CASE REPORT

ABNORMAL UTERINE BLEEDING ET CAUSA

SIMPLEX ENDOMETRIAL HYPERPLASIA

COUNSELOR:
DR. NI MADE INDRI, SPOG

WRITTEN BY:
CAKRA DININGRAT 61112032

CLINICAL MEDICAL STUDENTS

OBSTETRY AND GYNECOLOGY DEPARTMENT OF EMBUNG FATIMAH HOSPITAL
MEDICAL FACULTY OF BATAM UNIVERSITY
2016
URGENCY

AUB:
Primary reason for at least 1/3 gynecology visits

AUB is often a difficult diagnostic and therapeutic

challenge

Physicians are often unable to identify the cause of

abnormal bleeding after a thorough history and
physical examination
AUB accounts for > of all hysterectomies
performed in USA

Affects daily activities troubled while working

(28%) affect economy sector

20% of hysterectomy specimens removed for AUB

has no visible pathology AUB are potentially
treatable using hormonal therapy or other systemic
and local modalities
Improperly managed anovulatory bleeding
endometrial cancer (1-2%)
PATIENT STATUS

Patient Status:
Identity
Name : Mrs. Sa
Age : 43 years old
Sex : Female
Medic Record Numb : 165953
Adress : Masyeba Indah Housing cc
no. 4 Belopa District.
Occupation : Housewife
Religion : Islam
Date of Entry : December 1st 2016 02.15 PM
ANAMNESIS

Patient came to Mother and Child Polyclinic of

Embung Fatimah Hospital with her family on
Thursday, December 1st 2016.

Chief Complaint
Bleeding per vaginam
History of Present Illness
1. Bleeding which flowing and clotted with dark red
colour from her vagina since 1 week ago, changed
her pads 4 times a day in last week.

2. Nausea (-), vomit (-), dizzy (+) with spinning

sensation, fatigue (+), defecation (+) hard to pass,
urination (+) normal, hard to sleep (+), sore (+) on
ankle, spread to soles of the feet.
3. 1st bleeding per vaginam happened in 2015, but she has
forgotten the date and the month. She has been bleeding 20
days. Blood looked fresh red, flowing. She changed pads,
unaccountable each a day.

4. Then, she went to a doctor in Makassar. The doctor diagnosed:

Premenopause Syndrome, she didnt want to continue the
therapy because she thought its a variation of normal bleeding.

5. In August 2015, she had the 2nd bleeding. She had been
bleeding per vaginam for 30 days. Blood looked dark red,
flowing, clotting. She changed pads 4 times a day and finally
went to hospital because feeling really weak
7. In the hospital, she got blood transfused as much
as 8 unit and got examinated with USG and
diagnosed with Abnormal Uterine Bleeding.

8. Since the transfusion, the HBsAg test result became

(+)

9. Then, she got curettaged. But the preparation was

not given to anatomic pathology department since
the departments not exist in that hospital.
Menstruation History
- Menarch in 13 years old
- Menstruation cycle: 28 days
- Duration: 5 days, regular getting not regular
since the first bleeding per vaginam in 2015. After
the abnormal bleeding, she could get menstruation

as long as 3 days, then stop for 2 days, and get

menstruation again.
Family Illness History
Hypertension (+) mother
Asthma (-)
DM (-),
Allergies (-).

Marriage History
Married, once, for 27 years until now.

Contraception History
Never use contraception
Obstetric history:
1st child: Female, BW: 3600 g, alive, spontaneous delivery in 1990 with midwife
2nd child: Female, BW: 3500 g, alive, spontaneous delivery in 1995 with midwife
3rd child: Female, BW: 3500 g, alive, spontaneous delivery in 1997 with midwife
4th child: Female, BW: 3400 g, alive, spontaneous delivery in 2001 with midwife
5th child: Female, BW: 3400 g, alive, spontaneous delivery in 2004 with midwife
6th child: Female, BW: 3300 g, alive, spontaneous delivery in 2008 with midwife
Gynecology History
Vaginal discharge (-)
Postcoital bleeding (-),
Late of period (-),
Painful menstrual (-),
Painful sex (-).
Past Illness History
Hypertension (-)
DM (-)
Drug allergies (-)
Asthma (-).

