ABNORMAL UTERINE

BLEEDING
DR ST AFOLAYAN

UPDATE/REVISION COURSE IN OBSTETRICS AND GYNAECOLOGY OF THE

NATIONAL POSTGRADUATE MEDICAL
COLLEGE OF NIGERIA
27 JULY 2023

1
OUTLINE
• Introduction
• Definition of terms
• Pathophysiology
• Aetiology
• Management
• Conclusion

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INTRODUCTION

3
 INTRODUCTION
• Alterations in the pattern or volume of blood flow of
menses are among the most common health
concerns of women and their impact on health-
related quality of life is burdensome.
• It is one of the reasons for presentation at the
OutPatient Departments/Gynaecological Clinics.
• The impact of abnormal uterine bleeding (AUB) in the
reproductive years is substantial worldwide, with a
prevalence of approximately 3%–30% among
reproductive aged women.
• Higher incidence occurring around menarche and
perimenopause 4
 INTRODUCTION (CONT)
• Up to one-third of women will experience abnormal
uterine bleeding in their life, with irregularities most
commonly occurring at menarche and
perimenopause
• It can present in many ways such as infrequent
episodes to excessive flow.
• Overall, it affects the quality of life of the affected
women and in some cases, the reproductive
experience too.

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 INTRODUCTION (CONT)
• Many women do not seek treatment for their
symptoms, and some components of diagnosis are
objective while others are subjective.
• Older terms such as oligomenorrhea, menorrhagia,
and DUB should be discarded in favor of using
simple terms to describe the nature of AUB.

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DEFINITIONS
7
 DEFINITION

AUB
• Abnormal uterine bleeding is a broad term that
describes irregularities in the menstrual cycle involving
frequency, regularity, duration, and volume of flow
outside of pregnancy.

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Types of AUB
• Acute AUB
• Excessive bleeding that requires immediate intervention to
prevent further blood loss.
• Chronic AUB
• The irregularities in menstrual bleeding for most of the
previous 6 months.

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Recommended Terminologies for Normal and Abnormal
Menses

Quality Normal Abnormal Old Terms

Volume 5-80 mL Light(<5 mL) Heavy (>80 Hypomenorrhoea,
mL) Menorrhagia
Duration ≤8 d Prolonged (>8d) Hypomenorrhoea,
Menorrhagia

Frequency (days between menses)

24-38 d Frequent (<24 d) Polymenorrhoea,

Infrequent (>38 d) Oligomenorrhea
Amenorrhoea (>90 d)
Regularity (numbers of days by which cycle length vary)
≤7-9 d Irregular ≥10 d

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PATHOPHYSIOLOGY

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PATHOPHYSIOLOGY

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 PATHOPHYSIOLOGY (CONT)
• The uterine and ovarian arteries supply blood to the uterus. These
arteries become the arcuate arteries; then, the arcuate arteries send
off radial branches which supply blood to the two layers of the
endometrium, the functionalis and basalis layers.
• Progesterone levels fall at the end of the menstrual cycle, leading to
enzymatic breakdown of the functionalis layer of the endometrium.
This breakdown leads to blood loss and sloughing, which makes up
menstruation.
• Functioning platelets, thrombin, and vasoconstriction of the arteries
to the endometrium control blood loss.
• Any derangement in the structure of the uterus, clothing pathways,
or disruption of the HPO axis ) can affect menstruation and lead to
abnormal uterine bleeding.
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AETIOLOGY

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 CLASSIFICATION OF AUB (FIGO 2018)
PALM-C0EIN

Structural Causes Nonstructural Causes

• Polyp • Coagulopathy
• Adenomyosis • Ovulatory
• Leiomyoma • Endometrial
• Malignancy/ • Iatrogenic
Hyperplasia • Not otherwise classified

