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Abnormal Uterine Bleeding

Dr. Majda Komaikh; FRCOG, Reproductive Medicine


Associate Professor, Obstetrics & Gynaecology
Faculty of Medicine
Abnormal Uterine Bleeding

 Common gynaeological symptom, accounting for 25%


of gynaecological surgeries.

 Before menarche

 Childbearing age

 Postmenopausal women
Before Menarche:

 Trauma

 Sexual abuse

 Malignancy
Childbearing Age:

 Pregnancy-related conditions:
Ectopic pregnancy, miscarriage, trophoblastic disease

 Iatrogenic:
Medications, herbal, HRT, OCP, IUCD

 Systemic disorders:
CAH, Cushing, coagulopathy, thrombocytopenia
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 Pituitary-ovarian axis:
Hyperprolactinemia, PCOS

 Genital tract pathology:


Infection, neoplasm, trauma

 Dysfunctional uterine bleeding (DUB)


Postmenopausal Age:

 HRT

 Atrophic Vaginitis

 Malignancy
Terms Used to Describe Abnormal Uterine Bleeding

Oligomenorrhea:
Bleeding occurs at intervals of > 35 days and usually is caused by a prolonged
follicular phase.

Menorrhagia:
Bleeding occurs at normal intervals (21 to 35 days) but with heavy flow
( ≥ 80 mL) or duration ( ≥ 7 days

Menometrorrhagia:
Bleeding occurs at irregular, noncyclic intervals and with heavy flow
( ≥ 80 mL) or duration ( ≥ 7 days).

Polymenorrhea:
Bleeding occurs at intervals of < 21 days and may be caused by a luteal-phase

Defect
Amenorrhea:
Bleeding is absent for 6 months or more in a nonmenopausal woman

Postmenopausal bleeding :
Bleeding recurs in a menopausal woman at least 1 year after cessation of
cycles
Dysfunctional uterine bleeding:

This ovulatory or anovulatory bleeding is diagnosed after the exclusion of


pregnancy or pregnancy-related disorders, medications, iatrogenic causes,
obvious genital tract pathology, and systemic conditions.
Differential Diagnosis of Abnormal
Uterine Bleeding
Pregnancy and pregnancy-related
Medications and iatrogenic causes conditions
Anticoagulants
Antipsychotics Ectopic pregnancy
Hormone replacement Miscarriage
Intrauterine devices Trophoblastic disease
Oral contraceptive pills,
including progestin-only pills
Tamoxifen

Genital tract pathology Systemic conditions


•Infections: cervicitis, endometritis, Adrenal hyperplasia and Cushing’s dx
myometritis, salpingitis Blood dyscrasias : leukemia/ thrombocytopeni
Coagulopathies
•Benign anatomic abnormalities: Hepatic disease
adenomyosis, leiomyomata,
polyps of the cervix or endometrium Hypothalamic suppression
(from stress, weight loss,
•Premalignant lesions: cervical excessive exercise)
dysplasia, endometrial Pituitary adenoma or
Hyperplasia Hyperprolactinemia

•Malignant lesions: cervical Polycystic ovary syndrome


squamous cell carcinoma, Renal disease
endometrial adenocarcinoma, Thyroid disease
estrogen-producing ovarian
tumors, testosterone-producing
ovarian tumors, leiomyosarcoma
Dysfunctional uterine
•Trauma: foreign body, abrasions, bleeding
lacerations, sexual abuse or assault (diagnosis of exclusion)
Ovarian Cause

PCOS

•Obesity, acne, oligomenorrhea/secondary amenorrhea

•Unopposed E stimulation, elevated androgen, insulin resistance

•Anovulation

•Treatment: ovulation induction,


progestogens
Pituitary Cause

Hyperprolactinemia
Symptoms: galactorrhea, olig- ,amenorrhea

Treatment: Bromocriptine, Cabergoline


Hypothalamic

Hypothalamic disorders:

• Eating disorders

• Stress

• Exercise-induced
Genital Tract

•Uterine causes:
Fibroid uterus
Endometrial polyp

•Cervical causes:
Endometrial polyp
Cervical cancer
Evaluation of Abnormal Uterine Bleeding:

Diagnostic step Pertinent signs, Conditions


symptoms, and tests

Pelvic pain Abortion, ectopic


History Nausea, vomiting, Pregnancy

Wt gain, cold intolerance Hypothyroidism

Easy bruising, tendency to bleed Coagulopathy

Jaundice, hepatitis Liver dx

Hirsutism, acne,obesity PCOS

Postcoital bleeding Cervical causes

Galactorrhea,headache, visual Hyperprolactinemia


disturbances

Thyroidenlargment Hypothyroidism
Physical examination Hepatomegaalt, Bruises Liver diseases
Enlarged uterus Fibroid uterus
Adnexal mass PCOS

Laboratory Tests BhCG

CBC
Pregnancy

Anemia

LFT Liver Dx
TSH,prolctin, Hypothyroidism, hyperprolactnemia
Pap smear Cervical dysplasia
Endometrial biopsy Endometrial causes

Ultrasound scan Fibroids, polyps


Genital Tract

Genital Tract Pathology

Fibroid Menorrhagia

Treatment : Myomectomy
Endometrial polyp

Gross App.

Hysteroscopic Hysteroscopic
Resection Appearance.
Cervical Polyp

Postcoital bleeding, Intermenstrual bleeding


Cervical Cancer

Postcoital bleeding, Intermenstrual


bleeding
Dysfunctional Uterine Bleeding (DUB):

• Diagnosis of exclusion
Management

•Medical Treatment
•Minimal invasive surgery
•Surgical treatment
Medical treatment

•OCP
•Progestogens: anovulatory cycles
•Mefenamic acid , Tranxamic acid: Menorrhagia
•Mirena IUCD
Menorrhagia

Mirena releases a low amount of progestin levonorgestrel continuously


over a 5-year period
Endometrial Ablation or Endometrial resection

•Indications

•Procedure

•Complications
Hysterectomy

•Completed her family

•Age

•Seek definite treatment

•Other pathology