Surgery History
Curretaged with indication of abnormal uterine bleeding in August
2015

Habit History
Smoking (-), alcoholism (-), drugs & herbs (-).
GENERAL STATUS

General condition: Patient seems sick, mild

condition.
Sensorium : Compos mentis
Weight : 52 Kg
Height : 162 cm
Vital Signs :
BP : 130/90 mmHg
P : 74x/minute
RR : 18x /minute
T : 36.0 C
Head : Normocephaly, black hair, not easily fall
Eye : conjungtiva anemis (+), sclera not icteric,
Palpebral edema -/-
ENT : Ear discharge -/-, nouse discharge -/-,
tonsil not hyperemic T1-T1
Neck : Lymfadenopathy (-), thyroid papabled -
not getting bigger
Thorax :
Mammae : Hyperpigmentation, nipples
protruding +/+
Pulmo : breath sound vesicular +/+,
ronchi -/-, wheezing -/-
Cor : S1-S2 regular, murmur (-),
gallop (-)
Abdomen : Fine skin turgor , Simetric
Extremity : warm acral (+/+), edema (-/-)
GYNECOLOGIC STATUS

Bleeding per vaginam :(+) flowing, clotted

Inspeculum :Not applied
Bimanual :Not applied
WORK UP Laboratory Studies: December 1st 2016
WORK UP Laboratory Studies: December 2nd 2016
WORK UP Laboratory Studies 24-12-2016
WORKING DIAGNOSIS

Abnormal uterine bleeding et causa simplex

endometrial hyperplasia + HbsAg (+)
MANAGEMENT

Working Plan:
Check CBC
Transfusion, PRC 2 units

Therapy:
IVFD RL 20 dpm
Inj. Ceftriaxone 2x1

Inj. Vit K 3x1

Inj. Vit C 3x1

Cycloproginova tab 1x1

PATIENT CAME TO MOTHER & CHILD HEALTH
POLYCLINIC December 1st 2016 10.15 AM

S Bleeding per vaginam since 7 days ago. Sometimes

clotted. Sore feet. Curattaged 2 months ago in
Sulawesi.
O General condition: Good
Sensorium: Compos mentis
BP: 120/80 mmHg P: 76x/minute
RR: 22x/minute T: 36.8 C
USG TV: Uterus in normal limit (7x5 cm)
Endline 1.6 cm
A Abnormal uterine bleeding et causa simplex
endometrial hyperplasia + HbsAg (+)
P R/ Consult the anatomic pathology result to dr. Indri,
SpOG to be read.
R/ Consult the anatomic pathology result to dr.
Indri, SpOG to be read.

Preparation number: 659016/H/PA/RSUD Batam. Date Entry: Monday,

October 17th 2016:
Macroscopic:
Fragments of tissue as much as 2 cc, blackish brown, spongy consistency
partly fragile.

Microscopic: Curratage preparation consists of:

Stroma and proliferative endometrial gland
Tubular form partly dilated
Layered by hyperplastic thoracic cell
Cells are still normal
Fragments of endocervix tissue layered by hyperplastic thoracic cell
Polypoid structured
Nucleus cell is still normal
Among the preparation there is clotted blood and lymphocyt, hystiocyte,
and some PMN cell infiltration
FOLLOW UP IN MAWAR WARD
December 1st 2016 05.25 PM

S Bleeding per vaginam.

