ABNORMAL UTERINE

BLEEDING
DR T. KASSO

OBGYN DEPT. UPH

Outline
• Introduction
• Classification
• Aetiology
• Clinical presentation
• Management
• Conclusion
 Introduction
• Abnormal uterine bleeding (AUB) refers to any deviation from the normal
menstrual cycle in terms of frequency, duration, and/or volume of bleeding.
• It is a common gynaecological complaint with significant implications for
women’s reproductive health and their quality of life.
• Abnormal uterine bleeding (AUB) occurs in women of every age group, from
adolescence to menopause and includes heavy menstrual bleeding (HMB),
irregular or intermenstrual bleeding (IMB) and postmenopausal bleeding (PMB),
dysfunctional uterine bleeding (DUB)
• Vaginal bleeding during pregnancy is excluded
 Introduction
• Menstruation - This is a woman’s monthly bleeding from the reproductive
tract, as a consequence of cyclical changes in hormonal activity.
• It is also called menses, menstrual period or period. When a woman has her
period, she is menstruating.
• The menstrual blood is partly blood and partly tissue/fluid from the
endometrial lining of the uterus.
• Amount : < 80mls
Introduction
Bleeding in any of the following situations is considered abnormal uterine bleeding
irrespective of the volume:
• Bleeding or spotting between periods
• Bleeding or spotting after sex
• Heavy bleeding during periods
• Bleeding that soaks through one or more tampons or pads every hour
• Bleeding that lasts more than 7 days
• Menstrual cycles that are longer than 35 days or shorter than 21 days
• “Irregular” periods in which cycle length varies by more than 7 to 9 days
• Not having a period for 3 to 6 months
• Bleeding after menopause
Classification
AUB can be classified using various systems, but the PALM-COEIN
system is widely accepted:
• PALM: Structural causes
• Polyps
• Adenomyosis
• Leiomyoma (fibroids)
• Malignancy and hyperplasia
• COEIN: Non-structural causes
• Coagulopathy
• Ovulatory dysfunction
• Endometrial (e.g endometritis
• Iatrogenic
• Not yet classified
Classification
Aetiology
AUB can stem from a multitude of factors:
• Hormonal imbalances
• Anatomical abnormalities
• Coagulation disorders
• Medications
• Systemic illnesses
Understanding the underlying cause is crucial for effective
management.
.
Aetiology

A. Structural abnormalities in the B. Hormone imbalances

uterus • Anovulation/ Polycystic ovary
• Polyps. syndrome(PCOS).
• Fibroids. • Thyroid disease.
• Adenomyosis. • Obesity can lead to hormone
imbalances that may cause
abnormal uterine bleeding.
 Aetiology
• C. Infections • D. Precancerous/Cancerous
• Trichomoniasis. lesions
• Cervicitis • Uterine malignancy
• Chlamydia • Cervical malignancy
• Gonorrhoea. • Vaginal malignancy
• Endometritis. • Ovarian malignancy
• Vaginitis. • Endometrial hyperplasia.
Aetiology
• E. Medications • F. Other medical conditions
• Blood thinners (anticoagulants) • Von Willebrand disease
and aspirin. • Liver disease.
• Hormone replacement therapy. • Kidney disease.
• Tamoxifen (breast cancer drug). • Pelvic inflammatory disease
• Intrauterine devices (IUDs). (PID).
• Birth control pills and • Leukaemia or platelet disorders.
injectables - Depo-Provera®,
NuvaRing®, Implanon®.
.

