Abnormal uterine bleeding

15/4/2006Dr. Mahmoud Abdel-Aleem, 2012
Abnormal Uterine Bleeding
Dr. Mahmoud A. Abdel-Aleem
Diploma of Reproductive Medicine,
Geneva University, Suiss.
M.D. Obstetrics and Gynecology.
Assiut University.

Mechanism Of Normal
Menstruation

Menstruation occurs as a universal endometrial event following the
withdrawal of estrogen and progesterone subsequent to a normal
ovulatory cycle.
1. Phase of vasoconstriction:
i. The first morphological effect is shrinkage of the
tissue due to spiral arteriole vasoconstriction,
probably predominantly under the effect of PGF2a,
leading to reduced blood Flow.
ii. The arterioles undergo episodic vasoconstriction and
relaxation leading to endometrial ischaemia and
reperfusion damage leading to local release of a
range of cytokines.
iii. The vasoconstriction process is limited
predominantly to the first 24 h.

2. Phase of shedding:
i. With further shrinkage, a variable
quantity of the functional layer breaks
down into fragments which are shed into
the cavity and expelled.
ii. A variable quantity of blood and tissue
Fluid is also lost during this process.

3. Phase of clotting:
i. Fibrin generation is an essential part of
normal blood clotting, and is stimulated in
endometrium.
ii. The balance between generation of
coagulation factors, to control bleeding, and
fibrinolysis, to prevent clot organisation and
intrauterine adhesions, shifts from being
haemostatic in the secretory phase to be
fibrinolytic during menstruation.

Causes of AUB

• Systemic disease: conditions of impaired
hemostasis.
• Congenital:
• Traumatic:
• Inflammatory:
• Neoplasms:
• Causes of pelvic congestion: myoma,
prolapsed ovaries, uterine prolapse, chronic
PID, R.V.F, chronic cervicitis.

• Complication of early pregnancy:
• Iatrogenic:
• Dysfunctional: diagnosis by exclusion; it is
the abnormal uterine bleeding in the
absence of organic lesion, genital or extra
genital.

Types of AUB

How to know that the patient is having abnormal
uterine bleeding?
1.Bleeding away from the normal menses.
2.Menses lasting ≥8 days .
3.Menses occurring at intervals of ≤3 weeks.
4.Menses requiring more sanitary pads “> 2-3/ day"
5.Pallor" clinical sign " or anemia" laboratory term".
6.Flooding of blood.
7.Passage of blood clots " because the amount of
blood is more than the capacity of the fibrinolytic
system of the endometrium".

Metrrorhagia
Organic Dysfunctional
PolymenorrheaMenorrhagia
Regular=
Ovular=
Cyclic
Clinical Types of AUB
Irregular=
Anovular=
Acyclic

• Polymenorrhea: period occurs every less than 3
weeks.
• Menorrhagia: regular cyclic heavy "requiring
more daily sanitary pads "and /or prolonged
periods “lasting for 8 days or more".
• Polymenorrhagia: combination of the above 2
types.
• Metrorrhagia.
• Intermenstrual bleeding: bleeding of variable
amounts occurring between regular menstrual
periods.
• Postcoital (contact) bleeding: bleeding occurring
after intercourse.
• Postmenopausal bleeding.

Dysfunctional Uterine
Bleeding

• Definition:
• Types:
–Ovulatory bleeding:
• Polymenorrhea.
• Menorrhagia.
–Anovulatory bleeding:
• Metropathia hemorrhagica.
• Threshold bleeding.

• Diagnosis:
Obtain a good history
&
Perform meticulous general and local
examination
&
Do appropriate investigations
Because
The
aimis
to
exclude
all possible
causes

History and Physical findings
• Assessment of menstrual blood loss
A- Methods proved to be of little value:
– History:
– The number of sanitary pads or tampons
used.
– The duration of bleeding.
– Hemoglobin concentration: as women with
true menorrhagia may not necessarily drop
Hb their, as losses of 800–1000 ml can occur
without anemia.

B- Semi-quantitative methods:
• Pictorial blood loss assessment chart (PBAC):
C- Quantitative methods:
• Noninvasive ‘alkaline hematin method’, where sanitary devices are
soaked in 5% sodium hydroxide to convert the blood to alkaline
hematin and optical density is measured.
• Weighing technique:
Ovulatory or non-ovulatory: Cyclic, predictable menses every 21-35
days are usually associated with ovulation, whereas anovulatory
bleeding is typically irregular in timing and flow, and is often
interspersed with episodes of amenorrhea.
Exclude coagulopathy: congenital or acquired coagulopathy by
reviewing the medical and family history.
Bimanual examination: A careful bimanual examination of the corpus
should be performed, seeking evidence of pregnancy, adenomyosis
and leiomyomas, as well as findings that are suggestive of an
adnexal mass or an ectopic gestation.

• Laboratory investigation
–Hemoglobin.
–Hematocrit.
–Urinary (or serum) b-human chorionic
gonadotropin levels
–Coagulation profile
–Serum assay for progesterone
–Anovulatory patients:
• TSH assay
• Serum prolactin.
• Serum free testosterone.