O General condition: Good
Sensorium: Compos mentis
BP: 160/100 mmHg
P: 78x/minute
RR: 22x/minute
T: 36.8 C
A Abnormal uterine bleeding et causa simplex endometrial
hyperplasia + HbsAg (+)
P R/ Observe vital signs
Observe bleeding per vaginam
Check CBC
IVFD RL 20 dpm Inj. Vit K 3x1
Inj. Ceftriaxone 2x1 InjVit C 3x1
Inj. Traneksamat 3x1 Inj. Ketorolac 2x1
Aprazolam tab 2x1
FOLLOW UP IN MAWAR WARD
December 2nd 2016 05.35 AM

S Dizzy (+) with spinning sensation, bleeding per vaginam.

O General condition: Good
Sensorium: Compos mentis
BP: 160/100 mmHg
P: 80x/i
RR: 22x/i
T: 36.7 C
b/v: (+) spotting
A Abnormal uterine bleeding et causa simplex endometrial
hyperplasia + HbsAg (+) + Post transfused PRC 2 kolfs.
P IVFD RL 20 tpm
Inj. Ceftriaxone 2x1
Inj. Traneksamat 3x1
Inj. Vit K 3x1
InjVit C 3x1
Inj. Ketorolac 2x1
Aprazolam tab 2x1
FOLLOW UP IN MAWAR WARD
December 3rd 2016 06.00 PM

S -
O General condition: Good
Sensorium: Compos mentis
BP: 130/90 mmHg
P: 80x/i
RR: 20x/i
T: 36.4 C
b/v: (+) spotting, slimy
A Abnormal uterine bleeding et causa simplex endometrial hyperplasia +
HbsAg (+)
P IVFD RL 20 dpm
Inj. Ceftriaxone 2x1
Inj. Traneksamat 3x1
Inj. Vit K 3x1
InjVit C 3x1
Inj. Ketorolac 2x1
Aprazolam tab 2x1
FOLLOW UP IN MAWAR WARD
December 4th 2016 06.30 AM

S -
O General condition: Good
Sensorium: Compos mentis
BP: 130/90 mmHg
P: 80x/i
RR: 20x/i
T: 36.4 C
b/v: (+) spotting, slimy
A Abnormal uterine bleeding et causa simplex endometrial hyperplasia +
HbsAg (+)
P IVFD RL 20 tpm
Inj. Ceftriaxone 2x1
Inj. Traneksamat 3x1
Inj. Vit K 3x1
Inj. Vit C 3x1
Inj. Ketorolac 2x1
Aprazolam tab 2x1
FOLLOW UP IN MAWAR WARD
December 5th 2016 07.10 PM

S -
O General condition: Good
Sensorium: Compos mentis
BP: 170/100 mmHg
P: 88x/i
RR: 20x/i
T: 36.0 C
b/v: (-) spotting, slimy
A Abnormal uterine bleeding et causa simplex endometrial
hyperplasia + HbsAg (+)
P IVFD RL 20 tpm
Inj. Ceftriaxone 2x1
Inj. Traneksamat 3x1
Inj. Vit K 3x1
InjVit C 3x1
Inj. Ketorolac 2x1
Aprazolam tab 2x1
FOLLOW UP IN MAWAR WARD
December 6th 2016 07.10 PM

S -
O General condition: Good
Sensorium: Compos mentis
BP: 170/100 mmHg
P: 88x/i
RR: 20x/i
T: 36.0 C
b/v: (-) spotting, slimy
A Abnormal uterine bleeding et causa simplex endometrial hyperplasia +
HbsAg (+)
P IVFD RL 20 tpm Vit C tab 3x1
Mefenamic acid tab 3x500 mg Cycloproginova tab 1x1
Tranexamat acid 3x500 mg
SF tab 1x1
Vit K tab 3x1
Amlodipine tab 1x5 mg
RESUME
Patient, female, 43 years old came with irregular heavy menstrual bleeding.
The bleeding is flowing, clotting, dark-red coloured, she had to changed her
pads 4 times a day. General status: moderate. Vital signs: normal.
She had blood got examinated with USG and diagnosed with hyperplasia
endometrium, got transfused 8 units and currataged in August 2015 in
Makassar.
The patient also got currataged in Embung Fatimah Hospital, and the
preparation enter the anatomic pathological deparment on Monday,
October 17th 2016. The results are the possibility of endocervical polyp or
endometrial hyperplasia.
On December 1st-6th 2016, the patient got treatment on Embung Fatimah
Hospital.
When she was home, the medical drugs just stopped the bleeding for
temporary time. She had bled again. On December 24th 2016, the patient
went to Embung Fatimah Hospital for the second time. She got USG, D & C,
and anatomic pathological examination.
RELATED LITERATURE
DEFINITION

