REFERAT

Abnormal Uerine Bleeding (AUB)

Kepaniteraan Obstetrik & Ginekologi

RSUD Pasar Minggu
Universitas Kristen Indonesia
Fakultas Kedokteran
 ABNORMAL
UTERINE BLEEDING
Introduction
- AUB is any form of uterine bleeding
that is abnormal in amount, duration,
and/or timing; it can be acute or
chronic.
- Such bleeding can be a normal
physiologic event or pathologic, life-
threatening conditions.
 Normal And Abnormal Bleeding
Patterns

- Interpretation of abnormal bleeding depends on

the ability to differentiate between normal and
abnormal bleeding patterns.
- Normal menstrual cycles vary from woman to
woman in frequency, duration, and amount of
flow.
- Menstrual cycles tend to be most irregular for
5 years after menarche and 5 years before
menopause.
- The average interval for menstrual cycles is 28
days (normal range 21–35 days), the duration
is 4-5 days.
- Normal values for blood loss during a
menstrual period: 25 mL to 69 mL (average
loss of 35 mL to 40 mL)
Blood loss outside of these parameters may
be abnormal, but it can be difficult for a
woman to accurately quantify the amount of
blood lost.

Counting used pads or tampons to estimate blood

loss is also inaccurate because absorption rates
among brands of pads and tampons vary greatly…!!!
 Classification Of Abnormal
Uterine Bleeding
International Federation of Gynecology and Obstetrics
established a standardized classification of AUB → the
PALM-COEIN classification system

PALM COEIN
(Structural Causes) (Non-Structural Causes)
Polyp AUB-P Coagulopathies AUB-C
Adenomyosis AUB-A Ovulatory Dysfunction AUB-O
Leiomyoma AUB-L Endometrial AUB-E
Malignancy and Hyperplasia Iatrogenic AUB-I
AUB-M Not Yet Classified AUB-N
 Abnormal Uterine Bleeding during
Adolescence and Perimenopause
- Physiologic anovulation→In the early years after
menarche→variability and irregularity
menstrual cycle
- Von Willebrand’s disease→the most prevalent
of all inherited → heavy menstrual bleeding in
adolescents.
- It has been reported in 5% to 24% of women
and as many as 20% of adolescents.
 Abnormal Uterine Bleeding during
Adolescence and Perimenopause
- Enter perimenopause→Declines of number of
follicles in the ovaries and ovarian function
gradually ceases.
- Decrease in ovarian function→inconsistent
follicular development→ ↑↑ FSH→the menses
may become irregula in amount, duration, and
timing.
HISTORY AND PHYSICAL
ASSESSMENT
- It is important for a woman to describe the
onset, frequency, and duration of the
abnormal bleeding.
- Color and character of the flow and any
related signs and symptoms (eg, pain, odor,
discharge, symptoms of pregnancy, postcoital
bleeding) are relevant.
- Contraceptive use: type, length of time used,
and any side effects..
- The gynecologic history: abnormal bleeding,
abnormal Papanicolaou tests, gynecologic
surgeries, sexually transmitted infections, or other
infections of the genital tract or organs.
- lifestyle history: inquire about prescription, over-
the-counter, and illicit drug use; exercise patterns;
stressors; and nutritional status.
- Inquire about family history of endocrine
disorders and patterns of bleeding or similar
bleeding problems, including blood dyscrasias,
coagulation defects, or easy bruising.
- Physical examination: Height, weight, vital
signs, and body fat distribution are important
parameters to assess, rule out suspected organic
or systemic causes for the abnormal bleeding.
- Pelvic examination: essential for a woman of
any age who has been sexually active, complains
of abdominal/pelvic pain, is anemic, or reports
bleeding that is so heavy that her hemodynamic
stability might be compromised.
- Use of a speculum allows inspection of the vagina and
cervix for evidence of infection, trauma, or foreign
objects.
- If a pelvic examination is required for a client who is
young and/or not sexually active, a pediatric speculum
should be used with care.
- During the bimanual examination, assess for tumors,
cervical polyps, ovarian cysts, uterine tenderness or
enlargement, or adnexal pain or masses.
- If a bimanual examination is indicated in a young
adolescent who is not sexually active, a gentle
examination with one digit should suffice.
 Laboratory Testing
- Initial laboratory evaluation for all types of
AUB: pregnancy test, complete blood count,
thyroid function Studies, testing for sexually
transmitted infections if at risk.
- Only if specifically indicated should other
laboratory studies be ordered.
Diagnostic Testing
- Ultrasound or endometrial biopsy→diagnosis
of uterine or endometrial abnormalities
- Pelvic ultrasound is often used for initial
imaging to evaluate AUB
- The transvaginal should be used if possible.
- Ultrasonography is useful for detecting uterine
and adnexal structural abnormalities and
measuring the thickness and appearance of
the endometrium.
- If intrauterine pathology is suspected after the
initial transvaginal ultrasound, an endometrial
biopsy may be indicated.
- or the woman may be referred for additional
testing for a more detailed evaluation of the
endometrium such as a saline infusion
sonohysterography/sonohysterogram or
hysteroscopy
 CLINICAL MANAGEMENT
Goals management of AUB
1. Normalize the bleeding
2. Correct any anemia
3. Prevent cancer
4. Restore quality of life.
Treatment of Acute Abnormal Uterine Bleeding