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Endometrial Polyps
• Soft, fleshy intrauterine growths that are
composed of endometrial glands, fibrous
stroma, and surface epithelium.
• May be single or multiple, measure from a few
millimeters to several centimeters, and be
sessile or pedunculated
• Estrogen has been implicated in their growth,
and higher receptor levels are noted within
polyps compared with adjacent normal
endometrium.
• Most commonly found in reproductive age
women.
• Patient risk factors include increasing age,
obesity, and tamoxifen use.
• Usually benign

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Adenomyosis
• Presence of endometrial glands and
stroma in the uterine myometrium
leading to hypertrophy of the
surrounding endometrium
• Multiparity and any process that
allows for penetration of
endometrial glands and stroma
past the basalis layer are common
risk factors
• Enlarged asymmetric uterus on USS
• Abnormal bleeding due to
adenomyosis is thought to be as a
result of altered uterine contractility
and associated with dysmenorrhea.

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Leiomyoma
• Benign tumours of the myometrium.
• Most common pelvic tumour.
• Reproductive age group.
• Mechanisms for AUB:
• ↑Surface area of the endometrium
• Inefficient uterine contractility
• Dysregulation of PGs

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Malignancy
• Bleeding from cervical malignancy presents as coital
bleeding or IMB
• Endometrial cancer is mostly secondary to prolonged
exposure to hyperestrogenic state (chronic anovulation,
PCOS, obesity etc)
• Oestrogen-producing ovarian tumours (Granulosa theca
tumours)
• Lynch syndrome

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Coagulopathy
• Disorders of blood coagulation:
• von Willebrand disease (most common)
• Prothrombin deficiency
• Haemophilia
• Leukaemia

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Ovulation Dysfunction
• Anovulatory bleeding is most common during the extremes of
reproductive life: in the first few years after menarche and
during perimenopausal years:
• In the adolescent: anovulation is due to an immaturity of the HPO
axis and failure of positive feedback of oestradiol to cause LH surge
• In the perimenopausal woman: lack of synchronization between the
components of the HPO axis occurs as the woman approaches
ovarian decline at menopause
• Weight loss, severe exercise, stress etc
• PCOS
• Abnormalities of other nonreproductive hormone (thyroid
hormone, prolactin, and cortisol)
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 Iatrogenic
• Abnormal bleeding resulting from medications.
• Most common of these are hormonal preparations, such as
SERMs, gonadotrophic releasing hormone agonists and
antagonists
• Interactions between oral contraceptives and other
medications such as antibiotics and anticonvulsants may
alter circulatory levels of steroids, allowing follicular
recruitment and increased endogenous levels of oestrogen.
• Chronic anticoagulation as a result of heparin, low molecular
weight heparin, direct thrombin inhibitors, and direct factor
Xa inhibitors.
22
Endometrial
• Heavy menstrual bleeding in the absence of other abnormalities are thought
to have underlying disorders of the endometrium or are otherwise
unclassified.
• The primary line of defense to excessive bleeding during normal menses is
the formation of the platelet plug, followed by uterine contractility, largely
mediated by PGF2α.
• Thus prolonged and heavy bleeding can occur with abnormalities of the
platelet plug or inadequate uterine levels of PGF2α.
• in some women with HMB, there is excessive uterine production of
prostacyclin, a vasodilatory prostaglandin that opposes platelet adhesion
and may also interfere with uterine contractility.
• Deficiency of uterine PGF2α or excessive production of PGE (another
vasodilatory prostaglandin) may also explain ovulatory AUB
• The ratio of PGF2α/PGE correlates inversely with menstrual blood loss
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Not Otherwise Classified
• Abnormal bleeding not classified in the previous
categories.
• Examples of such conditions may include foreign bodies
or trauma.
• Treatment is tailored to the specific cause.
• Endometritis
• AVMs

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MANAGEMENT
25
History
Detailed history must be obtained from a patient who presented with
complaints related to menstruation.
• Age
• Menstrual history
• Sexual and reproductive history
• Associated symptoms/Systemic symptoms
• Family history, including questions concerning coagulopathies, malignancy,
endocrine disorders
• Social history, including tobacco, alcohol, and drug uses.
• Occupation; the impact of symptoms on quality of life
• Surgical history

