ABNORMAL UTERINE BLEEDING OG 24.

2
Define, classify and discuss abnormal
uterine bleeding, its etiology, clinical
features, investigations, diagnosis and
management.
Dr Trinayan Mili
Asst. Prof.
O&G deptt.
LMCH
 DEFINITIONS
AUB:
Any uterine bleeding outside the normal volume,
duration, regularity or frequency is considered
abnormal uterine bleeding (AUB).

MENORRHAGIA (SYN : HYPERMENORRHEA)

• Menorrhagia is defined as cyclic bleeding at
normal intervals; the bleeding is either excessive in
amount (> 80 mL) or duration (> 7 days) or both.
• POLYMENORRHEA (SYN : EPIMENORRHEA)
Polymenorrhea is defined as cyclic bleeding where the cycle is
reduced to an arbitrary limit of less than 21 days and remains
constant at that frequency. If the frequent cycle is associated with
excessive and/or prolonged bleeding, it is called epimenorrhagia.

METRORRHAGIA
• Metrorrhagia is defined as irregular, acyclic bleeding from the
uterus. Amount of bleeding is variable.

• OLIGOMENORRHEA
Menstrual bleeding occurring more than 35 days apart and which
remains constant at that frequency is called oligomenorrhea.
• HYPOMENORRHEA
When the menstrual bleeding is unduly scanty and lasts for less than 2
days, it is called hypomenorrhea.

• DYSFUNCTIONAL UTERINE BLEEDING (DUB)

DUB is defined as a state of abnormal uterine bleeding without any
clinically detectable organic, systemic, and iatrogenic cause (Pelvic
pathology, e.g. tumor, inflammation or pregnancy is excluded).
Currently DUB is defined as a state of abnormal uterine bleeding
following anovulation due to dysfunction of hypothalamo-pituitary-
ovarian axis (endocrine origin).

• Heavy menstrual bleeding (HMB) is defined as ableeding

that interferes with woman's physical, emotional, social and maternal
quality of life.
 ETIOPATHOLOGY OF AUB
OVULATORY DYSFUNCTION (AUB-O)
• Most of the AUB are due to ovulatory dysfunction. Many are the result of
different endocrine or metabolic dysfunction. These are polycystic ovarian
syndrome, hypothyroidism, hyperthyroidism, hyperprolactinemia, obesity or
due to hypothalamic dysfunction (stress, weight loss).
ENDOMETRIAL (AUB-E)
• Primary disorders of the endometrium may be the cause of AUB or DUB.
Imbalance in the levels of different hemostatic mechanism may be
responsible for heavy menstrual bleeding (AUB). Optimum levels of
endothelin-1, PG F2α, formation of platelet plug or fibrin seal are essential
to control bleeding. Excess production of plasminogen activators,
production of substances that promote vasodilatation (PGE2, PGI2) may
result in AUB. Other local endometrial factors to cause AUB are endometrial
inflammation (chronic endometritis), infection, and endometrial vascular
pathology (angioma).
IATROGENIC (AUB-I)
• Breakthrough bleeding following the use of combined oral
contraceptives; erratic use of pills or any contraceptive
steroids (vaginal rings), use of IUCDs, or LNG-IUS.
 PATHOPHYSIOLOGY OF DUB
The physiological mechanism of hemostasis in
normal menstruation are:
(1) Platelet adhesion formation.
(2) Formation of platelet plug with fibrin to seal the
bleeding vessels.
(3) Localized vasoconstriction.
(4) Regeneration of endometrium and
(5) Biochemical mechanism involved: In increased endometrial
ratio of PGF2α/PGE2.
The endometrial abnormalities in DUB may be primary or
secondary to incoordination in the hypothalamo-pituitary-
ovarian axis. It is thus more prevalent in extremes of
reproductive period—adolescence and premenopause or
following childbirth and abortion.
The abnormal bleeding may be associated with or without
ovulation and accordingly grouped into:
• Ovular bleeding (20%)
• Anovular bleeding (80%)
• Ovular Bleeding
™Polymenorrhea or polymenorrhagia:
The follicular development is speeded up with resulting
shortening of the follicular phase. This is probably due to
hyperstimulation of the follicular growth by FSH.
Oligomenorrhea:
The disturbance may be due to ovarian unresponsiveness to
FSH or secondary to pituitary dysfunction. There is undue
prolongation of the proliferative phase with normal secretory
phase.
Functional menorrhagia:
Two varieties are found:
 „Irregular shedding of the endometrium
 „ Incomplete withdrawal of LH even on 26th day of cycle →
incomplete atrophy of the corpus luteum → persistent secretion
of progesterone.
 „ Persistent LH → inhibition of FSH → suppresses ripening of
the follicle in the next cycle → less estrogen → less
regeneration.

