Abnormal Uterine Bleeding

(AUB)

Ms. Lim Yii Ting

Introduction
•
Abnormal Uterine Bleeding:
•

- Menstrual bleeding of abnormal quantity,

duration, or schedule
•
Common gynaecological problem
•

•
55.7% of adolescents experience menstrual bleeding in
the 1st year or so after the onset of menarche
•

- because of immaturity of the Hypothalamo-

Pituitary-Ovarian axis - anovulatory cycle

•
Generally takes 18-24 months for regular cycles to be
established
Normal Menstrual Physiology

•
400-500 cycles in an average female
•

•
Superficial functional layer is shed
•

•
Regeneration occurs from remaining basalis
•

•
These cyclical changes occur under the influence of
complex, cyclical, dynamic & interactive processes of
endocrinological & reproductive systems
•

•
Any interruption in this system leads to endometrial
breakdown & Dysfunctional Uterine Bleeding
Normal Menstrual Parameters
 Abnormalities

Frequency Regularity
• Frequent • Absent
(Polymenorrhea) (Amenorrhea)
• Infrequent • Irregular
(Oligomenorrhea) (Metrorrhagia)

Duration of Flow Volume of Blood

• Prolonged Loss
(Menorrhagia) • Heavy
• Shortened (Menorrhagia)
(Hypomenorrhea) •
Patterns
Patterns
Cycle duration
Duration of Flow Amount of
(d) (d) Flow (ml)

Normal 21 - 35 3-7 30 - 80

Menorrhagia 21- 35
N/ ↑ N/ ↑
Polymenorrhea < 21 N
N/ ↑
Polymenorrhagia < 21
N/ ↑ N/ ↑
Oligomenorrhea > 35 N/ ↓ N/ ↓
Hypomenorrhea 21-35 ↓ ↓
Metrorrhagia Irregular Irregular Irregular
 Classification

• Depending on whether ovulation is occurring or not

• Anovulatory cycles (80%) - Oestrogen

•

- Proliferative endometrium
- Hyper plastic endometrium (could be premalignant)

• Ovulatory cycles (20%) - Progesterone

•

- Secretory or mixed ( secretory + proliferative )

Pathogenesis
 Anovulatory cycles
Anovulation ( No corpus luteum - No progesterone)

Unopposed estrogen

Excessive proliferation of endometrium

Proliferation exceeds the blood supply/

structural integrity of the stromal matrix

Breakdown (repetitive) of the fragile endometrium

Patchy irregular shedding +
Absence of normal control mechanisms

Heavy prolonged bleeding

 Ovulatory cycles
• Commonest cause for subjectively reported menorrhagia
•

• Probable aetiology:
Local prostaglandin imbalance between
Vasodilators (PGE2 & Prostacyclin) &
Vasoconstrictors (PGF2α & Thromboxane)

+
Excessive local fibrinolytic activity
•

• Most cases of Ovulatory menorrhagia have an underlying

organic pathology (like fibroid, adenomyosis etc), hence
may not be true AUB
 Causes
Haematological/ Anticoagulants & Pregnancy: Peri menarchal:
coagulation Antiplatelet drugs Miscarriage, ectopic/ Anovulatory AUB
disorder Molar pregnancy

Endocrinal: Exogenous Uterine tumours: Peri menopausal

Hypothyroidism / oestrogen Fibroid, Adenomyosis,
Hyperthyroidism Endometrial polyps

Live cirrhosis OC pills - Ovarian tumours: Postmenopausal

(hyper estrogenic Breakthrough Follicular cysts,
state) bleeding Hormone producing
tumours
Renal causes Infections: PID, TB
Endometritis
Psychological Others: Caesarean
upsets scar defects, Foreign
body (IUCD), trauma
 NEW FIGO CLASSIFICATION OF AUB

• Term “DUB” is discarded.

