4TH YEAR CLERKSHIP LECTURE

1. Abnormal Uterine
Bleeding
Dr.Bülent Urman

2. Definition and Prevalence
• Abnormal uterine bleeding (AUB) refers to
menstrual bleeding of abnormal quantity, duration,
or schedule.
• A common gynecological complaint (1/3 of visits)
• A United States population-based survey of women
ages 18 to 50 years reported an annual prevalence
rate of 53 per 1000 women
• Caused by a wide variety of local and systemic
diseases or related to medications

3. Terminology
• Structural causes
• Hormonal causes-Dysfunctional uterine bleeding
• Systemic diseases that cause abnormal uterine
bleeding

4. Terminology
• A revised terminology system for abnormal uterine
bleeding (AUB) in non-gravid reproductive age
women was introduced in 2011 by the
International Federation of Gynecology and
Obstetrics (FIGO)
• Goal was to avoid poorly defined or confusing
terms used previously (eg, menorrhagia,
menometrorrhagia, oligomenorrhea)

6. Normal Menses
• Frequency: every 21 to 35 days
• Occurs at fairly regular intervals
• Volume of blood ≤80 mL
• Volume of blood is difficult to measure. In clinical
practice, heavy menses are generally defined as:
• soaking a pad or tampon more than every two hours, or
• a volume of bleeding that interferes with daily activities (eg,
wakes patient from sleep, stains clothing or sheets).
• Duration is 2-5 days
• Normal menstrual bleeding is a estrogen-
progesterone withdrawal bleeding

7. Patterns of Abnormal Bleeding
• Hypermenorrhea (menorrhagia): Heavy/prolonged
bleeding
• Hypomenorrhea: light menstrual flow
• Obstruction: cervical or hymenal stenosis
• Oral contraceptives, LNG-IUD
• Uterine synechia (Asherman’s syndrome)
• Polymenorrhea: Periods that occur less than 21
days apart
• Oligomenorrhea: Periods that occur more than 35
days apart

8. Patterns of Abnormal Bleeding
• Metrorrhagia (intermenstrual bleeding): bleeding
that occurs at any time between menstrual periods
• Menometrorrhagia: bleeding that occurs at
irregular intervals. Amount and duration may vary
• Contact bleeding (Postcoital bleeding)

9. Differential diagnosis of AUB

11. Initial Evaluation-History
• Gynecologic and obstetric history
• Menstrual history, LMP
• Sexual intercourse? Trauma? (Bleeding after trauma
usually suggests vaginal or cervical etiology)
• Contraceptive use (IUD, OCP, progestin-only pill use)
• Other medical history
• Systemic diseases (especially endocrine, liver, renal, and
hematological diseases)
• Family history (esp. bleeding disorders)
• Medication use (hormonal, drugs that ↑PRL,
anticoagulants)
• Excessive exercise, eating disorders

12. Initial Evaluation-History
• Is the patient pregnant?
• All patients with AUB should have pregnancy testing
• It should also be performed in women who report no
sexual activity and in those who report use of
contraception.
• Is the patient premenarchal or postmenopausal?
• The differential diagnosis of AUB for reproductive-age
women differs from that of premenarchal or
postmenopausal patients

13. Initial Evaluation-Symptoms
• Are there any associated symptoms?
• Lower abdominal pain, fever, and/or vaginal discharge
could indicate infection (pelvic inflammatory disease
[PID], endometritis)
• Dysmenorrhea, dyspareunia or infertility suggest
endometriosis and possible adenomyosis.
• Changes in bladder or bowel function suggest
extrauterine uterine bleeding or a mass effect from a
neoplasm.
• Galactorrhea, heat or cold intolerance, hirsutism, or hot
flashes suggest an endocrinologic issue.

14. Initial Evaluation-Physical Exam
• Vital signs should be assessed first
• A general examination should be performed to look for
signs of systemic illness, such as
• Anemia
• Fever
• Ecchymoses
• Enlarged thyroid gland
• Evidence of hyperandrogenism (hirsutism, acne,
clitoromegaly, or male pattern balding)
• Acanthosis nigricans may be seen in women with polycystic
ovarian syndrome (PCOS)
• Galactorrhea (bilateral milky nipple discharge) suggests the
presence of hyperprolactinemia

15. Initial Evaluation-Physical Exam
• A complete pelvic examination should be performed
• Abnormal findings along the genital tract (mass, laceration,
ulceration, friable area, vaginal or cervical discharge, foreign
body)
• An enlarged uterus → pregnancy, leiomyoma, adenomyosis,
malignancy
• Limited uterine mobility → pelvic adhesions or a pelvic mass
• Pelvic adhesions → prior infection, surgery, or
endometriosis
• A boggy, globular, tender uterus is typical of adenomyosis.
• Uterine tenderness → pelvic inflammatory disease (PID)
• Presence of an adnexal mass or tenderness