• Evaluation of the endometrial cavity
• Histologic assessment:
– Recommended as an initial part of the investigation in
women with AUB who are >40 years, or in women of
any age with chronic anovulation.
– Office endometrial sampling with narrow disposable
catheters has generally been demonstrated to be
equivalent to the so-called `formal' dilatation and
curettage, utilizing dilators and sharp curettes.
– It is indicated for:
• All women with abnormal bleeding aged more than 40 years
and in women who are at increased risk of endometrial
cancer. Risk factors include nulliparity with a history of
infertility, obesity (>90 kg), a family history of
endometrial or colonic cancer, abnormal PAP-smear and
tamoxifen therapy.

• Younger women:
– if abnormal bleeding does not resolve with medical
treatment.
– In polycystic ovary syndrome in which endometrial
hyperplasia is more common, endometrial
assessment may be necessary if abnormal bleeding
is a presenting feature, or unusual sonographic
endometrial appearances are discovered.

• Imaging
– TVS: it is a suitable screening test for
evaluation of the endometrial cavity.
• Timing: should be performed after menstruation in
the follicular phase of the menstrual cycle.
• Value:
– Sonohysterography is the sonographic
evaluation of the endometrial cavity following
the transcervical instillation of saline, an
approach that has comparable results for
structural anomalies of the endometrial cavity to
those of hysteroscopy.
– Radiographic hysterography is less accurate
than hysteroscopy for cavity evaluation.

• Hysteroscopy:
– Hysteroscopy and biopsy is indicated for
women with erratic menstrual bleeding, failed
medical therapy, or transvaginal ultrasound
suggestive of intrauterine pathology such as
polyps or submucous fibroids.
– Diagnostic hysteroscopy can be performed
either as an outpatient procedure without
anesthetic or as a formal theater procedure.

Individual types of
AUB

POLYMENORRHEA
• The uterus is likely to be normal and the error is in the
ovary.
• If affecting the luteal phase , it is due to poor function of
the corpus luteum" i.e. the premenstrual endometrial
biopsy shows lagging secretory endometrium.
• Common causes:
– Dysfunctional: common cause: LPD.
– Organic: Pelvic Congestion Syndrome, because they reduce life
span of the corpus luteum.
• Diagnosis:
– Clinical examination: to exclude organic causes.
– U.S. an aid to exclude organic causes.
• Management:
– Organic: of the cause.
– Dysfunctional: hormonal treatment.

MENORRHAGIA
• May be due to:
– Increased surface area of the endometrium.
– Pelvic congestion.
– Conditions of impaired hemostasis.
– Dysfunctional:
Poor C.L. Persistent C.L.
--->inadequate hormonal support to
the endometrium ---> premature
shedding of the endometrium --->
premenstrual spotting.
D&C: lagging secretory endometrium
and low progesterone levels during
the luteal phase.
Incomplete and slow degeneration of
C.L. ----> delayed shedding of the
endometrium  postmenstrual
spotting.
D&C: mixed endometrium "patchy
progestational endometrium in a
proliferative endometrium".

• Diagnosis:
– Clinical examination:
– U.S. and sonohysterography :an aid to exclude
organic causes.
– Hysteroscopy.
– D&C.
• Treatment:
– Organic: treatment of the cause.
– Dysfunctional:
• First type: hormonal treatment: progesterone 15th
-25th day of the cycle.
• Second type: difficult; hormonal treatment:
suppression of ovulation.

Metrorrhagia
May be due to:
• Organic:
• Dysfunctional:

Threshold bleeding Metropathia Hemorrhagica
[Shroider disease]
Ovarian underactivity.
Flat ovary.
Atrophic endometrium.
Low FSH.
Low estrogen.
Common at extremes.
TTT: sequential O&P
Ovarian hyperactivity.
Cystic ovary.
Thickened endometrium.
No LH surge.
High estrogen.
Common at extremes.
TTT: suppression
O
n-O
ffbleeding
A
m
enorrhea
Painless
vaginal bleeding

Treatment of DUB

Aim of therapy
1. Control of bleeding.
2. Achieve regular cycles.
3. Induction of ovulation if there is infertility

General Lines
• Reassurance.
• Iron and vitamin c.
• Blood transfusion if there is a need for it
(Hb <6gm% or acute attack causing
hemodynamic instability).

Medical Treatment
A- Non-Hormonal
Antifibrinolytic
drugs
Capillary
stabilizers
Anti-PGs
Tranexamic acid Daflon Mefenamic acid

B- Hormonal
Acute attacks
Estrogen
therapy
High- dose
E&P therapy
[Medical curettage]
Oral- IV Oral - Parenteral

B- Hormonal
Chronic Attacks
Ovular Bleeding Anovular bleeding
Endometrial
Support
Suppression
Polymenorrhea
Menorrhagia [I]
Menorrhagia [II]
M. Hgica
Threshold
bleeding
Follicular Cyst
Corpus Luteum
Endometrial
Building
Induction of ovulation

Surgical
Treatment
D&C
Hysteroscopy Hysterectomy
Diagnostic DiagnosticTherapeutic Therapeutic
Radiotherapy
ZER
O

Postmenopausal Bleeding
• Definition:
• Causes:
• The most common is-----------
• The most risky is----------
• All women should be subjected to:
– TVS
– Endometrial assessment.

THANK YOU FOR
YOUR
ATTENTION

Abnormal uterine bleeding

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