Dysfunctional Uterine Bleeding (DUB)

• DUB is defined as “AUB that is not associated with a physical lesion, inflammation or
pregnancy.”
• It is diagnosed in women with abnormal uterine bleeding in whom no clear aetiology
can be identified.
• It can be excessively heavy or light and prolonged.
• It can be frequent or random, and is typically unpredictable.
• 90% of DUB is anovulatory.
• It is the most common cause of abnormal uterine bleeding and affects both ends of
the reproductive spectrum (that is, teens and perimenopausal women)
• Teens typically experience DUB during the first 2 years after menarche, when their
hypothalamic-pituitary-adrenal axis (HPA axis) is immature.
• AUB affects up to 50% of perimenopausal women, and DUB in these women is most
likely caused by a decline in ovarian function.
 Clinical presentation of AUB
Patients with AUB may present with various symptoms, including irregular
menstrual cycles, heavy or prolonged bleeding, intermenstrual bleeding,
postcoital bleeding, or postmenopausal bleeding.
• Menorrhagia (prolonged or heavy menstrual bleeding).
• Metrorrhagia (irregular bleeding between periods).
• Menometrorrhagia (prolonged or heavy bleeding at irregular intervals).
• Intermenstrual bleeding.
It is essential to obtain a thorough medical history and perform a
comprehensive physical examination.
 Management

The diagnostic workup for AUB involves a systematic approach, including:

• Detailed history-taking
• Physical examination, including pelvic examination
• Laboratory investigations
 History taking
• Biodata: Age, parity
• Detailed menstrual history- Menstrual calendar
• Ask for- LMP, number of pads used, flow rate, presence of blood clots, pain,
interval between periods, post - coital bleeding,
• Other relevant history - drugs, hormone replacement therapy, IUCD,
bleeding from other orifices, or bleeding disorders, previous surgeries, etc
• Ask for symptoms of anaemia: easy fatigability, weakness, fainting spells
 Physical examination
General examination
• Pallor
• Anterior neck swelling
• Oedema

Systemic examination
• Cardio-pulmonary
• Abdomen
• Pelvic examination
 Investigations
• Laboratory tests:
• Full blood count (FBC) to assess for anemia.
• Thyroid function tests.
• Coagulation profile.
• Endocervical swab for MCS
• Papanicolaou smear (Pap smear)

• Imaging studies:
• Trans-vaginal ultrasound to evaluate pelvic organs.
• Hysteroscopy for direct visualization of the uterine cavity.

• Endometrial biopsy to rule out malignancy or hyperplasia.

Treatment strategies
 Treatment strategies
Management of AUB depends on the underlying cause, patient preferences,
and reproductive goals.
Treatment modalities may include:
• Pharmacological interventions (e.g., hormonal therapy, non-steroidal anti-
inflammatory drugs (NSAIDS) e.g mefenamic acid, antifibrinolytics e.g
tranexamic acid
• Surgical interventions (e.g. dilation and curettage, endometrial ablation,
hysterectomy)
• Conservative measures (e.g., lifestyle modifications)
• Patient education and counseling
 Treatment strategies
Treatment depends on the underlying cause, patient age, desire for fertility, and
severity of symptoms.
• Medical management:
• Nonsteroidal anti-inflammatory drugs (NSAIDs) for symptomatic relief.
• Hormonal therapy (e.g., combined oral contraceptives, progestogens, gonadotropin-releasing
hormone agonists, danazol, gestrinone) to regulate menstrual cycles.
• Tranexamic acid to reduce menstrual blood loss.
• Surgical management:
• Endometrial ablation for focal endometrial pathology.
• Myomectomy or hysterectomy for uterine fibroids or refractory cases.
• Dilation and curettage (D&C) for diagnostic or therapeutic purposes for endometrial hyperplasia
• Fertility preservation options for women desiring future pregnancy.
• Patient education and counseling
 Conclusion
• Abnormal uterine bleeding is a very common gynaecological disorder, a
multifactorial condition with diverse aetiologies and presentations.
• Timely diagnosis and appropriate management are crucial to alleviate
symptoms and prevent complications.
• Comprehensive patient evaluation and individualized treatment plans are
essential for optimizing outcomes and improving quality of life.
• As healthcare providers, it is essential to have a thorough understanding of
AUB to provide optimal care to our patients.
 .

THANK YOU.