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Abnormal uterine bleeding

Dr. Enas Halawa


• It is a common gynecologic symptom
• Normal menstruation Normal menstruation is defined as:

●Frequency – 24 to 38 days
●Regularity – Variation ≤7 to 9 days
●Duration – ≤8 days
●Volume –a volume that does not interfere with a woman's
physical, social, emotional, and/or material quality of life.
Research definition is ≤80 mL vaginal "blood" loss per cycle
• Abnormal uterine bleeding , describes any symptomatic
variation from normal menstruation and covers the full
range of symptoms of abnormal bleeding.

• Acute AUB :
An episode of uterine bleeding that is of sufficient quantity
to require immediate intervention to prevent further blood
loss.

• Chronic AUB:
Bleeding from the uterine body (or corpus), that is abnormal
in frequency, regularity, duration, and/or volume, and has
been present for at least the majority of the past six months
●If periods start more often than every 24 days, the patient
is categorized as having frequent uterine bleeding.

●If they start less often than every 38 days, the category is
infrequent. the term oligomenorrhea is replaced by the
term infrequent uterine bleeding

"secondary amenorrhea is the absence of menses for more


than three months in girls or women who previously had
regular menstrual cycles or six months in girls or women
who previously had irregular menses."
prolonged menstrual bleeding
• when the duration of a woman's menstrual periods is
consistently more than eight days

• there is no clinically relevant definition of a "shortened"


duration of bleeding.

• over 50 percent of the total menstrual loss is an endometrial


transudate, and the whole blood component usually varies
between 30 and 50 percent
• When AUB occurs between well-defined cyclical menses,
the symptom is called intermenstrual bleeding (IMB)

• Cyclic midcycle intermenstrual bleeding is a common


physiologic phenomenon in 9%of women
• Cyclic premenstrual or postmenstrual intermenstrual
bleeding .These symptoms may be indicative of a luteal
phase defect (late cycle bleeding) or of other conditions,
such as endometriosis, endometrial polyps, or other
structural lesions of the genital tract.
Acyclic intermenstrual bleeding :
• When the IMB is not cyclical or predictable
• such as chronic cervicitis or polyps of the cervix or
endometrium or uterine tumor
• PALM-COEIN CLASSIFICATION OF AUB
ETIOLOGIES
Polyps (AUB-P)
• Endometrial polyps are localised hyperplasic Overgrowths of
endometrial glands and stroma which form projections from
the surface of the endometrium

Diagnosis:
• Ultrasound
• Saline infusion sonogram hysteroscopy ( the gold standard)
Adenomyosis (AUB-A)
The spectrum of findings in u/s includes:

a) Globular, bulky uterus.


b) Asymmetric myometrial thickness
c) Heterogeneous echogenicity
d) Subendometrial echogenic linear striations
e) Subendometrial echogenic nodules (specific sign)
f) Small myometrial cysts / sub endometrial cysts (specific sign).
g) Loss of clarity of endomyometrial interface
Leiomyoma(AUB-L)

• Uterine fibroids (leiomyomas or myomas) are benign


monoclonal tumours of smooth muscle cells and fibrous tissue
that develop within the wall of the uterus

• Heavy and/or prolonged menses is the typical bleeding pattern


with myomas. Intermenstrual bleeding and postmenopausal
bleeding are NOT characteristic of myo
• Leiomyomas (AUB-L)
• On US : definite outline
Malignancy and hyperplasia (AUB-M)
• Endometrial hyperplasia with cytological atypia and
carcinoma, including endometrial stromal sarcomas, are
epithelial neoplasms of the endometrium that are usually
diagnosed with transcervical endometrial sampling.
Coagulopathy (AUB-C)
• The term coagulopathy is used to encompass the spectrum of
systemic disorders of hemostasis (coagulation factor deficiency
or inherited or acquired platelet disorder)
• von Willebrand disease, immune thrombocytopenia, platelet
dysfunction, and thrombocytopenia secondary to malignancy or
treatment for malignancy
• von Willebrand disease is most common
• identifiable in up to 24 percent of women with the symptom of
HMB
The minimum laboratory evaluation for bleeding disorder in
adolescents with excessive menstrual bleeding should include :
a) Complete blood count with platelets
b) peripheral blood smear
c) ferritin
d) PT, PTT, FNG
e) a von Willebrand panel
●Plasma von Willebrand factor (VWF) antigen
●Plasma VWF activity (ristocetin cofactor activity)
●Factor VIII activity
Ovulatory dysfunction (AUB-O)
• Irregular bleeding associated with AUB-O is typically
characterized by phases of no bleeding that may last for two or
more months and other phases with either spotting or episodes of
heavy bleeding.
• More common at the extremes of reproductive age
• polycystic ovarian syndrome, thyroid disease,
hyperprolactinemia
Endometrial causes (AUB-E)
• the cause of such bleeding is a primary disorder of the
endometrium.
• the patient may have a primary disorder of mechanisms
regulating local endometrial hemostasis
• In women with predictable and cyclic menses suggestive of
normal ovulation who have AUB
• There may exist in case of endometritis
• AUB-E is assigned after excluding other etiologies of AUB in
women of reproductive years
Iatrogenic causes (AUB-I)
• The AUB-I category includes AUB due to medical devices,
mainly intrauterine contraception systems, or pharmaceutical
therapy.
• Medications that may cause AUB-I include:
 Gonadal steroids
 Gonadal steroid-related therapy
 Anticoagulants
Not otherwise classified (AUB-N)
• Examples include arteriovenous malformation and AUB in the
context of a uterine isthmocele
Clinical approach
Where is the bleeding coming from?

