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Abnormal Uterine Bleeding

This document defines and describes abnormal uterine bleeding (AUB) and its various types, including heavy menstrual bleeding, intermenstrual bleeding, acute AUB, and chronic AUB. It discusses the pathophysiology and classification of different structural and non-structural causes of AUB, such as polyps, adenomyosis, leiomyomas, coagulopathy, and ovulatory dysfunction. The document also covers the epidemiology, diagnosis, and treatment of AUB through medical history, examinations, imaging, endometrial biopsy and other tests and procedures. Management options include local progestogen exposure, NSAIDs, antifibrinolytic agents, and GnRH agonists.

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112 views5 pages

Abnormal Uterine Bleeding

This document defines and describes abnormal uterine bleeding (AUB) and its various types, including heavy menstrual bleeding, intermenstrual bleeding, acute AUB, and chronic AUB. It discusses the pathophysiology and classification of different structural and non-structural causes of AUB, such as polyps, adenomyosis, leiomyomas, coagulopathy, and ovulatory dysfunction. The document also covers the epidemiology, diagnosis, and treatment of AUB through medical history, examinations, imaging, endometrial biopsy and other tests and procedures. Management options include local progestogen exposure, NSAIDs, antifibrinolytic agents, and GnRH agonists.

Uploaded by

mendato marcaban
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Abnormal UTERINE BLEEDING

 Definition, Pathophysiology & Types of AUB

 Abnormal Uterine Bleeding (AUB) describes any abnormality in normal frequency,


regularity, heaviness (volume or amount) and duration of the menstrual bleeding.

Heavy Menstrual Bleeding


 Heavy Menstrual Bleeding is defined as excessive menstrual blood loss which interferes
with a woman’s physical, emotional, social and material quality of life, and which can
occur alone or in combination with other symptoms.

Intermenstrual Bleeding
 Intermenstrual Bleeding (IMB), recommended by the consensus group to replace the
term “metrorrhagia”, occurs between clearly defined cyclic and predictable menses,
which may occur randomly or predictably on the same day in each cycle. The term
dysfunctional uterine bleeding (DUB) was commonly used to describe abnormally heavy
or irregular bleeding without recognizable organic pathology.

Acute Abnormal Uterine Bleeding


 Acute AUB is an episode of bleeding in a woman of reproductive age, who is not
pregnant, that is of sufficient quantity to require immediate intervention to prevent
further blood loss. It ranges from modestly HMB to excessively heavy bleeding
associated with hypovolemic shock. It occurs more frequently in anovulatory women.

Chronic Abnormal Uterine Bleeding


 Chronic AUB is bleeding from the uterine corpus that is abnormal in duration, volume,
regularity, and/or frequency and has been present for the majority of the last 6 months.

 Refers to the structural pathology measurable through imaging or histopathology.

 Pathophysiology
 PALM
 Refers to bleeding unrelated to structural abnormalities.

 Pathophysiology
 COEIN
Polyps (AUB-P)
 categorized as being present (AUB-P1) or absent (AUB-P0)
 based on one or a combination of ultrasound and hysteroscopic imaging with or without
histopathology
 no further categorization of the polyps based on size, location, or number in this system.
Adenomyosis (AUB-A)
 Hypotheses have been introduced in the formation of AUB and these include:
 Increased endometrial surface
 Altered PGE/PGF2alpha balance
 Hampered myometrial contractility
 Abnormal myometrial angiogenesis associated with fragile blood vessels

Leiomyomas (AUB-L)
 AUB secondary to myomas may be due to the following factors:
 Mechanical distortion
 Bleeding from ulcerated endometrium overlying the submucous myoma
 Dilatation of the venous plexuses draining the endometrium
3 classifications of Leiomyoma:
 Primary classification – reflects only the presence (AUB-L1) or absence (AUB-L0) of the
leiomyoma, regardless of the location, number and size, confirmed on ultrasound
examination.
 Secondary classification – differentiates leiomyomas involving the endometrial cavity
(submucosal from others), since submucosal lesions cause majority of the AUB
 Tertiary classification – further categorizes submucous, intramural and subserous
myomas

Leiomyomas (AUB-L)

 Malignancies & hypertrophy (AUB-M)


 would be classified as AUB-M1.
 Malignancies are still further classified using FIGO staging system.

