Abnormal Uterine

Bleeding
AUB

DEFINITION
Bleeding from the uterine corpus that
is abnormal in regularity, volume,
frequency or duration and occurs in
the absence of pregnancy.
Acute or Chronic

AUB CASE
A 39y/o woman is referred by the haematologist
w/ a diagnosis of anemia not responding to
treatment in the medical unit. Shes been
complaining of increasing tiredness & shortness
of breath for 3 months w/ frequent headache. Her
periods occur every 24 days. Flow on the 1st day
is generally moderate but becomes heavier from
2nd to 4th day. Bcs of heavy flow, she has to use
both tampons & sanitary towels. Theres no
associated abdominal pain. Theres no h/o
intermenstrual bleeding or postcoital bleeding.
Her last pap smear 2 years ago was normal. She
has had 2 normal deliveries & currently practices
barrier methods for contraception. Theres no
significant past medical history. Her present
condition is causing significant distress as her

POSSIBLE DIFFERENTIAL DIAGNOSIS

Uterine fibroids
DUB
Endometrial polyps
Adenomyosis
Endometrial hyperplasia
Endometriosis
Endometrial cancer

ASSESSMENT

1) GENERAL PHYSICAL EXAMINATION

Look for signs of pallor
BMI
Any evidence of thyroid disease

 2) ABDOMINAL EXAMINATION
Look for palpable pelvic masses
If there is a abdomino-pelvic mass
palpable, determine its size
(measured in cm or is stated relative
to a pregnant uterus) & its
characteristics (consistency,
tenderness, mobility, arising from the
pelvis) are defined.

 3) PELVIC EXAMINATION
Includes speculum & bimanual pelvic
examination
Speculum excludes local causes
(cervical polyp, ectopy or any features
of cervical malignancy)
Bimanual examination assess uterine
size, position (anteverted, axial or
retroverted) and any adnexal masses.

INVESTIGATIONS
1) FBC
To confirm iron deficiency anemia
due to excessive blood loss
To assess need for blood transfusion
2) Thyroid function test
Not routinely done unless highly
suspected

3) PT/APTT
4) Ultrasound transabdominal or transvaginal
5) Pipelle sampling (endometrial biopsy) for
the following patients:
-age >35 years
-obese
-DM
-HPT
-suspected polycystic ovarian disease

6) D&C is indicated in the following situations:

-consider D&C in patients at high risk for
endometrial hyperplasia & carcinoma
-consider D&C rather than pipelle sampling if
suspected diagnosis is endometritis, atypical
hyperplasia or carcinoma
-perform in patients having heavy,
uncontrolled bleeding
-perform if histologic examination is required
but biopsy is contraindicated

MANAGEMENT
A) GENERAL
-signs of hypovolemia or
haemodynamically unstable, iv lines
should be initiated rapidly
-preparation for blood transfusion and
clotting factor replacements

B) MEDICAL
1) 1st choice : Progestogens
-T.Duphaston 10m BD
-given for 21 days followed by 7 days rest
-significantly reduces menstrual flow
2) Androgens
-Danazol 200mg TDS
-synthetic steroids that suppresses estrogen & progestrone
receptors in the endometrium leading to endometrial atrophy
& reduced menstrual loss
-not to be taken for more than 6 months due to the side effects

3) Combined OCP
-regulates menses, reduces blood loss &
as contraception
4) Levonorgestrel intrauterine system :
Mirena
-releases steady amount of levonorgestrel
20mcg/24hrs
-suitable for women aged 30-40 years

5) Anti-fibrinolytic agents
-Tranexamic acid 1g TDS for 1 st 5days of
menses
-For regular menstrual cycles with heavy
bleeding
6) NSAIDS
-reduce PG level through inhibition of COX
enzyme
-reduction in blood flow

C) SURGICAL
-if medical treatment is not effective
-suitable for those who have
completed family
1) D&C
2) Hysterectomy (last resort)
3) Endometrial destruction procedure
(endometrial ablation)