• Acute AUB is defined as an episode of heavy

bleeding that, in the opinion of the clinician,
is of sufficient quantity to require immediate
intervention to prevent further blood loss.
•

• Chronic AUB is defined as bleeding from the

uterine corpus that is abnormal in volume,
regularity, and/or timing, and has been
present for the majority of the past 6 months.
 Evaluation
• History
• Examination
•

• General examination
• Abdominal &
• Pelvic examination
• Laboratory Testing
• Imaging
•

•
Ultrasonography
• Hysteroscopy
 History
• Age
• Menstrual history
• Age at menarche
• Cycles: - Frequency
•

- Regularity
- Duration of flow
- Dysmenorrhea
• Obstetric history
• Contraceptive history
• Medication history
•

-
Antihypertensives
- Anti psychotics
- Steroids
- Warfarin

• Family history
•

- Thyroid disease
- Coagulation
disorder
 Assessment of blood loss(Does not reflect
the actual blood loss)

• Subjective assessment
• Changing pads every 1-
2hours
• Changing pads at night (>1)
• Passage of moderate to large
blood clots

• Tiredness, fatigue or
shortness of breath
(symptoms of anaemia)
• Heavy menstrual flow that
interferes with regular
lifestyle
 Objective Assessment

•
50% of excessive menstruation have normal
amount of blood loss by objective methods

Objective:
•
Iron deficiency anemia
•
Menstrual calendar
•
Admission & pad assessment
•
Pictorial blood loss chart

Risk of iron deficiency

anemia:
When menstrual loss exceeds
Menstrual Calendar
Phone App – My Calendar
 Pictorial Blood Loss Chart
Pad
1
1 point
5 points 2

3
20 points
4
1p clot 1 point
5p clot 5 points 5

Flooding 10 points
6

Score >100 = Menorrhagia 7

 Physical Examination

• Height, weight and BMI

• Vital signs & pallor
• Skin (ecchymoses)
• Hirsutism, Acne, Acanthosis nigricans
• Obesity
• Thyroid
• Pubertal development
• Galactorrhoea
• Abdominal examination: Abdominal mass,
Pregnancy,
Ascites.

• Pelvic examination:
•

Cervix: Growth, infection, polyp.

Uterus: Fibroids, pregnancy.
Adnexa: Ovarian neoplasm, tubal pathology.
•

• Recto abdominal examination: In adolescents.

 Investigations
• General assessment
•

- Full Blood Count.

• Determine ovulatory status
•

- Detailed structural history.

- Progesterone assessment in the
mid luteal.
• Screening for disorders of hemostasis
•

- Bleeding disorder - Coagulation

profile
- Von willebrand factor.
• Evaluation of the endometrium
•

- Endometrial sampling.
 Trans Vaginal
Ultrasonography
•
Assessment of Endometrial thickness (ET),
myometrium and ovaries
•

•
Endometrial hyperplasia,
•
Fibroids,
•
Polyps and
•
Carcinoma.
•

•
Initial investigation for post-menopausal
•

- If ET ≤ 4mm: pathology excluded in 95%

- If ET > 4 mm or persistent bleeding - Biopsy
 Endometrial Hyperplasia

•
Thickness increased
•
Hyper echoic
•
Intact interface between
endometrium &
myometrium
 Endometrial Carcinoma
• Thickness increased
• Hyper echoic irregular
• Mixed echogenecity, “bridging” of the
endometrium
• Endometrial myometrial interface is not intact
 Saline Infusion Sonography
• Alternative to office hysteroscopy
• Better tolerated than office hysteroscopy
• Helpful in differentiating fibroids & polyps with
normal endometrium
• Irregular but intact interface between
endometrium &
myometrium.
 Diagnostic hysteroscopy

Endometrial Polyp Sub mucous fibroid

Endometrial carcinoma
 Endometrial Study Techniques

As an outpatient procedure

Methods:
•

• Vacuum aspiration
• Curette
• Vabra aspirator
• Pipelle curette
• Sharman curette, Gravlee jet washer, Isac cell
sampler
 Dilatation & Curettage (D&C)
•
Less effective than hysteroscopic biopsy
•
Samples only 40% of endometrium
• Arrests bleeding (if severe/ persistent)
• D&C < 35 yrs: 3000 - 4000 performed for 1 CA
•