Normal Uterine bleeding:

Consensus of HIFERI in Bogor (2013): a physiological process
where there is a bleeding, mucus and cellular debris from the
uterus periodically at regular intervals that occurred since
menarche to menopause with the exception of pregnancy and
breastfeeding, which is the result of harmonic regulation of
hormonal organs.
 LIMITATION OF NORMAL MENSTRUAL PARAMETERS OF
REPRODUCTIVE AGE
Menstruation Clinical Dimention Clinical Indicator Normal Limit

Menstruation and menstrual cycle (percentile 5 95 th)

Frequency (day) Frequent <24
Normal 21-35
Infrequent >38
Menstrual cycle regularity, variation from Absent No Bleeding
cycle to cycle during 12 months (day)

Regular Variation 2-20 hari

Irregular Variation > 20 hari

Duration (day) Prolong >8.0

Normal 4.5-8.0
Shorten <4.5
Blood Loss Volume per months (ml) Heavy >80
Normal 5-80
Slight <5
What is AUB?

AUB is broadly defined as any uterine bleeding that

occurs outside the parameters of normal
menstruation during the reproductive years.

AUB is a term used to describe all of menstrual

abnormalities both in the amount and duration.
Epidemiology

AUB is a common diagnosis 5-10% of cases in the

outpatient clinic setting.
Occur in 9 to 14% women between menarche and
menopause.
Prevalence varies in each country
Estimated at 1113% in the general population and
increases with age, reaching 24% in those aged 36
40 years
20% teenagers
50% individuals aged 40-50 years old
In a study of 400 perimenopausal women
bleeding pattern >> menorrhagia (67.5%),
pathology >> simple endometrial hyperplasia w/o
atypia (31%)
Classification & Etiology

Patterns of Uterine Bleeding Definition

Amenorrhea Absence of menstruation for 6
months in nonmenopausal woman

Polymenorrhea Uterine bleeding at intervals < 21

days
Oligomenorrhea Uterine bleeding at intervals > 35
days
Menorrhagia/Heavy menstrual Excessive bleeding at regular
bleeding intervals; heavy flow ( 80 ml) or
duration ( 7 days)

Menometrorrhagia Heavy, irregular bleeding

Metrorraghia/ Instermenstrual Irregular intervals (between
menstrual periods)
Midcycle spotting : Spotting occuring just before
ovulation, typically from
declining estrogen levels
Postmenopausal : Recurrence of bleeding in a
bleeding menopausal woman at least 1 year
after cessation of cycles
Acute emergent AUB : Bleeding characterized by
significant blood loss that results
in hypovolemic shock
Dysfunctional uterine : Ovulatory or anovulatory
bleeding bleeding, diagnosed after the
exclusion of pregnancy,
medications, iatrogenic causes,
genital tract pathology, and
systemic disease
DUB

DUB excessive uterine bleeding in cases in which no uterine pathology

can be identified

Because there is greater understanding of AUB and availability of more

sophisticated diagnostic techniques, this term is less frequently used
today.

DUB term is used to refer to widely divergent causes of AUB, a national

consensus group recently concluded that this term is unlikely to improve
diagnosis or treatment and thus no longer has any usefulness in clinical
medicine.

DUB term is not included in the system and should be abandoned, per
the agreement process.
Classification

Acute
Excessive bleeding.
Immediate management to prevent blood loss.
Can occur in chronic AUB or without history before.

Chronic
AUB happens 3 months.
Usually need no immidiate management.

