ABNORMAL UTERINE BLEEDING

• Abnormal Uterine Bleeding/aub- encompasses any significant term "menorrhagia" discarded & replaced by HMB ( heavy intermenstrual bleeding (IMB) is
deviation from normal frequency, regularity, heaviness ( volume or menstrual bleeding) recommended to replace the term
amount) and duration of menstrual bleeding. Also describes all abnormal  defined as excessive menstrual blood loss which “metrorrhagia"
menstrual signs & symptoms arising from the uterine corpus interferes with a woman's physical, emotional, social &  occurs bet clearly defined
• Normal limits of menstruation & its cycle material quality of life, and which can occur alone or in cyclic & predictable menses,
freq: 24-38d Epidemiology combination with other symptoms may occur randomly or
regularity: variatn of +- 2-20d predictably on the same day in
duration of flow: 4.5- 8d 4 - 51.6% each cycle
volume of monthly blood loss: 5-80 ml
dysfunctional uterine bleeding/dub should be discarded acute aub - an episode of bleeding in a woman of reproductive • chronic aub - bleeding frm
 accdg to FIGO, the justifications for abolishing the term "dub" are age,who is not pregnant, that is of sufficient quantity to require the uterine corpus that is
A. a dx of exclusion & admission of ignorance abt local mechanisms immediate intervention to prevent further blood loss abnormal in duratn, flow &/
B. "old dub" includes coagulopathies, ovulatory disorders & endometrial  range frm modest to excessive hmb associated w/ frequency & has been
dysfunction( infectn, dsturbances of local hemostasis,inflammatn, hypovolemic shock present for the majority of
vasoactive regulators)  more common in anovulatory women the last six months
 requires urgent/ emergent medical intervention that
often leads to frequent use of urgent care,emergency &
operating room resources
Pathophysiology FIGO Classification System for Causes of AUB
Factors that come into play for hemostasis PALM grp refers to structural entities that can be measured COIEN grp refers to non structural
1. higher thromboxane level(PGF2) in relatn to prostacyclin PGE2 visually with imaging techniques &/ histopathology entities not identified by imaging or
2. fibrin clot formatn histopathology
3. stabilizatonn of hemostatic platelet plug
Polyp (AUB-P) Adenomyosis (AUB-A) Leiomyoma(AUB-L) Malignant & hyperplasia (AUB-M)
-- endometrial polyps are widely --hypothesis of AUB in usually presents as HMB sufficiently severe to cause anemia. -- premalignant hyperplasia or
recognized structural abnormalities adenomyosis AUB results from malignant process
causing AUB a) increased endometrial surface a) increased surface area of endometrium due to mechanical
-- fd in all age grps; mostly in older b) altered PGE/PGF2£ balance distortion
women c) hampered myometrial b) ulceration & hemorrhage of endometrium overlying the
-- present as hmb,imb or contractility submucous fibroids
postmenopausal bleeding & may be asso d) abnormal myometrial c) interference by the myomas w/normal uterine hemostasis
w/dysmenorrhea angiogenesis asso w/ fragile blood d) mechanical compression of the venous drainage by the
-- dx based on eithr a combinatn of vessel myomas at any site
ultrasound or hysteroscopic imaging w/ e) dilatation of the venous plexuses draining the endometrium
or w/o histopath -- types
a) close to cavity: submucosal
- are highly vascularized w/large fragile vessels on their
surfaces-- bleeding during menses cnt be stopped promptly by
myometrial contractions because of their intracavitary position
b) myometrium: intramural
c) close to outer surface: subserosal
d) independent of uterus: parasitic
Polyp (AUB-P) Adenomyosis (AUB-A) Leiomyoma(AUB-L) Malignant & hyperplasia (AUB-M)
Coagulopathy(AUB-C)
-- spectrum of systemic
disorders of hemostasis asso
w/aub
-- 13% prevalence rate of von
willebrand's dse in hmb
--persons on chronic
anticoagulant drugs ie
warfarin,heparin & low
molecular wt heparin
Ovulatory dysfunction (AUB-O)
-- usu manifests as a combination of
unpredictable bleeding & variable
amount of flow
-- asso w/ nonsecretory endometrium
-- most common after menarche or just
before menopause
-- maybe also due to endocrinopathies ie
PCOS,hypothy,
hyperprolactinemia,mental
stress,obesity, anorexia, wt loss or
extreme exercise
Iatrogenic (AUB-I) Endometrial (AUB-E) Not yet Classified (AUB-N)
-- manifest w/irregular bleeding or -- predictable & cyclic bleeding -- chronic endometritis, AV mal
commonly as breakthrough bleeding & without identified causes & myometrial hypertrophy
-- result from inconsistent use of
medicated or inert IUD & pharma
agents that directly impact the
endometrium,interfere w/ blood
coagulation mechanisms or influence
the systemic control of ovulation
-- eg intake of coc's, IUD's,steroids,
tranquilizers,digitalis,dilantin,rifampicin
& griseofulvin