Disadvantages:
•
Small lesions can be missed
•
Sensitivity of detecting intrauterine pathology: only
65%
•
Good TVS excludes intrauterine disease - role of D & C
is questioned
 Hysteroscopic sampling of endometrium

Method of choice

Indications:
• Erratic menstrual bleeding
• Failed medical treatment
• Suspected intrauterine pathology
 Advantages over D & C
• Whole uterine cavity visualized
• Even small lesions can be identified, biopsied/
removed
• 98% sensitivity in detecting intrauterine
pathology
• Outpatient procedure

Disadvantages:
• Cost
• Lack of availability/ experience
 Possible HPE Reports of
Endometrial Biopsy

• Proliferative
• Secretory
• Atrophic endometrium
• Simple hyperplasia without or WITH atypia
• Complex hyperplasia without or WITH atypia
• Endometrial carcinoma
Possible Reports with Endometrial biopsy
Hyperplasia  Carcinoma

• Hyperplasia
•

- Simple
- Complex
• Atypical hyperplasia
•

- Simple
- Complex
SIMPLE ENDOMETRIAL
HYPERPLASIA
ATYPIA

VITTAL
COMPLEX HYPERPLASIA

VTTAL
COMPLEX HYPERPLASIA
WITH ATYPIA
 Management of
Abnormal Uterine
Bleeding
Ms. Joanne Tam
 Medical Treatment
1. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
2.

• Prostaglandin synthetase inhibitors

• Inhibits endometrial prostaglandin synthesis -
reduce menstrual blood loss
• Taken during the day 2 - 5 of menstruation
• NSAIDs used for treatment of menorrhagia:
•

• Mefenamic acid: 500mg 3 times daily

• Ibuprofen: 400mg 3 times daily
1. Anti - fibrinolytic agents
Tranexamic acid:
•

• Inhibitor of fibrinolysis - reduces menstrual blood flow in patients with

DUB
• Dose: 3-6 gm in divided doses
• Minimal side effects : 1/3rd of woman experience gastrointestinal side
effects
• 90% of menstrual blood is lost in the first 3 days of full flow,
• side effects can be minimized by limiting the number of treatment days
to the first 3 or 4 days of the period
 Hormonal
1. Combined Oral Contraceptive Pills (COCP)
2.

• Safely prescribed to most young women without

any contraindications
• Used frequently for treatment of menorrhagia
• Taken for 21 days of the cycle
• Additional advantages:- contraceptive cover and
regular withdrawal bleeding
 2. Gestogen therapy
•

• Drug dosage and duration of use will influence

the effect on the endometrium and
consequently the pattern of bleeding
• Effective in excessive menstrual bleeding in
anovulatory cycles
• Progestogens may be safely used for long term
treatment of DUB
•

• 1) Medroxy Progesterone Acetate: 10 mg

• 2) Dydrogesterone: 10 mg
Other Medical Therapies

1. Danazol
2.

• Anti – estrogenic and anti – progestogenic activities –

endometrial atrophy & reduced blood loss
• Androgenic side effects:- weight gain, muscle cramps & skin
rashes
• Limited use of danazol as a treatment option for women with
gynaecological disease
• Mainly used as 2nd line therapy esp. as a short term pre –
surgical treatment
 1. Gonadotrophin Releasing Hormone analogues (GnRH)
2.