Intermenstrual/metrorrhagia
Occurs between clearly defined cyclic and predictable menses.
May occur at random times or may manifest in a predictable fashion
at the same day in each cycle.
PALM COEIN

Based on International Federation of Gynecology

and Obstetrics (FIGO), there are 9 main categories
organized according the acronim PALM COEIN
which was introduced by FIGO in 2011
PALM (structural) COEIN (non-structural)

Polyp Coagulopathy

Adenomyosis Ovulatory dysfunction

Leiomyoma Endometrial

Malignancy and hyperplasia Iatrogenic

Not yet classified

PALM discrete (structural) entities that can be
measured visually with imaging techniques and/or
histopathology

COEIN entities that are not defined by imaging or

histopathology (non-structural).

The system was constructed recognizing that any

patient could have 1 or several entities that could
cause or contribute to AUB
Polip (AUB-P)

Often asymptomatic, but it is generally accepted that

at least some contribute to the genesis of AUB.

Lesion Usually benign, but a small minority may

have atypical or malignant features.

Defined by:
USG
Hysteroscopy
Histopathology
Cervical polyp
Adenomyosis (AUB-A)

Often asymptomatic
The relationship between adenomyosis and the genesis of AUB is
unclear,
Prevalence of adenomyosis vary widely: ranging from 5% to 70%
probably related to inconsistencies in the histopathologic
criteria for diagnosis.

Generally, these criteria have been based on:

USG (absolute presence of heterotopic endometrial tissue in the myometrium
and partly due to the related myometrial hypertrophy)
MRI
Hysterectomy Histopathologic evaluation of the depth of endometrial
tissue beneath the endometrialmyometrial interface
Leiomyoma (AUB-L)

Benign fibromuscular tumors of the myometrium

leiomyoma, myoma, and the frequently used
fibroid.
Often asymptomatic
Prevalence
70% in Caucasians
80% in women of African ancestry),
their spectrum of size and location: subendometrial,
intramural, subserosal, and combinations
Schematic Diagram of Varying Fibroid Location in Uterus
Malignancy and hyperplasia (AUB-M)

Atypical hyperplasia and malignancy are important

potential causes relatively uncommon must be
considered in nearly all women of reproductive age.

The present classification system is not designed to

replace those of WHO and FIGO for categorizing
endometrial hyperplasia and neoplasia.

PALM COEIN AUB-M WHO or FIGO

classification system.
WHO Classification of Endometrial Hyperplasia
FIGO Classification of Endometrial Hyperplasia
Coagulopathy (AUB-C)

13% of women with HMB have biochemically detectable

systemic disorders of hemostasis von Willebrand
disease >>
However, it is not clear how often these abnormalities
cause or contribute to the genesis of AUB and how often
they are asymptomatic or minimally symptomatic
biochemical abnormalities.
For some reproductive-aged women w/ chronic
anticoagulation (a necessary and life-preserving
intervention) undesirable adverse effect, HMB >>
considered iatrogenic (AUB-I) would be more
appropriate to classify the AUB to coagulopathy (AUB-C).
Ovulatory dysfunction (AUB -O)

Manifestation : combination of unpredictable timing

of bleeding and variable amount of flow, which in
some cases results in HMB.

In many regions, particularly (but not limited to) the

USA, ovulatory disorders comprised the vast
majority of cases encompassed by the now-discarded
term DUB.
Although most ovulatory disorders elude a defined
etiology, many can be traced to endocrinopathies (e.g:
POCS,
hypothyroidism,
hyperprolactinemia,
mental stress, obesity,
anorexia,
weight loss, or
extreme exercise such as that associated with elite
athletic training).
In some instances, the disorder may be iatrogenic,
gonadal steroids (estrogens, progestins, and androgens) or
drugs that impact dopamine metabolism:
such as phenothiazines
tricyclic antidepressants

unexplained ovulatory disorders frequently occur at

the extremes of reproductive age: adolescence and
the menopause transition.
Endometrial (AUB-E)