Coagulopathy (AUB-C)
 Includes a wide range of systemic clotting disorders
 von Willebrand disease markers has a 13% prevalence rate among women with heavy
menstruation
 Women taking anticoagulant drugs such as warfarin, heparin, and low molecular weight
heparin are also placed under this category.

Ovulatory dysfunction (AUB-O)


 Usually manifests as a combination of unpredictable bleeding and variable amount of
flow
 Associated with a non-secretory endometrium
 Most common after the menarche or before the menopause
 May occur at other times

Endometrial (AUB-E)
 Secondary to a basic disorder of the endometrium is characterized as predictable and
cyclic, typical ovulatory cycles, and without other identified causes.
 Primary disorder affects the mechanism that regulate local endometrial hemostasis may
also be present in women with HMB.
Iatrogenic (AUB-I)
 Usually manifest with irregular bleeding, and may result from an inconsistent use, or,
more commonly, as a “breakthrough” bleeding.
 May occur secondary to use of pharmacological agents, medicated or inert intrauterine
devices that may injure the endometrium, prevent blood coagulation, or affect the
systemic control of ovulation.
Not yet classified (AUB-N)
 Other uterine entities such as chronic endometritis, arteriovenous malformations, and
myometrial hypertrophy, may cause AUB. However, these entities are poorly defined
and have no conclusive findings.

Epidemiology & Diagnosis of AUB


 EPIDEMIOLOGY
 Incidence of HMB - 4% and 51.6%
 DIAGNOSIS
 History
 Frequency, duration, and amount of bleeding
 Menstrual pattern changed

Physical Examination
 Presence of anemia, thyroid disease and coagulopathies
 Abdominal palpation : enlarged uterus
 Pelvic examination
 Bimanual examination : uterine size, pelvic tenderness and adnexal mass

 III. Blood Tests


 An initial complete blood count (CBC) with platelets, prothrombin and partial
thromboplastin time is indicated in all adolescents with HMB including adult patients
with positive screening history for bleeding disorder.
o Specific tests:
 Von Willebrand- ristocetin co-factor activity, von willebrand factor antigen, and factor
VIII

2. Pregnancy should be excluded in women of reproductive age.


 Bimanual pelvic exam
 β – hCG level
 Pelvic ultrasound
3. Coagulation tests should be considered in women with HMB since menarche, and/or
personal or family history suggestive of a coagulopathy.

4. Female hormone testing (estradiol, progesterone, luteinizing hormone, follicle


stimulating hormone)
not be routinely done
 Thyroid screening
 signs and /or symptoms of thyroid disease

IV. Imaging Procedures


 Ultrasound
 First line diagnostic tool for identifying structural abnormalities
 Transvaginal ultrasound may reveal myomas, adnexal pathologies, endometrial
thickening or focal masses
 Postmenopausal : less than 5 mm
 Premenopausal :
 Proliferative phase (4-8 mm)
 Secretory phase (8-14 mm).

 Saline infusion sonography


 useful tool in providing a more accurate evaluation of the uterus with intracavitary
lesions
 10 to 15 mL of saline or sterile water is usually introduced through the cervix with an
insemination catheter, or with a special catheter that has a balloon for inflation in the
cervical canal, allowing continuous infusion.

V. Others
 Hysteroscopy should be performed when the ultrasound results are inconclusive, or
when focal lesions are seen within the endometrium

2. Outpatient endometrial biopsy


 First line diagnostic tool
 The following are indications for endometrial biopsy:
 Age >40
 Risk Factors for endometrial cancer
 Failure of medical treatment
 Breast cancer patients on Tamoxifen who complain of abnormal vaginal bleeding
 Performed with a 3 mm Pipelle in the office, with little or no anesthesia.
 If not possible or if the tissue sample is insufficient, dilation and curettage (D&C) should
be performed under anesthesia.

Treatment & Management of AUB

ACUTE ABNORMAL UTERINE BLEEDING (AUB): OVULATORY DYSFUNCTION


 ABNORMAL UTERINE BLEEDING (AUB): ENDOMETRIAL
 Local Progestogen Exposure
 Local Progestogen Exposure
 NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
 Antifibrinolytic Agents
 Gonadotropin-Releasing Hormone Agonists

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