 Irregular ripening of the endometrium.

There is poor formation and inadequate function of the corpus
luteum. Secretion of both estrogen and progesterone is
inadequate to support the endometrial growth.
Anovular Bleeding
Menorrhagia:
In the absence of growth limiting progesterone due to
anovulation, the endometrial growth is under the influence
of estrogen throughout the cycle. There is inadequate
structural stromal support and the endometrium remains
fragile.
Cystic glandular hyperplasia (Syn: Metropathia
hemorrhagica, Schroeder’s disease)
 There is slow increase in secretion of estrogen but no negative
feedback inhibition of FSH. The net effect is gradual rise in the
level of estrogen with concomitant phase of amenorrhea for
about 6–8 weeks. As there is no ovulation, the endometrium is
under the influence of estrogen without being opposed by
growth limiting progesterone for a prolonged period. After a
variable period, however, the estrogen level falls resulting in
endometrial shedding with heavy bleeding
 Changes in the uterus: There is variable degree of myohyperplasia
with symmetrical enlargement of the uterus to a size of about 8–10
weeks due to simultaneous hypertrophy of muscles
 Microscopically, There is however, intense cystic glandular
hypertrophy rather than hyperplasia with marked disparity in
sizes
 Endometrium showing 'Swiss cheese'
Increased uterine size with myohyperplasia appearance
 PELVIC PATHOLOGY TO CAUSE
MENORRHAGIA
Due to congestion, increased surface area, or hyperplasia of the
endometrium
• Fibroid uterus
• Adenomyosis
• Pelvic endometriosis
• IUCD in utero
• Chronic tubo-ovarian mass
• Tubercular endometritis (early cases)
• Retroverted uterus—due to congestion
• Granulosa cell tumor of the ovary
Systemic: Liver dysfunction (cirrhosis)—failure to conjugate and
thereby inactivate the estrogens.
• Congestive cardiac failure
• Severe hypertension
Endocrinal
• Hypothyroidism
• Hyperthyroidism
Hematological
• Idiopathic thrombocytopenic purpura
• Leukemia
• von Willebrand’s disease
• Platelet deficiency (thrombocytopenia)
Emotional upset
• ™Functional
 CAUSES OF CONTACT BLEEDING
• Carcinoma cervix
• Mucus polyp of cervix
• Vascular ectopy of the cervix specially during
pregnancy, pill use cervix
• Infections—chlamydial or tubercular cervicitis
• Cervical endometriosis
 CAUSES OF ACYCLIC BLEEDING
• DUB—usually during adolescence, following
childbirth and abortion and preceding
menopause
• Submucous fibroid
• Utering polyp
• Carcinoma cervix and endometrial carcinoma
 CAUSES OF INTERMENSTRUAL BLEEDING

Apart from the causes of contact bleeding, other

causes are:
• Urethral caruncle
• Ovular bleeding
• Breakthrough bleeding in pill use
• IUCD in utero
• Decubitus ulcer
COMMON CAUSES OF OLIGOMENORRHEA