When AUB occurs in the context of

predictable and cyclic menstrual bleeding
typical of ovulatory cycles,
no other definable causes are identified,

primary disorder of the endometrium

Iatrogenic (AUB-I)

Mechanism:
Medicated* or inert intrauterine systems** and
pharmacologic agents that directly impact the
endometrium,
Interfere with blood coagulation mechanisms***, or
Influence the systemic control of ovulation

*Medication: antibiotic (rifampicin), antifungi (griseofulvin),

tricyclic antidepressant (amitriptilin)
**LNG-IUS
*** Anticoagulant (warfarin, heparin, and low molecular weight
heparin
Not yet classified (AUB-N)

there may be other disorders, not yet identified would be defined

only by biochemical or molecular biology assays Collectively,
these entities have been categorized as not yet classified.

Chronic endometritis, arteriovenous malformations, and

myometrial hypertrophyhave been poorly defined, inadequately
examined, or both.

As further evidence becomes available, they may be allocated a

separate category or be placed into an existing category in the
system.
Diagnosis

ANAMNESIS
Exclude the diagnosis of pregnancy first
qualification and quantification of bleeding:
Rule out bleeding source from the GI or urinary tract
onset, duration, frequency, amount and pattern

Additional complaint: degree of pain, vaginal discharge, fever, nause, and

vomitting
Address the presence of local and systemic disease
Rule out the presence of signs or symptoms indicative of bleeding disorders
easy bruising, bleeding gums, epistaxis, and excessive bleeding episodes during childbirth, surgery,
or dental procedures

Gynecologic and obstetric history

Contraceptive history
Medical therapy history
Change in the patients diet, weight, and exercise pattern
Physical Examination
First examination is applied to evaluate hemodynamic stability
Make sure the bleeding source is from cervicalis canal and not related to
pregnancy
BMI (obesity)
Signs of androgen excess (hirsutism, acne)
Thyroid enlargement or manifestations of hyperthyroidism or
hypothyroidism.
Galactorrhea (may suggest hyperprolactinemia)
Visual field deficits (raise suspicion of intracranial/pituitary lesion, e.g
pituitary adenoma)
Ecchymosis, purpura (signs of bleeding disorder)
Signs of anemia or chronic blood loss
A careful gynecologic examination, including Papanicolaou test (Pap
smear) and sexually transmitted disease (STD) screening, is warranted.
Blood loss estimation during menstruation.

PBAC score

Blood loss during menstruation can be assesed by

pictograph, such as PBAC. This chart can be used to
diagnose and evaluate progress of the AUB
management.
Pictogram of Menstruation Blood Loss Estimation
Inspeculum examination
Indication:
if there is a persistent bleeding or
a change of bleeding after using contraceptive for 3 months or
failed medical therapy or never get cervix cancer screening are exist
Inspect the cervix for polyps, sins of infection, or inflammation

Bimanual examination
Must be done if bleeding with other symptoms (pain, dyspareunia or
heavy bleeding) is exist
determine uterus size, adnexal masses, and the presence and character of
any tenderness
Laboratory Studies

Complete blood count test (evaluate anemia and/or

thrombocytopenia)
Urinalysis (evaluate urinary tract infection)

Liver function test

Thyroid function test (TSH, T3, T4)

Blood glucose, HbA1C (to evaluate diabetes)

FSH, LH, dan estradiol level test (evaluate PCOS)

Total testosteron, free testosteron, DHEAS, free androgen

index, test (if virilization symptoms exist, so PCOS can be

evaluated)
Hemostasis function
PT, PTT, thrombocytosis (evaluate ITP, Von Willebrand)

Criteria should be considered a positive screen for coagulopathies:

History of heavy bleeding starting at menarche
One of the following:
o Postpartum haemorrhage
o Surgery-related bleeding
o Bleeding associated with dental work

At least two of the following symptoms:

o At least one episode of bruising per month
o At least one episode of epistaxis per month
o Frequent gum bleeding
o Family history of bleeding symptoms