• Control menstrual loss by pituitary down regulation and inhibition of

cyclical ovarian activity (reversible hypo estrogenic state, reducing total
uterine volume)
• Ovarian suppression, amenorrhea, hypo estrogenic state and
endometrial atrophy including hot flushes, vaginal dryness and bone
mineral depletion (unless addback therapy is used)
• Not the 1st line therapy
• May be used for short – term treatment of women with intractable AUB
 3. Levonorgestrel Releasing Intrauterine System
(LNG - IUS, Mirena)
•

• Progestogen is delivered directly to the endometrium,

• Requires no patient compliance and
• Additional contraceptive benefits
• MOA:- Reduce endometrial prostaglandin synthesis & endometrial
fibrinolytic activity
• Reservoir contains 52mg of Levonorgestrel mixed with poly dimethyl
siloxane, and
• - Releases 20 µg of LNG/day
• Side effect:- irregular ‘breakthrough’ bleeding
Surgical Considerations

• Seldom indicated in young women with menstrual

disturbances

• Hysterectomy: for women who have no further wish

to conceive

• Uterine Artery Embolization – pregnancy is still

desired

• Endometrial resection and ablation

Hysteroscopic Methods(1st generation
devices)

1. Trans Cervical Resection of Endometrium (TCRE)

2.

•
Performed with 26 French gauge resectoscope fitted with a 4mm
forward oblique telescope and a 24 French gauge cutting loop
• Uterine irrigants used:- sterile 1.5% glycine, sorbitol or
sorbito/mannitol mixtures
•
Excise tissue is removed with a flushing curette
•
Resectoscope is re-inserted to check for any untreated areas and
bleeding points which can be coagulated with the cutting
loop/rollerball
 Rollerball Ablation
1.

(Endometrial “rollerball” electrocoagulation)

•

• Involves the modified urological resectoscope fitted with a ball and

bar electrode
• Easier than resection
• Less risk of perforation
 LASER ablation
1.

(Neodymium: YAG LASER)

•

• Involves the LASER fibre in contact with the endometrium to

develop several furrows down to the endometrium
Complications of Hysteroscopic Endometrial
Ablation

• Fluid overload
• Haematometra
• Cervical stenosis
• Uterine perforation
 Non Hysteroscopic Methods(2nd
generation devices)
• Mostly rely on heat production
•
Uterine distension is produced by a Balloon (Hot
Liquid Balloon)
• Methods used:-
•

- Thermal balloon endometrial ablation: Cavaterm,

ThermaChoice, Thermablate, Menotreat
- Microwave endometrial ablation(MEA)
- Radio Frequency Induced Thermal Endometrial
Ablation (RITEA)
- Cryoablation (Her option)
- Hydrothermal ablation (free fluid)
- Electrode balloon ablation
Cavaterm

• Consists of a computerized central unit and a

single use silicon balloon
• Balloon size can be adjusted according to the size
of the uterine cavity
• Fluid used: 5% glycine
• Treatment time: 15 min
• Depth of endometrial ablation: 6 - 8mm
Thermablate

• Pre lubricated balloon is inserted into the

endometrial cavity and the pressure is
automatically maintained at 180 mmHg

• Treatment time: 2 min 8 seconds

• Depth of tissue necrosis: 4 - 5 mm

 ThermaChoice
• Fluid used: 5% dextrose

• This fluid is heated externally to 87⁰C and is passed

into the uterus with the pressure being maintained by
the unit in the range 160-180 mmHg

• Treatment time: 8 min

• Depth of ablation: 4.5mm

 Microwave Endometrial Ablation
(MEA)
• Continuous temperature display to ensure that the
operator is in correct position in the uterine cavity
Radiofrequency Induced Thermal
Endometrial Ablation (RITEA)
• A 10mm diameter probe is inserted into the uterine
cavity

• Electromagnetic radiation is generated – causes

irreversible tissue damage
Cryo – Ablation of the Endometrium
(Her Option)
• Device used:- a 5.5mm probe and a self – contained
unit
• Uses cold temperature to destroy endometrium by
freezing the endometrium to -90⁰C
• Done under ultrasound guidance
• Depth (elliptical zone) of ablation: up to 12mm
• Treatment time: 10 – 20 mins
Complications of Non Hysterosopic
Endometrial Ablation
• Pain
• Nausea
• Vomiting
• Urinary infections
• Pelvic infections
• Uterine perforation
• Injury to bladder and bowel