• Age-related— during adolescence and

precedingmenopause
• Weight-related—obesity
• Stress and exercise related
• Endocrine disorders— PCOS (most common),
hyperprolactinemia, hyperthyroidism
• Androgen producing tumors— ovarian, adrenal
• Tubercular endometritis— late cases
• Drugs:
Phenothiazines • Cimetidine • Methyldopa
 CAUSES OF HYPOMENORRHEA
The causes may be
 Local (uterine synechiae or endometrial
tuberculosis),
 Endocrinal (use of oral contraceptives,
thyroid dysfunction, and premenopausal
period), or
 Systemic (malnutrition).
 DIAGNOSIS OF ABNORMAL UTERINE
BLEEDING
The investigation aims at:
 ‰To confirm the menstrual abnormality as
stated by the patient
 To exclude the systemic, iatrogenic or
‘organic’ pelvic pathology
 ‰ To identify the possible etiology of DUB
 ‰To work out the definite therapy protocol.
Detailed history taking and physical examination should be done.
 Medical history should include: Age of the patient,
patterns of abnormal uterine bleeding, severity, associated pain,
family history and use of medication.
 „General and physical examination: Pallor, edema, neck glands,
thyroid, and systemic examination, and pelvic examination (per
speculum, Pap smear, and bimanual examination) are included.
Laboratory investigations:
Complete hemogram, thyroid profile, pregnancy test,
coagulation profile.
Imaging studies:
 Ultrasonography (transvaginal),
 Saline infusion sonography (SIS),
 Hysteroscopy (SIS is superior to TVS for detection of
intracavitary pathology like, polyps, submucosal fibroids).
 Magnetic resonance imaging (MRI): MRI may be used as a
second line procedur specially in cases with adenomyosis

Laparoscopy: To exclude unsuspected pelvic pathology such as

endometriosis, PID or ovarian tumor (granulosa cell tumor).
The indication is urgent, if associated with pelvic pain.
Endometrial biopsy (EB)
Histological confirmation of pathology whenever possible.
 MANAGEMENT OF AUB
Management depends on:
Age,Desire for child bearing,Severity of bleeding,
Associated pathology.
• ‰ Pubertal and adolescent menorrhagia < 20
years
• ‰ Reproductive period (20–40 years).
• ‰ Premenopausal (> 40 years).
• ‰Postmenopausal.
• ‰Associated pathology.
 Reproductive Period
General
• ™Rest is advised during bleeding phase. Assurance
and sympathetic handling are helpful particularly
in adolescents.
• ™ Anemia should be corrected appropriately by
diet, hematinics, and even by blood transfusion.
• ™Any systemic or endocrinal abnormality should
be investigated and treated accordingly.
MEDICAL MANAGEMENT OF DUB
(A) Prostaglandin synthetase inhibitors (PSI)
Fenamates (Mefenamic acid)
(B) Antifibrinolytic agents
Tranexamic acid (TA)
(C) Hormones
 Norethisterone acetate
 Medroxyprogesterone acetate
 Progestin releasing IUCD: LNG – IUS
 Dydrogesterone
 Equine conjugated estrogen
 Combined estrogen and progestogen (contraceptive pills)
 19 Norsteroid derivative (Gestrinone)
 Danazol (17 α-ethinyl testosterone)
 Mifepristone (RU 486)
 GnRH analogs
 Desmopressin
The preparations are used:
• „. Cyclic therapy  Continuous therapy
• To stop bleeding and regulate the cycle:
• Norethisterone preparations (5 mg tab) are used
thrice
• daily till bleeding stops, which it usually does by 3–
7 days.
• Cyclic therapy
• • 5th–25th day course • 15th–25th day course.
Surgical Management of AUB
 ™Uterine curettage
 ™Endometrial ablation/resection
Uterine thermal balloon
Microwave endometrial ablation
Novasure
Transcervical resection of the endometrium TCRE
Uterine artery embolization

 ™Hysterectomy.