Examination: Including assessment of weight, pallor, thyroid, breasts, acne, hirsutism scoring (if present),
abdominal, P/S and P/V examination
Pap smear (evaluate cervical dysplasia)
Cervical culture
Endometrial biopsy
Rules out the chronic endometritis.
All women > 40 years old should have an endometrial biopsy
after pregnancy is excluded to detect endometrial hyperplasia
or cancer and
all women younger < 40 years old who have persistent AUB,
unopposed estrogen exposure, or failed medical management.
Miometrial biopsy
Endometrial Histopathology
Must be performed in the case of any risk factor for endometrial
cancer and for all patients older than 45 years
Diagnostic curratage under general anesthesia is not recommended
as a first-line treatment. 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,

 Imaging Studies
Ultrasonography
Recommended as first-line procedure for the etiological diagnosis of AUB.
TVUS
Doppler ultrasonography
3D USG

Hysteroscopy/hysterosonography
Suggested as a second-line procedure when ultrasound suggests an intrauterine
abnormalities or if medical treatment fails after 3-6 months
USG not clear Hysteroscopy

SIS/Saline Infusion Sonography

Not used as a first-line diagnostic tool.
Useful in the assessment of the uterine cavity distortion caused by myomas

MRI
TVUS of Endometrial Polyp

A: Hyperchoic mass within endcav, B: Internal vascularity within endometrial polyp

TVUS of Adenomyosis

Adenomyosis: No capsule
TVUS of Fibroid
Endometrial Thickening up to 16 mm

Endometrial Hyperplasia
Focal or diffuse thickening of endometrial
complex. Preservation of endometrial-
myometrial interface.
Doppler USG of Adenomyosis

Adenomyosis
- Spiral aterial endometrial blood
pattern

Fibroid
- Single vessel on the periphery
-
Hysteroscopy
Hysteroscopy of Endometrial Polyp
Hysteroscopy of Adenomyosis
 Hysteroscopy of Fibroid

SM

Superificial blood vessels easily visible through overlying stretched pale endometrium
Hysteroscopy of Endometrial Hyperplasia
Hysteroscopy of Endometrial Cancer
SIS of Endometrial Polyp
SIS of Submucosa Fibroid
 DIFFERENTIAL DIAGNOSIS
Genital tract pathologies
Infections: cervicitis, endometritis, myometritis, salpingitis
Neoplastic entities
Benign anatomic abnormalities: polyps of the cervix or endometrium, adenomyosis, leiomyomata,
Pre-malignant lesions: severe cervical dysplasia causing early invasion, endometrial hyperplasia,
Malignant lesions: cervical carcinoma, leiomyosarcoma and oestrogen-producing ovarian tumors.
Systemic conditions
Adrenal hyperplasia and Cushings disease,
Blood dyscrasias including leukaemia and thrombocytopenia,
Coagulopathies Von Willibrand disease,
Hepatic disease,
Hypothalamic suppression (from stress, weight loss, weight gain, excessive exercise, polycystic ovarian disease (PCOD),
Pituitary adenoma or hyper-prolactinemia may lead to cycle disturbances before developing amenorrhoea,
Polycystic ovary syndrome,
Renal disease,
Thyroid disease
Trauma
Foreign body,
pessary,
Intra Uterine Contraceptive Device (IUCD),
injuries,
sexual abuse or assault
Medication and iatrogenic causes
Anticoagulants,
Antipsychotics,
Corticosteroids,
Hormone replacement therapy,
Intrauterine devices,
Oral contraceptive pills, Depot provera including progestin-
only pills,
Selective serotonin re-uptake inhibitors,
Tamoxifen (Nolvadex),
Thyroid hormone replacement
MANAGEMENT OF PATIENTS WITH AUB BASED
ON THE ETIOLOGY

AUB-P
Recommendations for management of AUB-P
Hysteroscopic polypectomy (who desire to preserve
fertility)

multiple endometrial polyps + not desirous of continued

fertility hysteroscopic polypectomy + anatomic
pathology preparation benign LNG- IUS

