PALM-COEIN

PALM-COEIN

Nonstructural
Structural Causes
Causes

Polyps Coagulopathy

Ovulatory
Adenomyosis
dysfunction

Leiomyoma Endometrial

Malignancy and
Iatrogenic
hyperplasia

Not yet classified

 POLYPS (AUB-P)
u Localized tumors of columnar
epithelium of endocervix or
endometrial epithelium containing
both glandular and stromal
elements.
u Usually benign.
u Estrogen stimulation is thought to
play a key role in their development
u It may be single or multiple,
measuring from a few millimeters to
centimeters, and may be sessile or
pedunculated
u Prevalence: 7.8% to 34.9%
u Cervical polyps
u Occur most often in reproductive
years, esp. after age 40 years.
u Arise from endocervix potentially
from inflammation and hormonal
factors.
u Cervical polyps are rarely larger
than 3cm.
u Non-malignant.

Pic: Dr. Zubaidi Hj Ahmad

u Risk Factors
u age, tamoxifen use, increased
levels of endogenous or
exogenous estrogen, obesity and
Lynch syndrome.
u Investigation
u Transvaginal ultrasound
u Saline infusion sonohysterography
u Diagnostic hysteroscopy
u Hysterosalpingography.
u Treatment
u Asymptomatic polyps > 1.5cm
and Symptomatic polyps should
be considered for excision and
sent for pathologic examination.
 ADENOMYOSIS (AUB-A)
Diagnosis:
Definition:
• Histologic examination at
presence of endometrial
hysterectomy
glands and stroma in the
• MRI à distortion of
uterine myometrium
myometrial junction

Prevalence: Management:
5% to 70% • Definitive treatment
• Total abdominal
hysterectomy
Clinical Features:
bilateral salpingo-
• Asymptomatic in one-
oophorectomy
third
• Conservative
• HMB
• tranxenamic acid 1g
• Irregular bleeding
TDS/QID 3-5 days
• Dysmenorrhea
during menses
• Dyspareunia
 LEIOMYOMA (AUB-L)
u Aka myomas or fibroids
u Benign monoclonal tumors
arising from smooth muscle cells
of the myometrium
u Risk Factors:
u African-American race, early
menarche, early oral
contraceptive use, low parity,
obesity, hypertension and family
history.
u Prevalence: 70% - 80%
u Symptoms
u Painful menses, HMB
u Pelvic pressure, urinary frequency,
bowel symptoms, or reproductive
dysfunction.
u Treatment
u Asymptomatic à no treatment
needed.

u Diagnosis u Symptomatic
u GnRH analogues @ Lukrin to shrink
u Pelvic examination with the fibroid
ultrasound as standard
confirmatory test. u Myomectomy, Hysterectomy
 Malignancy and Premalignant Conditions
(AUB-M)

u Malignancy of vagina or uterus à abnormal bleeding.

u Bleeding from cervical malignancy classically presents as coital bleeding
or intermenstrual bleeding.
u Women have a 2.8% lifetime risk of developing endometrial cancer.
u Adenocarcinoma is the most common type of malignancy.
u Papillary serous, clear cell, mucinous and carcinosarcoma are rarer but
more aggressive endometrial cancers.
u In older premenopausal and Treatment
menopausal women, AUB may be Endometrial intraepithelial neoplasia
secondary to EIN.
Benign Oral progestins or
u Risk for EIN and malignancy hyperplasia Mirena and
without atypia followed with
u Unopposed estrogen with an intact endometrial
uterus, obesity, diabetes mellitus, surveillance
hypertension, nulliparity and Atypical and Hysterectomy
tamoxifen use. endometrial
malignancy
u Diagnosis à Imaging +
Histopathology
 COAGULOPATHY (AUB-C)

• heavy, prolonged menses

u Seen in adolescents from an early reproductive
age.
u Can be inherited (von Willebrand
• History of frequent bruising,
disease) or acquired (seen in epistaxis, gum/dental
adulthood) bleeding, postpartum
u Evaluation should begin with a history hemorrhage, and severe
surgical bleeding.
to assess symptoms and risk factors
• Family history of bleeding
for coagulopathy followed by problems
confirmatory testing.
u Management:
u Inherited coagulopathies
and HMB à factor
replacement and
desmopressin acetate +
hormone replacement
therapy.
u Acquired coagulopathies
à intravenous equine
estrogens + OCP or
medroxyprogesterone
acetate.
 OVULATORY DYSFUNCTION (AUB-O)

u It includes not ovulating on a u Disorders of anovulation present

regular basis or infrequently, as
which may lead to amenorrhea u Combination of unpredictable timing
but more likely results in irregular of bleeding and variable amount of
bleeding flow

u Seen in adolescents or u Amenorrhea

perimenopausal age groups. u Extremely light, infrequent bleeding

u Causes: u Episodes of unpredictable, extreme

HMB
u PCOS, hypothyroidism, obesity,
u Mostly painless
hyperprolactinemia, anorexia,
weight loss or extreme exercise.
u In women with AUB consistent with ovulatory dysfunction,
evaluation should be directed towards identifying treatable
causes

u Thyroid function test, human chorionic gonadotropin, prolactin

u In obese women, prolonged amenorrhea due to anovulation

and exposure to unopposed endogenous estrogen increases
the risk of EIN and endometrial cancer. Consideration for
endometrial sampling/assessment is important.