A Summary of differential diagnoses, approach, and management of AUBs, including vaginal bleedings in children and pregnant women.

1. Abnormal
Uterine
Bleeding
Presented by: Seyed Ali Mousavi-Aghdas
Tabriz University of Medical Sciences

2. Characteristics of normal
menstrual cycles
– Frequency: every 24-38 days (21-35 days in some references)
– Inter-cycle interval variation: <7-9 days
– Bleeding volume: 5-80 cc
– Duration of menstruation: 4.5-8 days

3. Definitions
– Polymenorrhea
– Menorrhagia or hypermenorrhea or heavy menstrual bleeding
– Metrorrhagia or inter-menstrual bleeding

4. Premenarchal vaginal bleeding
– Foreign bodies
– Sexual abuse
– Incidental ingestion of estrogen containing medications
– Idiopathic precocious puberty
– Tumors of the vagina or cervix (sarcoma botryoides)
– Tumors of the ovary, adrenal or pituitary

5. Approach
– Pelvic examination under sedation
- Rule out foreign body, abuse and local tumors
– CT or MRI of the pituitary, abdomen and pelvis
- Rule out tumors causing estrogen release

6. Bleeding in the pregnant women
and PPH
– 1st trimester: threatened or incomplete abortion, ectopic pregnancy, hydatiform
mole
– Later: abruptio placentae, placenta previa, vasa previa, accreta placenta,
uterine rupture
– Post-partum hemorrhage: Uterine atony, Lacerations, Retained placenta, DIC,
Uterine inversion, accreta placenta

7. Approach & Management
– Stabilize the hemodynamics with IV fluids
– Ultrasound will provide invaluable information
– Check for the fetal heart tones and obtain a non stress test if the case is a category C
, then emergent C/S
– Additional interventions for PPH: 1) check for uterine atony and performs a pelvic
examination, 3) reserve packed red blood cells for possible infusion, 2) use oxytocin,
prostaglandin E1 agonist, or ergot based agents to contract an atonic uterus, 4)
manual correction of uterine inversion 5) manual removal of retained placenta. If it
is firmly attached, consider accreta and abort the removal of placenta. 6) attempt
balloon tamponade for persistent bleeding. If a sophisticated device is not available
insert 2,3 Foley catheters and inflate. 7) inform the OR for possible laparotomy or
interventional radiologist for possible embolization.

8. FIGO 2011 ABBREVIATION PALM-COEIN
• Polyps
• Adenomyosis
• Leiomyomas
• Malignancy
• Coagulopathy
• Ovulatory disorders
• Endometrial
• Iatrogenic
• Not classified

9. First steps in approach to AUB
• 1st Determine the reproductive status
• 2nd Determine the pregnancy status
• 3rd History taking
Menstrual history, sexual history, previous OB-GYN surgeries, contraception history,
risk factors for endometrial cancer, dysmenorrhea, dyspareunia, infertility, fever,
lower abdominal pain
• 4th Determine the source of bleeding and bimanual examination
(extra-uterine bleedings tend to be low in volume with only spotting, occur postcoital,
accompany dyspareunia and visible lesion in pelvic examination)
• 5th Ultrasound (TV preferred) if the uterus is the suspected source of bleeding.
Pipelle biopsy for homogenously thickened endometrium (bilayer > 5mm).
Hysteroscopy for focal lesions. Pap smear and tests for cervicitis if the cervix is the
source.

10. Anatomic lesions causing bleeding
– Vaginal lesions: lacerations, varicosities, tumors, atrophy, lichen sclerosis
– Cervical lesions: polyps, cervicitis, tumor
– Endometrial: submucosal leiomyomas, chronic endometritis, AVMs, copper
IUDs, polyps, hyperplasia, cancer
– Myometrial: adenomyosis
– Hint: unpredictable bleeding without cramping between regular menses

11. Reasons for intermenstrual
bleeding
– Polyps
– Breakthrough bleeding from contraception
– Endometrial hyperplasia or cancer
– Chronic endometritis or PID
– Cervix related (cervicitis, polyp, cancer, ectropion)
– Anovulatory cycles (irregular, unpredictable bleedings without cramping)
– Hint: unpredictable bleeding without cramping between regular menses

12. Reasons for heavy menstrual
bleedings
– Leiomyomas
– Adenomyosis
– C/S scars defects
– Endometrial hyperplasia or cancer
– Copper IUDs (Paragard)
– Uterine AVMs
– Hemostasis disorders (onset from early adolescence)

13. – Work-up for endometrial hyperplasia or cancer in the following patients with
AUB:
– Postmenopausal
– Age > 45 but premenopausal
– Age < 45 but BMI>30, chronic ovulatory dusfunction, exposure to estrogen
without progesterone, failed medical management of AUB, women at risk
(Lynch or Cowden syndrome), prolonged periods of amenorrhea > 6m, under
treatment with tamoxifen.

14. Coagulopathy
– 15-20% of the adolescent patients with AUB
– History and examination may be positive for recurrent epistaxis, ecchymosis,
gingival bleeding.
– Von Willebrand disorder and ITP are the most common problems. Depending
on the subtype, there will be derangements in bleeding time and/or PTT.
Confirm by checking vWF activity.
– Check CBC, PT, PTT, INR, BT in adolescent patients and patients with heavy
bleedings.

15. Dysfunctional Uterine Bleeding
– Most common cause is anovulation
– Unopposed estrogen stimulation of the endometrium will cause fragile endometrium with breakthrough bleedings.
1. No prostaglandin, No cramping!
2. Clear, thin, watery cervical mucus
3. No elevation in the basal body temperature
4. Proliferative endometrium in biopsy
– Diagnosis is confirmed by a positive progesterone trial.
– Work-up should include the reversible causes such as, TSH and prolactin.
– If signs for hyperandrogenism, check testosterone (PCOS).
– If menopause is suspected, confirm by FSH, LH.
– Progestin therapy (cyclic MPA in the last 7-10 days) prevents endometrial hyperplasia and improves fertility. For those
who don’t desire conception, LNG-IUS (Mirena, Skyla) are the best choice.

16. Treatment options
– If hemodynamically unstable: 2 large bore IV catheters and crystalloid infusion (lactated ringer or normal saline) +
IV conjugated estrogen (Premarin) 25mg q2-6 hours until bleeding slows down then conversion to OCPs. Check the
coagulation profile and look for reversible reasons of bleeding. Inform the OR for possible D&C.
Outpatient care:
– NSAIDS: decrease dysmenorrhea, enhance clotting and reduce menstrual blood loss. Ibuprofen 600 mg daily,
mefenamic acid 500 mg q8h, Naproxen 500 mg stat then 3-5h later then 250-500 mg q12h. All for only 5 days.
– Progestins for anovulation
– Levenorgestrel eluting IUDs (LNG-IUDs)
– E+P contraceptives: YAZ (drosepirone/ ethynyl estradiol) 24 days on, 4 days off
– GnRH agonists
– Danazol
– Tranexamic acid: contraindicated in patients with a history of VTE or CVA and patients already on E+P
contraceptives. Dosing: 1.3g q8h for 5 days

17. Last resorts
– Endometrial ablation
– Interventional embolization
– Hysterectomy