Current update on management of

Abnormal Uterine Bleeding (AUB)

Kanadi Sumapradja
kanadisuma@yahoo.com

Department of Obstetrics and Gynecology

Faculty of Medicine Universitas Indonesia
 Prof. Malcolm G Munro

Prof. Munro’s slides at WHM meeting in Korea 2016

Our today’s discussion
• FIGO systems for AUB in the reproductive
years
• Understand the pathogenesis of AUB
• FIGO-based evaluation of the patient with
AUB

Prof. Munro’s slides at WHM meeting in Korea 2016

Our today’s discussion
• FIGO systems for AUB in the reproductive
years
• Understand the pathogenesis of AUB
• FIGO-based evaluation of the patient with
AUB

Prof. Munro’s slides at WHM meeting in Korea 2016

Research, education, evaluation and management
decisions for women with AUB are compromised by:

1. A confusing and inconsistent array of terms and

inconsistent nomenclature for the description of
symptoms

2. The absence of a system for classification of causes of

AUB to assist:
• Research
• Education
• Clinical care
• Patient education
Prof. Munro’s slides at WHM meeting in Korea 2016
 Menorrhagia DUB
Metrorrhagia
Spotting Hypermenorrhea

AUB nomenclature?
Polymenorrhea
Menometrorrhagia
HMB
Oligomenorrhea Prof. Munro’s slides at WHM meeting in Korea 2016
There is great confusion in the way these terminologies are
used and there is an urgent need for international agreement
on consistent use of terms and definitions for symptoms, signs,
and causes of abnormal uterine bleeding.

Woolcock JG, et al. Fertil Steril 2008;90:2269-80

Woolcock JG, et al. Fertil Steril 2008;90:2269-80
Nomenclature of professional communication
Use of the term “Menorrhagia”
100 consecutive papers (MEDLINE) describing heavy menstrual bleeding

n Regular Irregular Pathology

Symptom 34 + + +/-
28 + - +/-
16 + - -
Diagnosis 5 Alone
17 Combined (e.g. Idiopathic)
Total 100

Woolcock JG, et al. Fertil Steril 2008;90:2269-80

Two new FIGO system

1. Nomenclature (terminology) system for describing

normal menstruation and AUB symptoms

1. Classification of causes of AUB in the reproductive years

(PALM-COEIN)

Prof. Munro’s slides at WHM meeting in Korea 2016

System 1

Nomenclature (terminology) system for describing normal

menstruation and AUB symptoms

Prof. Munro’s slides at WHM meeting in Korea 2016

To develop an agreement process through an international initiative to
recommend clear, simple terminologies and definitions that have the
potential for wide acceptance.
A modified Delphi process, followed by a structured face-to-face meeting of
35 clinicians (mostly gynecologists) and scientists. Focused small-group
discussions led to plenary assessment of concepts and recommendations by
using an electronic keypad voting system.
Fraser IS, et al. Fertil Steril 2007;87:466-76
Essential components

Fraser IS, et al. Fertil Steril 2007;87:466-76

What is normal?

Fraser IS, et al. Fertil Steril 2007;87:466-76

System 2

Classification of causes of AUB in the reproductive years

(PALM-COEIN)

Prof. Munro’s slides at WHM meeting in Korea 2016

Munro MG, et al. Int J Gynecol Obstet 2011;113;3-13
 Can be defined by imaging or Cannot be defined by imaging
histopathology or histopathology
Structural Non-structural

PALM -
COEIN
May be seen but not a cause May be a cause but not be seen
Munro MG., et al. Int J Gynecol Obstet 2011;113:3-13
Prof. Munro’s slides at WHM meeting in Korea 2016
Our today’s discussion
• FIGO systems for AUB in the reproductive
years
• Understand the pathogenesis of AUB
• FIGO-based evaluation of the patient with
AUB

Prof. Munro’s slides at WHM meeting in Korea 2016

 “The Normal”
Interval 21-35 days
Duration between 1-7 days
Less than 1 pad or tampon
per 3 hour period

Ely JW., et al. J Am Board Fam Med 2006;19:590-602

Spiral arteries
Stromal cells
Gland cell
Extracellular matrix

Prof. Munro’s slides at WHM meeting in Korea 2016

ER ER
PR PR
Prof. Munro’s slides at WHM meeting in Korea 2016
 Ovulation
Proliferative phase Secretory phase

01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

ER  ER  ER  ER 
PR  PR  PR  PR 
TF  COX-2  TF  TF 
VEGF  PGF2a  VEGF  VEGF 
COX-2  MMP  COX-2  COX-2 
PGF2a  Endothelin-1  PGF2a  PGF2a 
MMP  PA  MMP  MMP 
Endothelin-1  PAI  Endothelin-1  Endothelin-1 
PA  PA  PA 
PAI  PAI  PAI 