17. Structural causes of AUB

20. Polyps
• Cervical
• Endometrial

21. Adenomyosis

22. Anovulatory uterine bleeding
DUB
• Anovulatory uterine bleeding and DUB are
interchangeable terms
• DUB occurs with the disruption of cyclic hormonal
changes that regulate the normal menstrual cycle
• In up to 90% of cases it is a manifestation of
anovulation leading to estrogen breakthrough
bleeding

23. Causes of DUB
• Polycystic ovary syndrome
• Immaturity of the HPO axis
• Postpubertal adolescents shortly after menarche
• Perimenopausal women
• Dysfunction of the HPO Axis
• Hyperprolactinemia
• Stress and anxiety
• Rapid weight loss
• Anorexia nervosa
• Hypothyroidism
• Perimenopause
• Abnormalities of normal feedback signals
• Liver disease, hypothyroidism
• Obesity
• Estrogen producing ovarian tumors

24. Evaluation of DUB

25. Laboratory Evaluation- Initial Tests
• Pregnancy test
• Repeat if positive
• Blood test if urine is negative
• Repeat in 1 week if negative
• Complete blood count
• Hemoglobin and/or hematocrit for anemia → women
with heavy or prolonged bleeding
• Platelet count → bleeding disorders
• White blood cell count for infection

26. Laboratory Evaluation- Endocrine
• Thyroid function tests -Hypo and hyperthryoidism
• Prolactin
• Androgens levels
• FSH or LH – Poor nutrition, exercise,
perimenopause
• Estrogen levels – estrogen secreting tumor (very
rare)
• Assessment of ovulatory function – Anovulation

27. Diagnostic procedures
• Ultrasound
• Transvaginal examination should be performed, unless there is a
reason to not perform the vaginal study (virginal patient)
• Transabdominal sonography should also be performed if
transvaginal imaging does not allow adequate assessment of the
uterus or adnexa or if a large pelvic mass is present.
• SIS if intracavitary pathology is suspected
• Polyps
• SM fibroids
• Endometrial biopsy
• DC
• Hysteroscopy

28. Endometrial Sampling
• Once pregnancy has been excluded, endometrial
sampling should be performed in women with AUB
if there is:
• increased risk of endometrial hyperplasia or cancer
• Suspicion of endometritis
• Retained products of conception in women with PP
bleeding

30. Saline Infusion Sonography

34. Treatment
• Treatment is planned according to the etiology
• Any medicine that may be responsible for AUB should be
stopped, if possible
• Polyps →polypectomy
• Fibroids and Adenomyosis →
• Medical:
• Tranexamic acid
• Estrogen-progestin pills
• Progestin implants-injections-pills
• Gonadotropin-releasing hormone agonists
• Levonorgestrel-releasing IUD (LNG-IUD)
• Surgical or invasive:
• Myomectomy
• Hysterectomy
• Embolization
• MR guided focused ultrasound

35. Treatment
• Endocrine disorders → Thyroid disease treated as
indicated, cabergoline for hyperprolactinemia
• Von Willebrand Disease and other coagulation
disorders →Desmopressin, tranexamic acid,
estrogen-progestin contraceptives, LNG-IUD
• Infection→Antibiotics according to suspected agent
• Endometrial hyperplasia → High-dose long-term
progestins, LNG-IUD, hysterectomy
• Genital cancer → Treated as indicated

36. Treatment of Acute, Heavy Bleeding in
Dysfunctional Uterine Bleeding
• If endometrium is denuded or attenuated, the best initial
treatment is estrogen therapy. When endometrium is
normal or thickened, high dose estrogen-progestin or
progestin alone may help.
• High-dose IV estrogen(25 mg conjugated E2 every 4 hrs)
gives rapid response
• In hemodynamically stable patients, oral conjugated E2 2.5
mg every 4-6 hrs for 2-3 wks
• Alternatively, OCPs 3-4 times the usual dose may be
preferred and tapered gradually
• Once bleeding has stopped, medroxyprogesterone acetate
5mg once or twice a day for 7-10 days
• Endometrial curettage is warranted when bleeding is acute
or fails to respond promptly to intensive medical therapy

37. Treatment Options for Dysfunctional
Uterine Bleeding
• OCPs regulate menses and decrease flow
• Progestins may be an alternative in patients who
can not use OCPs (eg, smokers over age 35)
• NSAIDs reduce mentstrual volume
• Tranexamic acid
• GnRH agonists + add back therapy with
progesteron+low dose E2 or progestin alone
• Danazol- effective but has side effects
• LNG-IUD