©UQUMed, Year 5 04/03/17

Abnormal uterine bleeding (AUB)

Dr. Abdalla H. Elsadig

M.D

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 Learning outcome of AUB session
 Recognize the characteristics of Normal Menstrual
Bleeding.
 Describe the etiologies of Abnormal Uterine
Bleeding (AUB.)
 Understand etiologies of AUB with respect to the
life stages of women.
 Understand the diagnostic tools of AUB.
 State the medical & surgical management options.
 ©UQUMed, Year 5 04/03/17

Outline of AUB session

 Understanding of normal menstrual cycle.
 Abnormal uterine bleeding (AUB):
 Definition and prevalence.
 Clinical types.
 Classification of causes according to PALM–COEIN system
 Etiology according to Life Cycles Approach
 Differential Diagnosis.
 Pathophysiology.
 Evaluation.
 Management.
 Conclusion.
 Questions. 3
 Normal Menstruation

 The first menstrual cycle is called menarche.

 The normal menstrual cycle starts with the first
day of bleeding of one period and ends with the
first day of the next.
 Blood loss: < 80 ml (average 30-35 ml)
 Duration of flow: 2-7 days (average 4 days)
 Cycle length: 21 - 35 days. In most women, the
cycle length is about 28 days (28 days +/- 7 days}
 Phases of the Menstrual Cycle

1. Reproductive Cycle (ovarian):

1. Follicular phase:
 Begins with Menses and ends with luteinizing
(LH) hormone surge
2. Ovulation phase (30-36 hours):
 Begins with LH surge and ends with ovulation
3. Luteal phase(14 days):
 Begins with the end of the LH surge and ends
with onset of menses
 Phases of the Menstrual Cycle

2. Endometrial phases:
1. Proliferative phase:
 Begins with menses and ends at ovulation
2. Secretory phase:
 Begins at ovulation and ends with menses
Menstrual
Cycle
Regulation
 Abnormal Uterine Bleeding (AUB)

Definition:
Any change in menstrual period regarding the:
 Flow
 Duration
 Frequency or
 Bleeding between cycles
 Abnormal uterine bleeding is a symptom and not
a disease
Prevalence:
 overall prevalence: between 10% and 30%.
 Clinical types of abnormal uterine bleeding
1. Menorrhagia (regular & cyclical):
 Cyclical bleeding at normal intervals which is excessive in
amount or duration. e.g. 5/28 or 8/28.
 Causes: benign organic disease of genital tract(fibroids,
adenomyosios, PID) and may be dysfuctional (ovulatory).

2. Polymenorrhoea (regular & cyclical):

 Cyclical bleeding which is normal in amount but occurring
at too-frequent intervals of less than 21 days e.g. 5/20.
 Causes: ovarian endometriosis, PID, DUB.
 Clinical types cont..
3. Polymenorrhagia:
 Cyclical bleeding which is both excessive and too
frequent, e.g. 9/20-12/20.
 Causes: DUB, PID.

4. Metrorrhagia (irregular or acyclical):

 Acyclical Bleeding of any amount occurring irregularly
or continuously.
 Always originates in the uterus.
 Causes (organic) : complications of early pregnancy,
ulceration or infection of benign tumors, malignancies
(perimenopausal)
 Clinical types cont…

5. Intermenstrual bleeding:
 Often dysfunctional (fall in oestrogen secretion following
ovulation).
 60% of ovulatory women have erythrocytes in their cervical
mucus if examined.
 Common with cervical and endometrial polyps, fibroids and
cervical carcinoma
 Classification of the causes of AUB

 Etiologies of AUB is classified by using the PALM–COEIN

system which developed to create a universally accepted
nomenclature

 The PALM–COEIN system: is the FIGO Classification

for causes of AUB in non gravid women of reproductive
age
 PALM stands for Structural causes.
 COEIN stands Non-Structural causes.
 PALM Stands For Structural Causes

 P: polyp (endometrial or cervical)

 Intermenstrual bleeding or Post Coital Bleeding
in 30-50 year old woman
 A: Adenomyosis
 Dysmenorrhea, dyspareunia, chronic pelvic
pain, sometimes menorrhagia
 L: Leiomyoma (Submucous myoma)
 Menorrhagia; rarely IMB; never metrorrhagia
 PALM Stands For Structural Causes