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History (Cont)
Menstrual History
• Age at menarche
• Last menstrual period
• Menses volume, duration, frequency, and regularity, of
the flow
• Dysmenorrhoea
• Intermenstrual bleeding

27
History (Cont)
Sexual and Reproductive History
• Obstetrical history, including the number of pregnancies
and mode of delivery
• Fertility desire and subfertility
• Current contraception
• History of sexually transmitted infections
• PAP smear history

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History (Cont)
Associated Symptoms/Systemic Symptoms
• Weight loss
• Pain
• Discharge
• Bowel or bladder symptoms
• Symptoms of anemia
• Symptoms or history of a bleeding disorder
• Symptoms or history of endocrine disorders

29
Physical Examination
• Signs of pallor, such as skin or mucosal pallor, Vital signs,
including pulse rate, blood pressure and BMI
• Signs of endocrine disorders
• Examination of the breasts
• Examination of the thyroid for enlargement or tenderness
• Excessive or abnormal hair growth patterns, clitoromegaly, acne,
potentially indicating hyperandrogenism
• Moon facies, abnormal fat distribution, striae that could indicate Cushing
syndrome
• Signs of coagulopathies, such as bruising or petechiae
• Abdominal exam to palpate for any pelvic or abdominal masses
• Pelvic exam: Speculum and bimanual
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Investigations
• Laboratory
• Pregnancy test, complete blood count, ferritin, coagulation panel, thyroid
function tests, gonadotropins, androgen, and prolactin (etc, as indicated).
• Imaging Studies
• Transvaginal ultrasound, abdominal ultrasound, MRI, and hysteroscopy.
• Histocytology
• Endometrial tissue sampling may not be necessary for all women with AUB
but should be performed on women at high risk for hyperplasia or
malignancy. An endometrial biopsy is considered the first-line test in women
with AUB who are 45 years or older. Endometrial sampling should also be
performed in women younger than 45 with unopposed estrogen exposure,
such as women with obesity and/or polycystic ovarian syndrome (PCOS), as
well as a failure of treatment or persistent bleeding.
• Pap smear, if indicated.

31
Treatment
• Treatment of AUB should be individualized and depends
on multiple factors:
• The clinical stability of the patient.
• Age group.
• Aetiology.
• Desirous for fertility (requirement for contraception).
• Other medical comorbidities.

32
Treatment (Cont)
Goals
• Establishment of hemodynamic stability.
• Correction of anaemia (acute or chronic).
• Establishment of normal menstrual cycle patterns.
• Prevention of recurrence.
• Preventing long-term consequences of anovulation
(anaemia, infertility, endometrial cancer).

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Treatment (Cont)
• Treatment can be:
• Conservative.
• Medical.
• Surgical.

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Conservative
• Counseling and follow up.
• Treatment of Iron deficiency anaemia.

35
Medical Treatment
• In general, medical options are preferred as initial
treatment for AUB.
• In the absence of a structural cause for excessive
uterine bleeding, it is preferable to use medical instead
of surgical treatment, especially if the woman desires to
retain her uterus for future childbearing or will be
undergoing natural menopause within a short time.

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Medical Treatment
• Non-hormonal
• NSAIDs.
• Antifibrinolytics.
• Hormonal
• Oestrogen.
• Progestagen.
• COCP.
• Androgen – Danazol.
• LNG – IUS.
• GnRH agonist.