What is the woman's age?

Is she sexually active? Could she be pregnant?

When does the bleeding occur?

What is her normal menstrual cycle like? Are there symptoms of ovulation? IS BLEEDING
ANOVULATORY OR OVULATORY? Contraceptive method?

What is the nature of the abnormal bleeding (frequency, duration, volume, relationship to
activities such as coitus)? Are there any associated symptoms, pain ?

Does she have a systemic illness or take any medications?

Has there been a change in weight, possibly associated with an eating disorder, excessive
exercise, illness, or stress? fever, and/or vaginal discharge ? Changes in bladder or bowel
function ?
Is there a personal or family history of a bleeding disorder? Gyneacological cancer?
Hx of surgery C.S?
Heavy menstrual bleeding

The most common etiologies of HMB are:


• Uterine leiomyomas
• Adenomyosis
• Cesarean scar defect
• Bleeding disorder.
• Endometrial hyperplasia or carcinoma
• IUD
• Endometrial polyps, endometritis, or PID
• Congenital or acquired uterine arteriovenous malformation
• Disorders of local endometrial hemostasis
Intermenstrual uterine bleeding may be related to a variety of
etiologies include:

a) Endometrial polyps
b) contraceptive method
c) Endometrial hyperplasia or carcinoma
d) Endometritis or PID
e) conditions of the cervix
LABORATORY EVALUATION
• Pregnancy test
• Complete blood count
Additional tests depend upon information obtained on history and
physical examination:
• Endocrine tests
i. -Thyroid function tests
ii. -Prolactin level
iii. -Androgen levels
iv. -Follicle-stimulating hormone or luteinizing hormone
v. -Estrogen levels
• Coagulation tests
• Cervical cancer screening
• Tests for cervicitis
Indications for endometrial sampling in women of reproductive-
age with AUB vary by age group :
• Age 45 years to menopause:
- Any AUB, including intermenstrual bleeding.
- Bleeding that is frequent (interval between the
Onset of bleeding episodes is <21 days)
- Heavy
- Prolonged (>5 days)
• Younger than 45 years:
- If AUB is persistent
- occurs in the setting of a history of unopposed
estrogen exposure (obesity, chronic anovulation)
- failed medical management of the bleeding
- women at high risk of endometrial cancer
a) Office endometrial biopsy
b) D&C
c) Hysteroscopic guide D & C
• Pelvic ultrasound is the first-line imaging study in women
with AUB.

• MRI: when it will provide information that is not available on


ultrasound

• saline infusion sonohysterography or hysteroscopy for


intracavitary evaluation
• The goal of initial therapy is to control the bleeding, treat
anemia (if present), and restore quality of life.
• Initial therapy is typically pharmacologic

For most women with HMB:


• estrogen-progestin contraceptives
• Oral or injectable progestin-only medications are also
reasonable as first-line management
• LNg52/5; Mirena

• Tranexamic acid or nonsteroidal antiinflammatory drugs are


useful for patients with HMB who have contraindications to or
would prefer to avoid hormonal agents.

• For women with AUB-O, estrogen-progestin formulations, oral


progestin therapy, or the LNg52/5 are first-line treatment
options
• Endometrial ablation is a reasonable choice in women who do
not desire future pregnancy and wish to avoid using or
changing an intrauterine device.

• Hysterectomy is a reasonable option in women who do not


desire future pregnancy, who desire definitive therapy, and who
are aware of the risk of perioperative complications

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