Polyp should be sent for histopathology. If histopathology

malignancy further management
LNG-IUS
AUB-A (Adenomyosis)
Desirous of preserving fertility but unwilling for immediate
conception, progestogens, esp LNG-IUS (first-line therapy) for
6 months resistant to LNG-IUS GnRH agonist (second-line
therapy ) + add back therapy

Not desirous of preserving fertility long-term GnRH agonists

LNG-IUS and GnRH agonists cannot be indicated Combined

oral contraceptives (COCs), danazol, NSAIDs, and progestogens

Failure/refusal for medical management laparoscopic

hysterectomy, adenomyomectomy with Osada technic,
AUB-L (Leiomyoma)

Treatment for AUB-L many variables such as age,

parity, symptoms, fertility desires may affect the treatment
preference.

Various options can be generalized as follows:

Intramural or subserosal myomas + desirous of
preserving fertility
tranexamic acid or COCs or NSAIDs medical treatment fails
and patient is not trying to conceive for at least 1 year LNG-IUS
Failed myomectomy by abdominal (open or laparoscopic)/
hysteroscopic route
 Sub-mucosal myomas
In small fibroids (<4 cm diameter) hysteroscopic resection
For >4 cm diameter abdominal myomectomy
Aged > 40 yo + not desirous of continued fertility LNG-IUS
hysterectomy (definitive treatment)
Short-term management (up to 6 months)
Peri-menopausal women : GnRH agonists myomectomy
Long-term management
LNG-IUS (except in AUB-L in 0 and 1 grade, may be tried in selected
cases of AUB-L 2) as first-line management.
Progesterone receptor modulators such as:
Ulipristal acetate and

Low dose mifepristone

AUB-M (Malignancy)

Endometrial hyperplasia with atypia

hysterectomy (the standard treatment)

Endometrial hyperplasia without atypia LNG-IUS

(first-line therapy) contraindicated/patient
unwilling oral progestins
AUB-C (Coagulopathy)

non-hormonal treatment
tranexamic acid (primary option) hormonal treatment with COCs/LNG-
IUS (secondary option) consult to hematologist:
For patients with uncontrolled uterine bleeding with above medical management,
specific factor replacement where possible or desmopressin in refractory cases to
be given
When surgical interventions are indicated, for appropriate pre-, intra- and post-
operative management of bleeding

NSAIDs are contraindicated (alter platelet function, drug

interaction 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)

Not desiring conception presently COCs (first-line

therapy) for 6-12 months
Cyclic luteal-phase progestins should not be used as a
specific treatment in women with AUB-O
Acute bleeding short-term management of 3 months
Norethisterone cyclically (for 21 days)
Assess response after 1 year of medical management
judge to continue/discontinue existing therapy
persistent AUB or failure of medical management
Surgical intervention
Contraindicated/unwilling with COCs LNG-IUS
In adolescents, both hormonal and non-hormonal therapies
can be prescribed
AUB-E (Endometrial)

Management of AUB-E can be similar to the

management of AUB-O .
AUB-I (Iatrogenic)

Whenever possible, medications causing AUB should

be changed to other alternatives, if no alternatives
are available, LNG-IUS is recommended.
AUB-N (Not defined)

Desire effective contraception LNG-IUS (first-line

therapy) contraindicated COCs (second line
therapy)

Bleeding that are mainly cyclic or predictable in timing

non-hormonal (NSAIDs and tranexamic acid)

When medical or conservative surgical treatments

(such as ablation) failed/contraindicated GnRH
agonists hysterectomy
Complication

AUB can has complication as followed:

Iron-deficiency anemia (blood loss of more than 1.6
L over a short time, or 60-80 ml for a menstrual
cycle)
Hemorrhagic shock due to excessive blood loss
Right-sided failure (rare) due to hypovolemia
Endometrial adenocarcinoma due to chronic
estrogen stimulation
TERIMAKASIH