 M: Malignancy and hyperplasia

Adenomatous hyperplasia (AH)  atypical AH 
endometrial carcinoma :
• Post-menopausal bleeding
• Recurrent perimenopausal metrorrhagia
• Chronic anovulator (PCOS) with
metrorrhagia
Leiomyosarcoma :
• Post-menopausal bleeding
©UQUMed, Year 5 04/03/17

COEIN

COIN Stands For Non-Structural Causes:

C- Coagulopathy (AUB-C)
O-Ovulatory dysfunction (AUB-O)
E- Endometrial (AUB-E)
I- Iatrogenic (AUB-I)
N- Not yet classified (AUB-N
 ©UQUMed, Year 5 04/03/17

COEIN ….(C ): Coagulopathy

Causes:
 Clotting factor deficiency or defect
 Liver disease
 Congenital (Von Willebrands Disease)
 Platelet deficiency (thrombocytopenia) with platelet count
< 20,000/mm3
 Idiopathic thrombocytopenic purpura (ITP)
 Aplastic anemia
 Platelet function defects
 ©UQUMed, Year 5 04/03/17

COEIN ..(C): Coagulopathy

Screen for underlying disorder of hemostasis if any of:
 Heavy menstrual bleeding since menarche
 One of the following:
• Post-partum hemorrhage
• Bleeding associated with surgery
• Bleeding associated with dental work
 Two or more of the following:
• Bruising 1-2 times per month
• Epistaxis 1-2 times per month
• Frequent gum bleeding
• Family history of bleeding symptoms
 COEIN…(O): Ovulatory
 Anovulation
 Age: peri-menarche and perimenopuse
 PCOS
 Stress
 Hypothyroidism
 Luteal phase defects
 COEIN..(O): Ovulatory

 Mainly due to anovulatory bleeding:

 Age-related: peri-menarche, perimenopause
 Estrogenic: unopposed exogenous or endogenous estrogen
 Androgenic: PCOS; Congenital adrenal hyperplasia (CAH),
acute stress
 Systemic: Renal disease, liver disease

 Diagnosis by exclusion:
 Menometrorrhagia not due to organic lesion or pregnancy
 COEIN…(O): Ovulatory
 Hyperthyroidism or hypothyroidism
• Bleeding can be excessive, light, or irregular
• Only severe, uncorrected thyroid disease causes abnormal
bleeding patterns
• Normal pattern when corrected to euthyroid
• 1o hypothyroidism associated with 2o amenorrhea:

Low T4 high TRH  high TSH  normal T4

high PRL amenorrhea + galactorrhea

 COEIN…(O): Ovulatory
 Luteal Phase Defect (LPD)
 Luteal phase lasts 7-10 days (normal:14 days) or
inadequate peak luteal phase progesterone (P).

Diagnosis
 Polymenorrhea (“periods < 21 days”)
 Mid-luteal phase P level between 4-8 ng/ml
 Endometrial biopsy.

Management
 Unexplained infertility: clomiphene, P supplement
 Pregnancy not desired: observation or COCs
 COEIN…(E): Endometrial
 Idiopathic
 Unexplained menorrhagia
 Endometritis
 Post-partum
 Post-abortal endometritis
 Endometritis component of PID
 PID
 Presents with abnormal bleeding (e.g.
menorrhagia, IMB) and pelvic pain
 Requires bimanual exam.
 COEIN…(I): Iatrogenic Conditions
 Anticoagulants
 Over-anticoagulation: menorrhagia
o Therapeutic levels will not cause bleeding problems
 Progestin-containing contraceptives.
 Intrauterine Contraceptive device (IUC)
 Menorrhagia
 PID, pregnancy (IUP or ectopic), perforation, expulsion.
 Chronic steroids, opiates
 COEIN…(N): Not Classified

 Chronic endometritis
 Uterine arterio-venous malformation (AVM)
 Myometrial hypertrophy
Etiology according to Life Cycles Approach

Life Cycles:
 Pre-Menarche
 Menarche
 Reproductive
 Postmenopausal
 Etiology of AUB
(Life Cycles Approach)