Prof. Munro’s slides at WHM meeting in Korea 2016

 Progesterone INFLAMMATION
withdrawal

VASOCONSTRICTION

VASODILATATION
MMP

BLOOD EXTRAVASATION

HAEMATOMA TISSUE
Late Early Late DESTRUCTION
proliferation secretion secretion

Spiral artery sensitives to steroid hormone

Detachment of functional layer

MENSTRUATION
Endometrial hemostasis
Contact activation Tissue Factor
(Intrinsic pathway) (Extrinsic pathway)

Collagen exposure
vWF Common pathway

Relatively more important

Platelet activation FIBRIN
Fibrinolysis
Platelet adhesion
Platelet aggregation Fibrin Degradation
Product (FDPs)
Platelet plug
Relatively less unimportant Prof. Munro’s slides at WHM meeting in Korea 2016
Endometrial hemostasis
Local endometrial requirements for menstrual hemostasis

High levels Low levels

Vasoconstrictors Vasodilators
- PGF2a - PGI-2
- Endothelin-1 - PGE-2

Clotting mechanisms Fibrinolytic activity

- Tissue factor pathway - Plasminogen activator
- Contact activation pathway

Prof. Munro’s slides at WHM meeting in Korea 2016

Our today’s discussion
• FIGO systems for AUB in the reproductive
years
• Understand the pathogenesis of AUB
• FIGO-based evaluation of the patient with
AUB

Prof. Munro’s slides at WHM meeting in Korea 2016

 AUB bleeding pattern

Period timing? Cyclical predictable Cyclical unpredictable

Complaint? HMB Inter- HMB and/or

menstrual unpredictable
bleeding AUB

AUB-A AUB-P AUB-O

Etiologies
most AUB-Lsm AUB-M
commonly
associated? AUB-C
AUB-E
Prof. Munro’s slides at WHM meeting in Korea 2016
Acute vs. Chronic AUB
Chronic abnormal uterine bleeding
Bleeding from the uterine corpus, that is abnormal in duration, volume,
regularity, and/or frequency and has been present for the majority of
the last six months

Acute abnormal uterine bleeding

Is an episode of bleeding that is of sufficient quantity to require
immediate intervention to prevent further blood loss

Prof. Munro’s slides at WHM meeting in Korea 2016

Prof. Munro’s slides at WHM meeting in Korea 2016
Initial screening for an underlying disorder of hemostasis in patients with heavy
menstrual bleeding (HMB) should be by a structured history

1. HMB since menarche

2. One of the following:

a. Post-partum hemorrhage
b. Surgical related bleeding
c. Bleeding associated with dental work

3. Two or more of the following symptoms:

a. Bruising 1-2 times/month
b. Epistaxis 1-2 times/month
c. Frequent gum bleeding
d. Family history of bleeding symptoms

If positive: patient should requires further investigation by consultation with

hematologist and/or testing of vWF and Ristocetin cofactor
Prof. Munro’s slides at WHM meeting in Korea 2016
Prof. Munro’s slides at WHM meeting in Korea 2016
 Orthostatic hypotension or hemoglobin < 10 g/dL or profuse active bleeding

Yes No

Hospital admission Outpatient management

1. Infused RL or transfusion if Hb < 7 g / d 1. CEE 2.5 mg po QID

2. CEE 2.5 mg po QID 2. D&C if no response after 2-4 dose CEE
3. D&C if no response after 2-4 dose CEE 3. After acute bleeding stopped, switch to OCP
4. After acute bleeding stopped, switch to OCP QIDx4d, TIDx3d, BIDx2d, 1x1 21d, then one
QIDx4d, TIDx3d, BIDx2d, 1x1 21d, then one
week off
week off
Cycle on OCP at least for 3 months
Cycle on OCP at least for 3 months
5. If OCP contraindicated, cycle progestin for at
5. If OCP contraindicated, cycle progestin for at
least 3 months
least 3 months
6. Oral iron 6. Oral iron

Ely JW, et al. J Am Board Fam Med. 2006;19:590-602

Which progestin?

Schindler AE., et al. Maturitas 2008;61:171-80

Progestin dose?

The induction of a characteristic change in the estrogen-primed endometrium.

Schindler AE., et al. Maturitas 2008;61:171-80
 Take home messages
Chronic AUB majority of cycles in previous 6 months

Step 1. FIGO system 1. Structured history

Step 2. Physical examination

Step 3. Starts PALM-COEIN matrix

Step 4. Interim/tentative diagnosis? Trial of Rx?

Step 5. Complete PALM-COEIN based investigation

Step 6. Therapeutic options based on findings

Prof. Munro’s slides at WHM meeting in Korea 2016

TERIMA KASIH