ABNORMAL UTERINE

BLEEDING
ANINDITA LARASATI
17710221
 MENSTRUAL DIMENSIONS
The mean menstrual blood loss in women with normal hemoglobin and iron levels is 35 mL, with 95% of
women losing <60 mL each menstrual cycle.

VOLUME & CYCLE

FREQUENCY REGULARITY DURATION

Normal : 21-35 days
Oligomenorrhea : >35 days
Polymenorrhea : <21 days
Normal blood loss : 5-80 mL
Regular cycles : 2-20 days
Light Cycle : <5-mL blood
loss
Menorrhagia : heavy, regular
periods with >80-mL blood
loss
Menometrorrhagia : heavy, Normal : 4 to 6 days
irregular bleeding that
includes intermenstrual Prolonged : >7 days
bleeding
Shortened : <3 days
Withdrawal bleeding : a
predictable pattern of
bleeding that occurs after DYSMENNORRHEA
the withdrawal of progestin
therapy

Metrorrhagia : Irregular Breakthrough bleeding :

bleeding, especially between unpredictable bleeding
cycles that occurs while on
hormonal contraception
 DIFFERENTIAL DIAGNOSIS OF ABNORMAL
UTERINE BLEEDING
• Prepubertal AUB
• Reproductive Age AUB
• Perimenopause AUB
• Postmenopause AUB
Prepubertal Abnormal Uterine Bleeding
Benign prepubertal bleeding may occur in the
first few days of life due to the withdrawal of
maternal estrogen, but all other cases of
bleeding require evaluation.
Reproductive Age Abnormal Uterine Bleeding
• Associated with pregnancy, anovulatory bleeding, structural
causes, and coagulation disorders.
• HISTORY
• sexual history
• past medical history
• gynecologic and obstetric history
• contraceptive and medication
• patient’s diet, weight, and exercise pattern
• Family history  for possible bleeding disorders
• Adolescent girls should be screened for physical
abuse
• PHYSICAL EXAM
• weight
• evidence of hyperandrogenism  hirsutism, acne
• thyroid nodules
• evidence of insulin resistance  acanthosis nigricans
• evidence of bleeding disorders  petechiae, ecchymoses, skin pallor
• Inspection of the vaginal vault  discharge  infection or evidence of trauma,
lesions, polyps, products of conception, or masses.
• A bimanual examination
• evaluate the internal os
• presence of cervical motion tenderness
• size and contour of uterus and adnexa
• presence of any palpable masses, lesions, or tenderness.
• DIAGNOSTIC TESTING
• β-hCG  pregnancy
• TSH
• Prolactin
• Complete blood count.
• Suggesting genital tract infection  cervical or vaginal swabs  sexually transmitted
infections  chlamydia, gonorrhea, herpes, or trichomonas
• In women with risk factors for neoplastic processes  a tissue diagnosis  endometrial
biopsy
• In women at risk for coagulopathy, targeted screening of bleeding disorders is
recommended
 Perimenopause Abnormal Uterine Bleeding
• most commonly due to anovulation and structural abnormalities  fibroids, polyps.
however may be attributed to hyperplasia or malignancy.
• HISTORY
• In addition to routine history obtained for women of other ages, menopausal
symptoms  vasomotor symptoms, sleep disturbances, mood disturbances
• EXAM & TESTING
• TSH
• FSH
• Prolactin.
• Imaging should evaluate for fibroids.
• Obtain tissue specimens/biopsies  cervical, endometrial  if
indicated.
• Infectious workup is recommended in patients at risk.
Postmenopause Abnormal Uterine Bleeding
• Primarily caused by endometrial and vaginal atrophy.
• 15% of these women will have some form of hyperplasia
• 7% to 10% will have endometrial cancer
• Tissue sampling and imaging in this population are essential.
• Infectious workup is recommended in patients at risk.
 EVALUATION OF ABNORMAL UTERINE
BLEEDING
• Ultrasonography
• Transvaginal ultrasonography (TVUS)
• Evaluate for the presence of fibroids, polyps, intrauterine pregnancy, and ectopic
pregnancy.
• In the workup for possible malignant processes  thickened endometrium and
masses within the uterus, adnexa, or cervix.
• Better in postmenopausal than premenopausal women
• Saline infusion sonography, or sonohysterography,
• involves distention of the uterine cavity with sterile saline to enhance visualization
of the endometrial surface during TVUS.
• the most sensitive noninvasive method of diagnosis for endometrial polyps and
submucous myomata. However, it does not distinguish between benign and
malignant processes.
• Hysteroscopy
• The gold standard for evaluating the endometrial cavity
• provides direct visualization of the endometrial cavity
• diagnostic and operative  directed biopsies and excision of polyps and small
myomas.
• Office hysteroscopy with targeted biopsies has a sensitivity and specificity of
98% and 95%
• Magnetic Resonance Imaging
• Pelvic magnetic resonance imaging (MRI)
• useful in the diagnosis of adenomyosis  accurately localize and measure fibroids, facilitating
determination of the best treatment  embolization, resection, hysterectomy