Menarche Reproductive Post-

Premenarchal
Menopausal

• E2 withdrawal • Coagulation • Pregnancy

@birth defects • Anovulation • Carcinoma
• Foreign Body • Hypothalamic • Medications • Vaginal Atrophy
• Sarcoma immaturity (hormones) • E2 Replacement
(Botryoides ) • Psychogenic • Tumours (benign)
• Ovarian Tumor
• Trauma
 Differential Diagnosis of AUB

Structural (Bottoms Up):

 Vulva
 Vagina
 Cervix
 Ovary
 Brain
 Vulvar

o Infections
o Human papilloma virus HPV
o Atrophy
o Benign lesions
o Cancerous lesions
o Dermatologic Causes

PHYSICAL EXAM: INSPECTION IS IMPORTANT

 Vagina

 Infections
 Foreign bodies
Diaphragm, Pessary
Tampon
Other
 Atrophic changes
 Laceration/trauma
 Malignancy :
Carcinoma
Sarcoma
Physical Exam: Inspection is important
 Cervix
o Neoplasia
 Cancer
 Polyps
 Myomas

o Cervical Eversion (Ectropion)

o Infection
 Cervicitis
 Condyloma Acuminata

IMPORTANT:
Visualize the Cervix!
 Uterus
 Myomas Postmenopausal
Bleeding
 Polyps is considered
endometrial cancer
 Endometrial Hyperplasia until proven otherwise

 Endometrial Carcinoma Postmenopausal

bleeding Most PMB
 Atrophy is evaluated Is due to
by an Atrophy
Endometrial
biopsy

PHYSICAL EXAM: Bimanual Exam

checks enlargement
 Pathophysiology Of AUB

 Estrogen Withdrawal:
 Sudden withdrawal of estrogen will cause the uterus to
bleed, either iatrogenic (bilateral oophorectomy) or
endogenous (natural drop of estradiol at mid cycle
ovulation).

 Estrogen Breakthrough (anovulatory):

 The corpus luteum fails to form → failure of
progesterone secretion with an unopposed production
of estradiol → endometrial overgrowth which outgrows
its blood supply → necrosis bleeding.
 Pathophysiology Of AUB

 Progesterone Withdrawal:
 Sudden decrease in the progesterone levels in a
female which is iatrogenic (a progesterone only oral
contraceptive).
 The endometrium Atrophies and ulcerates due to
lack of estrogen and is prone to bleeding
©UQUMed, Year 5 04/03/17

Evaluation of AUB

 History
 Examination
 Investigations

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 History

Is the patient pregnant?

 Pregnancy symptoms, esp. breast tenderness
 Intercourse pattern
 Contraceptive use
Is it uterine in origin?
 Coincidence with bowel movement, during or after urination
 Pain or irritation of vagina, introitus, vulva, perinuem, or anal
skin.
 History
Is bleeding ovulatory or anovulatory?
 Bleeding pattern: regular, irregular, none
 Previous history of menstrual disorders
 Recent onset weight gain or hirsuitism
 Menopausal symptoms
 History of excess bleeding; coagulation disorders
 Current and past medications.
 Chronic medical illnesses or conditions
 Nipple discharge from breasts
 Physical Exam
 Vital Signs and shock Signs
 General: BMI > 30
 Skin: acne, hirsutism, acanthosis nigricans; bruising
 Breasts: galactorrhea
 Abdomen: uterine enlargement, abdominal pain
 Pelvic exam:
 Vulva and perineum
 Anal and peri-anal skin
 Speculum: vaginal walls and cervix
 Bimanual: uterine enlargement, softness,
masses
 Investigations
 Pregnancy test.
 CBC: severe anemia; baseline value for observation
 Coagulation profile.
 Hormonal assay:TSH, Prolactin, FSH, LH.
 Evaluation of the Uterus
 Transvaginal &/or abdominal Ultrasound (TVS/AUS)
 Saline Infusion Sonohysterocopy (SIS)
 Hysteroscopy
 Endometrial Biopsy
 MRI
 Treatment of AUB

Treatment of AUB depends on:

 Clinical stability,
 Overall acuity
 Suspected etiology of the bleeding
 Desire for future fertility
 Underlying medical problems.