- A woman with heavy, excessive bleeding and a

severely low hematocrit requires consultation
with a physician or referral for high-dose
intravenous estrogen, intrauterine tamponade,
dilatation and curettage, or, in extreme cases,
hysterectomy.
- Dose of estrogen 25 mg/4-6 hours for 24
hours.
Treatment of Non-Emergent and Chronic Abnormal
Uterine Bleeding.

- Pharmacologic therapies for AUB in the

ambulatory setting include estrogen, progestin,
or combination formulations.
- Always carefully weigh the risks, benefits, and
side effects of each regimen.
Estrogen Therapy
- Most often administered for active bleeding
episodes with hemodynamically stable and
experiencing active bleeding that is heavy and/or
prolonged→high-dose oral estrogen usually stops
the bleeding.
- Also be useful when the endometrium is thin
secondary to low-estrogen stimulation.
- Estrogen 1.25 mg or 2 mg estradiol daily for 7-10
days In non-emergent bleeding with suspected
estrogen stimulation is low, promethazine 12.5 -25
mg rectally (as needed)
Progestogen Therapy
- To long- term treatment after resolved of acute
bleeding and women wich contraindication with
estrogen.
- If a woman is hemodynamically stable, active
bleeding, heavy and/or prolonged,
medroxyprogesterone acetate 10-20 mg 3x/day for
7 days or 20 mg daily for 3 weeks.
- To induce normal bleeding: Medroxyprogesterone
acetate 5 -10 mg for 7-14 days each month or
norethindrone acetate 2.5-10 mg once/day on days
5-25 of each cycle
- The levonorgestrel intrauterine system (LNG
IUS) and depotmedroxyprogesterone acetate
(DMPA) injection deliver progestin
continuously, effective to treat heavy
menstrual bleeding and effective
contraception.
Combination Oral Contraceptives
- Non-emergent AUB due to anovulation can be
managed with combination monophasic oral
contraceptive pills (OCPs).
- Ethinyl estradiol 35 mcg 2 x/daily for 5-7 days
followed by standard contraceptive dosing.
Additional Therapies
- Antiprostaglandin→ decrease bleeding in
women with heavy menstrual bleeding.
- Mefenamic acid 500 mg or Ibuprofen 600-800
mg 3 x/ day for 3-5 days during menstrual
bleeding.
- Alternatively, Naproxen sodium 500 mg initially
then 275 mg 4 x/day for 3-5 days during
menstrual bleeding.
- Tranexamic acid→an antifibrinolytic agent that
inhibits the activation of plasminogen.
- Tranexamic acid 1300mg 3 x/day for a
maximum of 5 days during cyclicmenstrual
bleeding.
- Hysterectomy