic drugs
HRT (Hormonal therapy) & hormonal contraception [Accidental intake or Irregular intake]
B) Local causes:
1) Obstetric (Pregnancy related) causes: Conception "Complications of Pregnancy"
-Bleeding in early pregnancy (Abortion, ectopic pregnancy, vesicular mole)
-APH (Antepartum Hge)
-PPH (Postpartum Hge)
2) Gynecologic (Non pregnancy related) causes:
a) Congenital:
Congenital anomalies of uterus (as bicornuate uterus d2 ↑↑ surface area of endometrium)
b) Traumatic: → FB, neglected pessary, sexual abuse & laceration of genital tract.
c) Inflammatory: → d2 pelvic congestion.
1- Cervicitis, endometritis & chronic PID.
2- Ulcers: → Trophic ulcers, TB, syphilis or bilharziasis.
d) Neoplastic:
1- Bg: → Fibroid (Leiomyoma), uterine polyps & endometrial hyperplasia.
2- Mg: → Cancer vulva, cancer vagina, cancer Cx
endometrial carcinoma, uterine sarcoma, GTT
functioning ovarian Tm
e) Other causes:
1- Genital displacement.
2- Endometriosis & adenomyosis.
3- Complication of Contraception: → IUD & tubal sterilization �
C) Ovarian dysfunction: → d2 dysfunction of HPO axis.
Classification of AUB
❶ Clinical classification (A2 Pattern)
 Regular (Cyclic)  related to menstrual period [mēn, month, + rhoia, flow]

Poly-menorrhea Frequent menstruation recurring every <21d' (3wks)

Length
Oligo-menorrhea Infrequent menstruation recurring every >35d' (5wks)
Menorrhagia*
Heavy (>80ml/cycle) & prolonged (>7d') menstruation
Replaced by HMB?! Duration
Menostaxis* & Prolonged menstruation (>7d') è normal amount
Hyper-menorrhea* Amount Heavy menstruation (>80ml) è normal duration
Hypo-menorrhea Scanty (<30ml) &/or short (<2d') menstruation
Heavy &/or prolonged menstruation recurring every <21d'
Polymenorrhagia
Combination (menorrhagia + polymenorrhea)
Oligohypomenorrhea Combination (Hypomenorrhea + Oligomenorrhea)??? PCOS ??

 Irregular (Acyclic)  not related to menstrual period

Metrorrhagia
(=metrostaxis) Irregular uterine bleeding not related to menstruation
(patient doesn't know her date of menstruation).
Replaced by IMB*
Menometrorrhagia Heavy &/or prolonged menstruation è IMB*
Not generally approved Combination (menorrhagia + metrorrhagia).
Contact bleeding Bleeding after intercourse or vaginal examination or douching
*Intermenstrual bleeding [IMB] Don't confuse () IMP & IMB
❷ Etiological classification

Organic genital bleeding: → Bleeding due to organic genital lesion.

Dysfunctional uterine bleeding (DUB): → Bleeding in absence of organic genital lesions