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AUB - Coagulopathy
• Present in early (adolescents)
• Systemic disorders of haemostasis
• Inherited (von Willebrand disease, most common)
• Acquired (Immune Thrombocytopaenic Purpura)
• Tranexamic acid
• Desmopressin
• No NSAIDs (antiplatelets)

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AUB - Ovulatory Dysfunction
Adolescents:
• Cyclic Progestogens (MPA) 10mg x 10 days (each month
for few months) to produce controlled menstrual cycles.
• COCPs for 3 - 6 months
• NSAIDS can be used (prior/onset of menses throughout
the duration)
• Haematinics

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AUB - Ovulatory Dysfunction
Reproductive Life:
• COCPs
• Cyclic Progestogens (MPA)
• NSAIDs
• Haematinics

40
AUB - Ovulatory Dysfunction
Perimenopausal Woman:
• Medical treatment can only begin when organic
pathology has been definitely excluded.
• Low-dose OCPs (20μg.) in nonsmoker.
• There is a lower threshold level for surgical mgt in this
group.

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AUB - Endometrial

Treatment Options:
• Prolonged regimen of progestogens.
• OCPs will reduce the blood loss in women with AUB-E
(↓40 – 70%).
• LNG – IUS – (↓74 -97%).

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AUB - Iatrogenic

• Should be managed based on the offending drug(s).

• If a method of contraception is suspected, change.
• LNG - IUS

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AUB - Not Otherwise Classified
• Antibiotics therapy
• Embolisation

44
Surgical Treatment
Indications
• Medical treatment fails
• Medical treatment is not tolerated
• Patient’s choice

Surgical Options:
• Dilatation and Curettage
• Endometrial ablation
• Uterine Artery Embolisation
• Hysterectomy
45
Dilatation and Curettage
• The performance of a D&C can be diagnostic and is therapeutic for the
immediate management of severe bleeding.
• For women with markedly excessive uterine bleeding who may be
hypovolemic, a D&C is the quickest way to stop acute bleeding.
• Therefore it is the treatment of choice in women who suffer from hypovolemia.
• D&C may be preferred as an approach to stop an acute bleeding episode in
women older than 35 when the incidence of pathologic findings increases.
• D&C is only indicated for women with acute bleeding resulting in hypovolemia
and for older women who are at higher risk of having endometrial neoplasia
• All other women, after having an endometrial biopsy, sonohysterography, or
diagnostic hysteroscopy to rule out organic disease, are best treated with
medical therapy, without D&C.

46
Endometrial Ablation
• If medical treatment is not effective or is
contraindicated.
• Alternative to hysterectomy
• Contraindicated in large uterus with fibroids or
abnormal pathology, such as endometrial hyperplasia or
cancer.

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Hysterectomy
• Offered to women with completed family size.
• Presence of other indications for hysterectomy such as
fibroids or uterine prolapse.
• Used to treat persistent abnormal uterine
• bleeding after all medical therapy has failed, medical
therapy is contraindicated.

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Acute AUB
It is important to assess the patient's clinical stability and replace volume with
intravenous fluids and blood products while attempting to stop the acute
abnormal uterine bleeding.
• Hormonal methods are the first line in medical management.
• IV conjugated equine estrogen, 25mg 4hourly for up to 3-6 doses.
• OCPs in taper fashion.
• Danazol 200mg daily.
• Tranexamic acid prevents fibrin degradation and can be used
• Desmopressin, administered intranasally, subcutaneously, or intravenously,
can be given for acute AUB secondary to the coagulopathy von Willebrand
disease.
• Dilatation and curettage is the surgical option in the acute phase
• Tamponade of uterine bleeding with a Foley bulb is a mechanical option

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CONCLUSION
50
 CONCLUSION
• Abnormal uterine bleeding is common among women worldwide.
A detailed history is an important first step in evaluating a
woman who presents with AUB, and clinicians should be familiar
with the normal pattern of menstruation, including frequency,
regularity, duration, and volume of flow. After a detailed history is
obtained and a physical exam is performed, further tests and
imaging may be warranted depending on the suspected
aetiology.
• Treatment of AUB should be individualized depending on the
suspected cause(s) and should be appropriate for age.

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REFERENCES
52
 REFERENCES
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[PubMed]

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 REFERENCES (CONT)
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THANK YOU FOR YOUR
ATTENTION

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