Abnormal Uterine Bleeding (CPG)

 Significant deviation from the normal duration, volume, regularity, frequency of menses
Duration of flow
 Normal: 4.5-8 days
 Prolonged: >8 days
 Shortened: <4.5 days
Frequency of menses
 Normal: 24-38
Volume of monthly blood loss
 Normal: 5-80ml
Regularity of menses
 Variation: 2-20 days

Heavy abnormal bleeding

 Used to replace the term menorrhagia
Dysfunctional uterine bleeding
 Heavy bleeding that is not due to complications of pregnancy or systemic or local pelvic pathology
 However this term is discarded by POGS
 Ovulatory DUB
o Regular cycles with heavy bleeding
 Anovulatory DUB
o Irregular, prolonged and/or heavy bleeding
Abnormal uterine bleeding
 This includes DUB and bleeding from organic causes
 Organic etiology
o Bleeding due to systemic causes or disorders of reproductive tract
 DUB
o Bleeding not due to organic causes
Acute AUB
 Ranges from moderate to heavy bleeding that causes significant blood loss leading to hypovolemia
(hypotension and tachycardia) and/or shock
Chronic AUB
 Bleeding from uterine corpus that is abnormal in volume, duration, regularity, and/or frequency and has
been present for >6 months

Pathophysiology
Normal hemostasis is achieved by:
 Stabilization of hemostatic platelet plug
 Higher thromboxane (PGF) to prostacyclin (PGE2) level
 Fibrin clot formation
Absence of any of the three causes AUB
Doc Pareja’s lecture
Vaginal bleeding
 Most common gynecologic complaint of women
 Reproductive age incidence- 3-30%
Abnormal uterine bleeding- any significant deviation to the normal duration, frequency, volume, flow of menstrual
bleeding
Heavy menstrual bleeding- replaced the term menorrhagia
Intermenstrual bleeding- bleeding occurring in between cycles
Dysfunctional uterine bleeding- basket diagnosis that has been discarded and is now under AUB

Criteria for abnormal uterine bleeding

Frequency: normal- 24-38 days
Duration: normal- 4-8 days
Flow: 5-80
Regularity: variation of 2-20 days

Heavy menstrual bleeding- is not quantified, as long as the bleeding is something that affects quality of life

PALM COEIN
Palm- structural abnormalities causing AUB
Polyps- occur in all ages but more common in older women
 Diagnosis by ultrasound or hysteroscopic imaging without histopath
 Seen as tongue-like protrusion
Adenomyosis- abnormal stromal and endometrial gland proliferation causing smooth muscle hyperplasia and
hypertrophy
 Can be diffused affecting all of the uterus or localized affecting only one part
 There is no delineation of endometrium from myometrium
 Pathophys:
o Hampered myometrial contractions
o Abnormal PGF/PGE ratio
o Increased endometrial surface
o Abnormal endometrial angiogenesis
 Types: presence of 2 or more highly associates with adenomyosis
o A- assymetric thickening
o B- myometrial cysts
o C- hyperechoic islands
o D- fan shaped shadowing
o E- echogenic lines and buds
o F- translesional vascularity
o G- irregular junctional zone
o H- interrupted junctional zone

Leiomyoma- aka fibroids

  Overgrowth of smooth muscle and connective tissue in the uterus
 Four types
o Intramural- within muscle or myometrium
o Intraserosal- closer to outer surface
o Parasitic- independent of the uterus
o Submucosal- within cavity, highly vascularized and difficult to stop with just myometrial contractions
 Presentation: heavy menstrual bleeding
 Results from
o Myoma interfering with normal hemostasis
o Increased endometrial surface
o Mechanical compression of venous drainage
o Dilation of venous plexuses draining the endometrium
o Ulceration and hemorrhage of endometrium
Malignancy- premalignant hyperplasia or malignant process