(PALM COEIN) 2011

PALM COEIN

Polyps Coagulopathy
Leiomyoma Ovulatory dysfunction
Adenomyosis. Endometrial
Mg & hyperplasia Iatrogenic
Not yet classified
❸ Age classification (A2 Age group)
Period Age Causes of bleeding
Prepubertal Neonatal 1st m' MC Cause  Birth crisis
MC Cause  FB
Infancy 1st 2y' Other common causes 
Traumatic Causes Sexual abuse
Inflammatory Causes Vulvovaginitis of children
Childhood 2-9y' Neoplastic Causes botryoid sarcoma of vagina
Dysfunctional Causes  -Precocious puberty
-Accidental intake of COC
Pubertal
"Perimenarcheal" 9-16y' MC Cause  DUB
MC Cause  Complications of pregnancy ‫نعمل تحليل بول؟‬
Any AUB or amenorrhea in CBP, You must exclude
Child bearing
period (CBP) 16-40y' Pregnancy & its Complication at first
Other common causes 
Fibroid, uterine polyps, exogenous hormone use & DUB.
MC Cause  DUB
Premenopausal 40-45y'* Other common causes 
Bg Tm  Fibroid, uterine polyps, endometrial hyperplasia
Perimenopausal 45-55y'* Mg Tm  cancer Cx or endometrial carcinoma
MC Cause  Atrophic endometritis
2nd MC Cause  ERT.
After
Most Serious cause:  Mg
Postmenopausal menopause (so, any PMB is considered Mg until proved otherwise &
endometrial biopsy should be done in all cases of PMB)
not because it's the most common but because it's the most serious
menopause‫*طالما لم تصل لل‬
 Prepubertal bleeding PMB [Postmenopausal Bleeding]
"Premenarchal"
Organic Lesion
❶ Congenital:
Congenital prolapse è trophic ulcer ❶ Traumatic:
❷ Traumatic: FB, direct trauma, Neglected pessary
FB Postcoital Bleeding
Direct trauma, sexual abuse ❷ Inflammatory:
Post circumcision bleeding ??
Estrogen deficiency Sequels
❸ Inflammatory: 1- Senile (atrophic) endometritis
Vulvovaginitis of children 2- Senile Vaginitis
❹ Neoplastic: ❸ Neoplastic:
botryoid sarcoma of vagina* -all Tm except GCT &Sarcoma botryoides
*Highly Aggressive -Commonly Tm  Endometrial carcinoma

No Obstetric cause No Obstetric cause

Dysfunctional Lesion
❶ General Causes ❶ General Causes
ITP, Leukemia -Blood diseases, Anticoagulant therapy
❷ Birth Crisis -Thyroid disorders
❸ Precocious Puberty
❷ ERT "Estrogen replacement therapy"
❹ Accidental intake of COCs

No DUB?? No DUB???
Diagnosis (work up) of AUB: Bleeding Sheet
❶ History:
1) Personal Hx:
a) Age.
b) Marital status (to exclude complications of pregnancy) �
2) Past Hx:
a) Medical disease .
b) Gynecological operation (as myomectomy)
c) Gynecological therapy (as estrogen therapy)
d) Contraception (if not currently used).
e) Drug therapy
3) Present Hx:
Bleeding (Menstrual Hx)??
• Onset, Course & Duration of bleeding
⃑⃑⃑⃑⃑⃑⃑⃑ of blood (Amount, Color or odor), Presence of blood clot
• 𝑪𝑪𝑪
• Relation of bleeding to menstruation.
• Bleeding from other body orifices
• Preceded by Direct Trauma or short period of amenorrhea "suggest bleeding in early
pregnancy or Metropathia hemorrhagica"
• Associated è Low back pain or colicky pain
• Associated è other gynecological or non-gynecological symptoms.
• Current use of contraception
• Hx of +ve pregnancy test
❷ Examination:
1) General:  For diagnosis of general causes (Goiter, CHF …………)
 detection of effects of bleeding (as Anemia)
2) Abdominal:
For detection of -abdominal or pelviabdominal masses [Ovarian Tm,…….]
-abnormalities in liver, spleen or kidneys
3) Local:
 For determination of exact source of bleeding
 diagnosis of local causes of bleeding.
❸ Investigations: Value ? Finding ?
1)Laboratory

a) CBC & Coagulation profile

b) Thyroid func tests.
c) Liver Func. tests
d) Kidney func. tests

e) Hormonal profile:  For -Assessment of progesterone status

-Diagnosis of LPD & anovulation.

