4. • Chief complaint:
– PV bleeding for 23 days(28th Asar- 21st Shrawan)
• HOPI:
– PV: Dark red colored,
8-9pads/day fully soaked,
Clots +
no lower abdominal and back pain
- No h/o trauma, fever, N/V, LOC and drug intake
- B/B habit: Normal
5. • Past History:
No h/o HTN, DM, TB ,Asthma and Thyroid d/o .
No previous surgical history
• Personal history: non-veg, non smoker
does not consume alcohol
• Family history: no history of any significant illness
in the family
6. • Menstrual history:
– LMP: Asar 28, 2075
– Menarche: 13yr
– Cycle: irregular from past 1 year (30-60 days)
– Flow: 4-5days/4-5pads per day
– Clots: +/-
– Dysmenorrhea: absent
• Obstetric h/o:
– Married for 26yrs
– P2L2A0
– P1: 26yr M (ND @ home)
– P2: 24yr M (ND @ home)
– BTL done after 6 months of 2nd delivery
7. On Examination
– GC: fair, well oriented to time, place and person
– Vitals: BP- 110/80mmHg
Pulse- 96 bpm (regular)
Temp.- 97°F
RR- 20bpm
– Cardinals: Pallor +nt, other cardinals absent
8. Systemic Examination
• Respi- normal vesicular breath sounds +
- no wheeze, crepitations or crackles
• CVS- S1 S2 heard , no murmur
• Per abdomen- soft, non-tender, no organomegaly,
- no shifting dullness, no fluid thrill
• Per Speculum - Cx- smooth,no bleeding, no discharge
• PV- Uterus- normal size,anteverted
CMT-ve
b/l fornices free
11. PROVISIONAL Dx.- AUB with severe anemia
Course of hospital stay-
Packed cell 4 pint transfused
– post BT Hb: 10.4g%
Plan for endometrial biopsy
Medication on discharge:
• Tab iron 1 tab PO OD for 1 month
• Follow up with endometrial biopsy report after 10 days
12. Abnormal uterine bleeding
• Definition- Any uterine bleeding outside the
normal volume, duration, regularity, or frequency is
considered abnormal uterine bleeding.
13. Normal Uterine Bleeding
• Age of patient: reproductive-aged women
i.e.menarche to menopause
• Frequency: 21-35 days interval
• Duration: 3-7days
• Flow: 35 ml, although 20ml – 80ml is considered
normal
Menarche: 1O-16 years
Menopause: 45-55 years
14.
15. Patterns of AUB
Definition Interval Amount Duration
Menorrhagia Regular Excessive
>80 ml
>7 Days
Hypomennorhea Regular Normal <3 Days
Metrorrhagia Irregular Normal Normal
Menometrorrhagia Irregular Excessive
>80 ml
Meno+Metro
Polymenorrhea <21 days Normal variable
Oligomenorrhea >35 days scanty variable
18. Causes of AUB according to age group
Age Group Causes
Pre-puberty Precocious puberty = hypothalamic, pituitary or ovarian origin
Adolescence Anovulatory cycles, coagulation disorders
Reproductive age group Complications of pregnancy
PID- eg: endometritis
Organic lesions- leiomyomas, adenomyosis, polyps, endometrial
hyperplasia, carcinomas
Iatrogenic - OCPs
DUB - anovulatory cycles
- ovarian dysfunctional bleeding i.e. inadequate luteal phase
Perimenopausal DUB - anovulatory cycles
- organic lesions- hyperplasia, polyps, carcinomas
Postmenopausal Endometrial atrophy
Organic lesions -hyperplasia, polyps, carcinomas
19. Dysfunctional uterine bleeding
• Definition -A state of abnormal uterine bleeding without
any clinically detectable organic, systemic and iatrogenic
cause.
• Currently, DUB is defined as a state of AUB following
anovulation due to dysfunction of HPO axis (endocrine origin)
• Two types: -Anovulatory (80%)
-Ovulatory (20%)
• 50% - at near menopause
• 30%- at reproductive age
• 20%- in adolescents
20. The physiological mechanism of hemostasis in
normal menstruation :
Platelet adhesion
formation
Platelet plug
formation
Localized
vasoconstriction
Regeneration of
endometrium
Biochemical mechanism involved are:
Increased endometrial ratio of PGF2α/PGE2
Progesterone increases the level of PGF2α from arachidonic acid
PGF2α causes vasoconstriction and reduces bleeding
Levels of endothelin, which is a powerful vasoconstrictor is also increased
Women with menorrhagia have low level of thromboxane in endometrium
21. Anovulatory DUB (80%)
Age: Perimenarchal and perimenopausal years
Cause: Hypothalamic – Pituitary – Ovarian hormonal axis
imbalance
Presents as- 1. menorrhagia-
2. metropathia hemorrhagica- periods of
amenorrhea followed by prolonged heavy
bleeding .