COEIN- nonstructural causes of AUB

Coagulopathy- bleeding disorders
 Von willebrand disease- most common coagulopathy causing AUB
 No longer indicates pharmacologic causes of bleeding
Ovulatory dysfunction- usually related to endocrinopathies
 Anorexia, weight loss, hypothyroidism, hyperprolactinemia
Endometrial dysfuction- not related to any endocrinopathies
 d/t deficiencies in production of local vasoconstrictors and accelerated lysis of endometrial clots
Iatrogenic- irregular or breakthrough bleeding
 may be due to use of OCPs or pharmacologic agents that cause bleeding
 steroids, IUDs, tranquilizers
Not otherwise classified- poorly defined and inadequately examined
 arteriovenous malformation, cesarean section niche or defect, myometrial hypertrophy

women with normal blood loss will tend to:

 interval between menstrual pad change is >3 hours
 tampon usage in one cycle is <21
 does not need to change pad at night
 not anemic
 passage of clots less than 1 cm

criteria to classify a person as having coagulopathy disorder as the cause of AUB

1 of any:
 postpartum hemorrhage
 surgical bleeding
 bleeding associated with dental work
2 of any:
  epistaxis
 frequent bruising
 bleeding gums
 family history of bleeding
PE: identify structural pathology or systemic disease as cause of AUB
Labs
 CBC with platelets- to check for anemia
 Pregnancy test
 PT, PTT, fibrinogen- for those positive with bleeding disorders
 Female hormone testing- not routinely done
 Thyroid screening- done in those only showing thyroid s/s
Imaging
 Ultrasound- first line diagnostic
 Transvaginal ultrasound- done in days 4-6 of menstrual cycle for more accuracy
o Can identify PALM causes of AUB
 Saline infusion- not first line
o Better suited for intracavitary lesions
 Hysteroscopy- done when ultrasound findings are inconclusive

Acute uterine bleeding- bleeding in a nonpregnant women of reproductive age occuring more than 7 days
 More common in anovulatory women
 Range from moderate to severe leading to hypovolemia (hypotension and tachycardia) and anemia
 Goal of treatment: build up endometrium with estrogen for hemostasis and progestins for endometrial
stability
Medical management- should be done first before surgical management unless bleeding is due to submucosal
myomas
 High dose conjugate equine estrogen- 25 mg IV CEEq4h to stop bleeding
 High dose COC in tapered doses
 Progestin- MPA 10mg TID for 7 days
 Tranexamic acid 1gm q6h
Definitive treatment: proceed once bleeding is controlled and anemia is corrected
 Palm causes- treat structural causes
 Coagulopathy- treat bleeding disorder
 Ovulatory- treat endocrine pathology
 Iatrogenic- remove item causing the bleeding
Surgical management
 D and C- not recommended as it is only temporary in stopping bleeding

Endometrial biopsy
Indications:
 Age >40 years old
 Risk factors for endometrial cancer: obesity
  Patients on tamoxifen
 Patients refractory to medical management
 Infrequent menses suggestive of anovulatory cycle
Endometrial cancer risk factors:
 Age more than 45
 Endometrial thickness >4mm
 Obesity
 Lynch syndrome
 Chlamydia trachomatis
Risk factors:
Major- long unopposed exposure to estrogen
 Hereditary nonpolyposis colon ca
 Estrogen producing tumor
Minor
 Obesity, nulliparity, PCOS,history of infertility, tamoxifen, nulliparity

Endometrial ablation- for women not desirous for contraception

Hysterectomy- should not eb first line in surgical management
 Indicated only when: failed medical management, not desirous of pregnancy, severelt affects quality of life

Chronic AUB
 LVG-IUS
 COC qlaira- estradiol valerate and dienogest
 Danazol and GNRH agonist- failed medical tx

Comprehensive Gynecology by LOBO

Abnromal uterine bleeding
 35mL- average blood loss per cycle
 >80mL- considered heavy menstrual bleeding
Polyps- proliferation of endometrial glands, stroma, with epithelium
 Common in reproductive women
 Due to estrogen
 Not seen in premenarche women
 Diagnosis based on ultrasonography or heteroscopy with or without histopathology
Adenomyosis- endometrial tissue in the myometrium
 Peak incidence at 5th decade of life
 Multiparity- most significant risk factor

Vulvovaginal disorders
Prepubertal
 Genital warts- suspect for possibility of abuse
 Tight hymenal ring- inability to insert tampon
 o Manage with manual dilation and small incision of 6 and 8 o’clock ring

Pelvic masses