2) U/S:
Types

1-TAS 2-TVS 3-Sonohysterography

Values

 Useful in diagnosis of many uterine & adnexal lesions & pelvic masses
Evaluation of endometrium
especially after development of TVS & sonohysterography.
3)Endometrial biopsy:
Types

1- Fractional D & C 2- Office endometrial biopsy 3- Hysteroscopic guided biopsy

Values

Diagnostic
Therapeutic "To stop Bleeding"

Findings (Possibilities of endometrial pattern detected by D&C)

1st 4 patterns not present in postmenopausal patients

❶ Normal proliferative endometrium
❷ Normal secretory endometrium
Possibilities
❸ Irregular ripening of endometrium (see later)
in
❹ Irregular shedding of endometrium (see later)
DUB
-----------------------------------------------------
❺ Hyperplastic (Endometrial hyperplasia)
❻ Atrophic endometrium
❼ Mg (Endometrial carcinoma)
❽ Specific endometritis (as TB endometritis)

4) Hysteroscopy:
Values

 Direct visualization of uterine cavity & EndoCx canal

"more reliable for identifying endometrial lesions & taking biopsy"

5) Other investigations: A2 suspected cause.

Radiologic
a) HSG: → For diagnosis of abnormal uterine cavity or space occupying lesions
(but C/I during bleeding episode)
b) CT scan or MRI

Endoscopic
-Laparoscopy For diagnosis of endometriosis, PID or ectopic pregnancy

-Pap smear & colposcopy.

Types of Endometrial Biopsy (Sampling)?

Office1 endometrial Hysteroscopic

Fractional D & C* biopsy guided biopsy
(The Best)
1-General anesthesia Endometrial aspiration using
Methods ((Steps))

2-Evacuate bladder Pippelle or Vebra aspirator

3-EUA
4-endocervical curettage
(1st sample)
5-Uterine sound
6-low corporeal curettage
(2nd sample)
7-high corporeal curettage
(3rd sample)
The classic method in the past, (Routine Nowdays) Only done in Certain
nowadays should be restricted ❶ Women at risk of circumstances:
to: Endometrial Hyperplasia
Indications

❶ DUB not responding to ttt è Suspected

❷Women at risk of
hormonal therapy ❶ SMF
Endometrial Carcinoma
" Therapeutic" ❷Intracavitary polypi
❸Women > 40y'
❷Office endometrial biopsy [Can be removed in
❹Women < 40y' è Chronic
can 't be done d2 Cx stenosis. same setting]
"Diagnostic" unopposed estrogen
breakthrough bleeding
1- More thorough sampling. Simple procedure that
Disadv Adv

2- Procedure may be therapeutic doesn't require anesthesia.

also.
.

Blind sampling Poor blind sampling Expensive

Need special Skills

*Dilatation & fractional curettage (formal D&C):

■ How it is fractional? → By obtaining separate biopsies from different uterine regions:
1- Endocervical biopsy. 2- Low corporeal biopsy. 3- High corporeal biopsy.
■ Why it is fractional? → To help in determination of site of lesion (Especially if Mg) w' may affect
management & prognosis.

● Should all patients undergo endometrial biopsy? → This depends on age:

a) Young adolescent Don't do D&C except after trial of all lines of ttt è persistent bleeding.
b) Woman in CBP  Postpone D&C for 3m' during w' give empirical ttt provided that there is no
organic lesion.
c) Perimenopausal & postmenopausal women  D&C is necessary.
● Time of endometrial sampling: → May be done:
a) During bleeding: → To determine endometrial pattern & help to stop bleeding.
b) Premenstrual [PMEB]: → To diagnose of anovulation & TB endometritis.

Treatment of AUD

ttt of Cause + ttt of DUB

 Dysfunctional Uterine bleeding [DUB]
Definition
-AUB in absence of gross Pelvic lesions
[Functional Disturbance in Normal mechanism of menstruation]
-Diagnosed by Exclusion