1. History
-- should include inquiry into
the character & nature of
bleeding, related symptoms
that may implicate a structural
or histologic abnormality, fam
hx, contraceptive hx & presence
of co- morbid factors
2. PE
-- to identify any structural
pathology or systemic dse as
etiology
3. Blood tests
- CBC should be obtained in all cases
- pregnancy test in reproductive age grp
- coagulation tests considered only in
HMB at an early age (since menarche) &
have a personal/family history suggestive
of coagulopathy
- female hormone testing (estradiol,
progesterone, LH & FSH) should not be
routinely done
- thy screening in pts w/ s/sx of thy dse
Diagnosis
4. Imaging procedures
a) utz: 1st line diagnostic tool for
identifying structural abnormalities
---> transvag utz is highly sensitive for
detecting endometrial CA (96%) &
endometrial abnormality (92%)
---> most sensitive in detecting dse in
postmenopausal bleeding w/ 5mm cut
off endometrial thickness
---> should be done bet day 4-6 of
menstrual cycle
b) saline infusion sonography(SIS)
-- should not be used as 1st line
diagnostic tool
-- provides a more accurate evaluation
of uterus w/ intracavitary lesions
c) hysteroscopy
- used as a diagnostic tool
when utz results are
inconclusive (as to determine
the exact location of fibroid or
exact nature of abnormality) &
in the presence of focal lesions
of endometrium
- allows direct visualization of
endom cavity & targeted
endometrial sampling of any
suspicious areas
outpatient endometrial biopsy
is recommended as 1st line
diagnostic tool
--- indications:
a) age >40
b) risk factors for endometrial
cancer
c) failure of medical treatment
d) breast cancer pts on
tamoxifen who complain of
AUB
 MANAGEMENT
Medical management of AUB Surgical management of AUB
Acute AUB Chronic AUB a) D & C
- should be considered before any surgical -- is not recommended since it provides only a temporary reductn in bleeding
procedure unless bleeding is due to --with hysteroscopy: valuable when intrauterine patholology suspected or tse sample is
intrauterine lesions ie submucous myoma desired

A. hormonal
1. high dose conjugate equine estrogen(CEE)
-- effective in treating acute severe AUB
--25mg iv CEE q 4h will stop the bleeding in 5h
2. high dose COC in tapered doses
3.progestins (oral & im)
A. hormonal
1.levonorgestrel-releasing IUS (Mirena)
-- highly effective w/ addl benefit of
relieving dysmenorrhea & reducing b) endometrial ablation
blood loss -- may be use as initial treatment in women not desirous of future pregnancies in the
-- reduce endometrial thickness & absence of structural or histologic abnormality
vascularity
2. COC (Qlaira)
-- combinatn of estradiol valerate &
dienogest
cyclic progestogen
-- given for 21d results in reductn of c) hysterectomy
blood loss -- should not be used as first line of treatment
4. danazol & GnRH agonist -- indicated only when there's failed medical treatment, severely affects quality of life
- may be used in cases of failed medical
treatment or when they are
contraindicated

B. non hormonal
tranexamic acid 1gm q6h
B. Non hormonal
1. antifibrinolytic agents
-- inhibit plasminogen activation &
fibrinolysis
2. NSAID's
--less effective