• Endometrial Sampling
• a rapid, safe, and cost-effective procedure that can be performed in the office to
evaluate AUB
• Women older than age 45 years as a first-line test
• Women younger than 45 years with risk factors for unopposed estrogen  obesity,
polycystic ovarian syndrome
• those who have failed medical management or have persistent AUB
• Dilation and Curettage
• diagnostic and therapeutic but incurs the cost of an operating room and
carries the risks of anesthesia
• indicated in
• women with non-diagnostic endometrial biopsies
• biopsies with insufficient tissue for analysis
• women with cervical stenosis making an office procedure unsuccessful
 SPECIFIC CAUSES OF ABNORMAL UTERINE
BLEEDING
• Pregnancy-Associated Bleeding
• should be suspected in any woman in her reproductive years.
• If urine β-hCG is positive  a pelvic examination must be performed and an
ultrasonographic study obtained.
• A quantitative serum β-hCG test is needed if an intrauterine pregnancy is not first
confirmed by ultrasound.
• The differential :
• ectopic pregnancy or threatened,
• inevitable, incomplete, or missed abortion. Any patient who is hemodynamically unstable, bleeding
heavily, or septic requires surgical intervention.
• Women with missed or incomplete abortions who are stable and not bleeding heavily
 offered expectant management or treated medically with misoprostol  success rate
of approximately 84%.
• Dysfunctional Uterine Bleeding
• diagnosis of exclusion for AUB without a demonstrable pathologic cause
• predominant causes anovulation or oligoovulation
• long-term anovulation  estrogen production occurs without the progesterone normally produced
from a corpus luteum creating an unopposed estrogen state  these women are at risk for
endometrial hyperplasia.
• Anovulation associated with polycystic ovary syndrome  risk of endometrial hyperplasia.
• Morbid obesity can also cause DUB.
• Peripheral conversion of androstenedione to estrone occurs in adipose tissue producing elevated
estrogen levels.
• Occasionally, DUB may be associated with ovulatory cycles.
• Treatment :
• Progestins
• COCs (combined oral contraceptive)
• NSAIDs
• Danazol
• Antifibrinolytic medications (e.g., tranexamic acid)
• Gonadotropin-releasing hormone (GnRH) agonists
• Surgical treatment
• D&C
• Endometrial ablation
• Hysterectomy
• Coagulation Disorders
• Menorrhagia during adolescence  attributed to a coagulation disorder until
proven otherwise.
• Bleeding from multiple sites  nose, gingiva, intravenous sites,
gastrointestinal, and genitourinary tracts  may suggest coagulopathy.
• There is a higher prevalence of bleeding disorders in women with
menorrhagia.
• Von Willebrand Disease
• inherited bleeding disorder  affecting 1% to 2% of the population
• menorrhagia is the most common manifestation, occurring in 60% to 95% beginning at
menarche.
• Women with vWD are also likely to report postpartum or postoperative bleeding or bleeding
related to dental work. They may also report easy bruising, epistaxis, or family history of
bleeding symptoms.
• The frequency of vWD in women with menorrhagia is 5% to 20%.
• Testing for vWD should be considered in women with a history of unexplained menorrhagia
beginning at menarche
• Several tests are performed to diagnose vWD: factor VIIIC activity, vWF antigen, ristocetin cofactor
activity (i.e., vWF activity), platelet function tests, and bleeding time.
• The ristocetin cofactor assay may be the best single screening test.
• Treatment :
• Oral contraceptives, desmopressin, and antifibrinolytic agents are options.
• Endocrine Disorders
• Endocrinopathies can cause anovulation, producing an environment of
unopposed estrogen.
• In the absence of progesterone  the endometrium eventually breaks down
 may or may not lead to the formation of hyperplasia.
• Hypothyroidism and hyperprolactinemia are common disorders that can lead
to anovulation.
• Hepatic Dysfunction
• Decreased metabolism of estrogen and decreased clotting factor synthesis 
common ramifications of liver failure.
• Anovulation & Menometrorrhagia is common.
• Liver function tests are necessary to make the diagnosis.
• Physical examination  jaundice, ascites, hepatosplenomegaly, palmar erythema,
pruritus, and spider angioma
• If the patient is coagulopathic and hemorrhaging, administration of packed red
blood cells and fresh frozen plasma may be indicated.
• Progestin therapy may also be beneficial.
• Medication Side Effects
• Psychotropic Medications
• Hormone Medications
• Anticoagulants
• Digitalis
• phenytoin
• corticosteroids
• Genital Infection
• AUB is not a common presenting symptom of either endometritis or cervicitis.
• if present :
• bleeding associated with endometritis  intermenstrual,
• bleeding associated with cervicitis  postcoital.
• Endometritis  diagnosed by uterine tenderness and sometimes fever. Any
recent history of instrumentation of the uterus adds to the suspicion of
endometritis.
• Chronic endometritis  diagnosed by endometrial biopsy as evidenced by
the presence of plasma cells.
• Cervicitis  diagnosed by clinical examination and results of cervical cultures.
• Benign Pathology
• Leiomyomata
• Polyps
• Endometrial Hyperplasia
• Atypical endometrial hyperplasia
• Malignancy
• Endometrial Cancer
• Cervical Cancer
• Ovarian Cancer
THANK YOU