Incidence
• In general, 10% of all gynecologic patients
• MC cause of AUB
• Common at extremities of reproductive age (Perimenarcheal & Perimenopausal)
Perimenarcheal Immature HPO axis Perimenopausal  Dysfunction of HPO axis
Classifications:
❶ Etiological classification (A2 Cause)
A) 1ry DUB: → d2 dysfunction of HPO axis
(some authors consider that type is the only type of DUB).
B) 2ry DUB: → Includes:
1) Cases è known extragenital disorder causing this bleeding [General Causes]
2) Cases associated è use of contraception [Hormonal or IUD] or other drugs
❷ Clinical classification (A2 Pattern)
A) Anovulatory DUB (90%) B) Ovulatory DUB (10%)  Cyclic (Regular)
1) Cyclic (regular): 1) Dysfunctional menorrhagia:
Pseudomenstruation (è COCs)? a) Irregular ripening of endometrium.
2) Acyclic (dysfunctional metrorrhagia): b) Irregular shedding of endometrium.
a) Birth crisis 2) Dysfunctional Polymenorrhea:
b) Threshold (withdrawal) bleeding. a) Short follicular phase.
c) Metropathia hemorrhagica. b) Short luteal phase.
3) Ovulatory spotting

❸ Hormonal Classification ?
Mechanism Occurs in
1)Estrogen Birth crisis
withdrawal bleeding threshold bleeding
↓↓ estrogen level → endometrial
 ovulation spotting
shedding.
 stopping of exogenous
estrogen therapy
2) Estrogen Unopposed estrogen action
breakthrough bleeding →hyperplastic endometrium è lack of Chronic anovulation
stromal support (d2 absence of progest.) Metropathia
"Previously known as → fragile unstable endometrium that hemorrhagica.
Metropathia hemorrhagica" undergoes superficial necrosis & sloughing
3) Progesterone ↓↓ progesterone level in estrogen
withdrawal bleeding primed endometrium
→ VC of endometrial BVs → endometrial  COCs use.
ischemia & shedding.

4) Progesterone Prolonged continuous progesterone Long acting progesterone

breakthrough bleeding administration → thin & atrophic contraceptive use
endometrium → irregular bleeding. (Long acting injectable)
Clinical types:
A) Pseudomenstruation: → Occurs è COCs use.
● Woman takes pills for continuous 21d' then stop it for 7d' → sudden hormonal withdrawal →
bleeding (progesterone withdrawal bleeding).
● Bleeding is cyclic [recurs every month] but anovulatory
B) Dysfunctional metrorrhagia:
1) Birth crisis: → Bleeding during 1st wk of life d2 withdrawal of placental estrogen from
neonatal blood
No Need of ttt, only assurance (Self-limited èin hours or days)
2) Threshold bleeding: → ↓↓ estrogen level below level (threshold) w' can maintain
endometrium
3) Metropathia hemorrhagica (Shroeder's disease):
● Definition: → Condition ch' by painless heavy bleeding preceded by short period of
amenorrhea (6-8wks) è absence of CL.
● Incidence: → Common after puberty, before menopause & after labor or abortion.
● Etiology: → Chronic anovulation.
● Pathogenesis:  Estrogen breakthrough bleeding.
■ Chronic anovulation + hyperestrogenemia → endometrium grows till become hyperplastic
èout shedding → period of amenorrhea.
■ Hyperplastic endometrium continues to grow till it can't be controlled by estrogen (relatively)
→ endometrial shedding → heavy bleeding.
● Pathology:
Uterus Ovaries
Symmetrically enlarged & soft
Large & multicystic
N/E -myometrial hypertrophy
(Bilateral Polycystic ovaries)
-thick polypoidal endometrium
-Myometrial hypertrophy
-No CL
M/E -Cystic? Endometrial hyperplasia
-Ovarian cysts lined by granulosa cells
(Swiss cheese appearance)
● C/P:
→ Short period of amenorrhea (6-8 weeks) followed by painless heavy vaginal bleeding
→ symmetrically enlarged soft uterus & Bilateral cystic ovaries.
● Investigations:
a) Hormonal profile: → High estrogen.
b) U/S → Symmetrically enlarged uterus + thick polypoidal endometrium + cystic ovaries
c) Endometrial biopsy: → Hyperplastic endometrium.
d) Hysteroscopy: → Hyperplastic polypoidal endometrium.
● DDx:
a) Causes of bleeding in early pregnancy.
b) Causes of symmetrically enlarged uterus.