22. No mature follicle, No corpus luteum
Failure of the cyclical secretion of progesterone
Continuous unopposed production of estradiol
Stimulates overgrowth of endometrium
Endometrium grows thick, outgrows its blood supply
Necrosis and irregular bleeding
23. Absence of progesterone
Alterations in prostaglandin production
More PGE2 and PGI2 <vasodilation and
antiplatelet> and less PGF2∝<vasoconstriction>
Increased fibrinolytic activity
Bleeding
Presents as menorrhagia
24. Changes in anovulatory DUB
Prolonged Unopposed Estrogen
Proliferative Endometrium
Simple Hyperplasia
Complex Hyperplasia
Complex Hyperplasia with Atypia
Adenocarcinoma
25. Ovulatory DUB (20%)
Age- reproductive age group (21-40 years )
Presents as- 1.Polymenorrhea
2.Oligomenorrhea
3.Functional menorrhagia
Causes are- 1. persistent corpus luteum , which does not
regress in 12 to 14 days.
2. Luteal phase defect , an inadequate corpus
luteal function.
26. Ovulatory DUB
• Mechanism-
Vessels supplying endometrium have decreased vascular tone
vasodilatation
increase rate of blood loss
• Thought to stem predominantly from vascular dilatation alone.
• Women with ovulatory DUB loose blood at rates 3x faster than
women with normal menses.
• But the number of spiral arterioles is not increased.
27. Diagnosis of AUB
Work Up-
History-
Age of the patient
Timing and Quantity of bleeding, menstrual h/o
associated signs and symptoms
h/o of trauma, use of medications
past history
sexual h/o, obstetrics h/o, contraceptive h/o
family h/o of malignancies and bleeding disorders.
28. Work up continued….
General and physical examination-
look of patient, vitals and cardinals
Assess for obesity, hirsutism
thyroid and other systemic examination
pelvic examination including per speculum, pap smear and
bimanual examination
R/o vaginal or cervical source of bleeding
29. Work up continued….
Lab investigations- complete hemogram,
thyroid profile, hormonal assay,
coagulation profile,
pregnancy test
Imaging studies-USG (ultrasonography),
SIS (saline infusion sonography),
hysteroscopy,
Dilatation and curettage
MRI (magnetic resonance imaging)
Cervical biopsy, endometrial biopsy
30. Management of AUB
General considerations
1. Medical management should be initial treatment for most
patients
2. Need for surgery (including type of surgery) is based on various
factors:
age of the patient
stability of patient
severity of bleed
contraindications to medical management
patient not responding to medical management
underlying cause
desire for future fertility
31. Initial Approach
Determine if AUB acute vs. chronic
If acute AUB, are there signs of hypovolemia/hemodynamic
instability?
If yes, resuscitate: IV access with 1 to 2 large bore IV;
Crystalloids vs colloids
Prepare for blood transfusion +/- clotting factor replacement
Once stable, evaluate etiology (PALM-COEIN)
Determine Treatment
32. Medical Management:
Non-hormonal
o Iron therapy
o PG synthetase inhibitors/NSAIDS – mefenamic
acid, much effective in case of ovulatory DUB in women aged
>35 years.
o Antifibrinolytics- tranexamic acid
33. Hormonal
o Progestins-
medroxyprogesterone acetate, norethisterone acetate
antiestrogenic action
more effective in anovulatory bleeding
inhibit pituitary gonadotropin secretion and ovarian hormone production
Preparations=
Cyclic therapy
Continuous therapy- oral/ IM/ DMPA implants
o Conjugated estrogen
o Combined estrogen and progestrone –OCP , more effective in
ovulatory bleeding.
34. Hormonal therapy continued…
Intrauterine progestogen – LNG-IUS
Medical hysterectomy
Induce endometrial glandular atrophy, stromal decidualization and
endometrial cell inactivation
Reduce blood loss upto -90%
first line therapy for a woman with HMB in the absence of any structural
or histological abnormality
an effective contraceptive measure
35. Hormonal therapy continued…
o Antiprogesterone- mifepristone
o Short-term therapy
a. Danazol- in patients waiting for hysterectomy and in patients with
recurrent symptoms
b. GNRH agonists- who wants pregnancy, also improves anemia.
o Desmopressin in VW disease and factor viii deficiency
36. Surgical Management Options
Uterine Curettage-
• predominantly as a diagnostic tool for elderly
women
• Quickest way to stop bleeding in hypovolemic
patients
• it has got hemostatic and therapeutic effect by
removing the necrosed and unhealthy endometrium.
37. Endometrial Ablation- >35 years, completed
family, failed medical therapy, small uterine fibroid
<3cm
Uterine Artery Embolization – large uterine fibroid
>3cm, heavy bleeding
Others include:
hysteroscopy with D&C
polypectomy
myomectomy
38. Hysterectomy in AUB
Indications-
conservative treatment fails or contraindicated
blood loss impairs the health and quality of life
endometrial hyperplasia and atypia
patient is approaching 40/ completed family
Types- 1. Total hysterectomy
2. Subtotal hysterectomy
3. Pan-hysterectomy
4. Extended hysterectomy
5. Radical hysterectomy
39. References
• DC DUTTA’S textbook of gynecology
• BEREK AND NOVAK’S gynecology
• WILLIAM’S textbook of gynecology