Treatment includes:
 Observation
 Medical
 Minimally invasive surgery
 Major surgery
 Medical Management

 Iron  Parenteral
estrogens
 Anti-fibrinolytics
 Androgens
 Progestins
 GnRH agonists
 Estrogen + progestins (OCP)
 Anti-
 Non-steroidal anti-
progestational
inflammatory drugs agents
Minimally Invasive Surgery

 Intrauterine Device (IUD) with progesterone

 Dilation & Curettage b(D & C)
 Endometrial Ablation
 Major Surgery

 Myomectomy
 Total Abdominal Hysterectomy (TAH)
 Total Vaginal Hysterectomy (TVH)
 Laparoscopic Hysterectomy
LSH (laparoscopic supra-cervical Hysterectomy)
TLH (total laparoscopic Hysterectomy)
LAVH (laparoscopically assisted vaginal
hysterectomy)
Robotic (TLH or LSH)
 Management of Acute AUB
Objectives of managing acute AUB is to:
1) Control the current episode of heavy bleeding
2) Reduce menstrual blood loss in subsequent cycles
Treatment includes:
 Monitor Vital signs, Start oxygen
 Type and Cross 2-4 units of blood
 IV fluids ( with wide bore IV catheter)
 IV Conjugated equine estrogren
 IM Progesterone
 NSAIDS (Anti-prostaglandins vs. Anti-fibrinolytics)
 Emergency Dilatation and Curettage (D&C)
 ©UQUMed, Year 5 04/03/17

Conclusion
 Abnormal uterine bleeding (AUB) is common accounting for
about two thirds of all hysterectomies.
 A complete understanding of the hormonal events of the
menstrual cycle and the endometrial tissue response to these
hormones will allow for medical treatment of (AUB) in almost
all cases.
 In perimenopausal women, AUB is diagnosed when there is a
substantial change in frequency, duration, or amount of
bleeding during or between periods
 In postmenopausal women, any vaginal bleeding is considered
abnormal and requires evaluation.
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 ©UQUMed, Year 5 04/03/17

Questions
Case 1:
22 year old G0P0 presents for well 1). How would you
woman care. She is concerned counsel this patient?
about her periods being irregular.
She describes her cycles as coming 2). Outline the
the 18th of one month & the 16th the reproductive (ovarian)
next month. She never knows and endometrial
when it is coming. phases of normal
menstrual cycle

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 ©UQUMed, Year 5 04/03/17

Questions
Case 2:

A 15-year-old girl student presents to the 1).What is the most

emergency department with a history of likely diagnosis?
excessive vaginal bleeding that started
yesterday but has been increasing since 2). What is the
early morning. She indicates that she responsible cause?
had her first period (menarche) at age of
3). Outline your
13 years and since then her periods have
management:
been irregular and unpredictable. She
looks pale but her vital signs are stable.
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 ©UQUMed, Year 5 04/03/17

Questions
Case 3

A 47-year-old woman presents to her 1). What PALM-

gynaecologist with a history of persistent COEIN system
vaginal bleeding for the past 3 weeks. stands for ?
Over the last year, her periods have been
longer and irregular. She denies any 2). Discuss the
exogenous hormone use. Her strategies of your
examination is unremarkable. Pregnancy management
is excluded. regarding this case.

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 ©UQUMed, Year 5 04/03/17

Questions
Case 4
1). What is your diagnosis?
year old G2P2002 presents to 32
the ER with 10 day history of 2). How do you manage this
heavy uterine bleeding. She is patient?
pale and appears frightened.
Pulse is 120, BP is 90/60.
Hemoglobin is 6, Hematocrit
is 18. Pregnancy test is
.negative

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 ©UQUMed, Year 5 04/03/17

References
 Kaplan, Step 2 CK, Lecture Notes: obstetrics and Gynecology.
 Hacker & Moore's Essentials of Obstetrics and Gynecology
 Essential Obstetrics and Gynaecology
 Gynaecology by Ten Teachers
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6081150/
 https://www.glowm.com/section_view/heading/Dysfunctional
%20Uterine%20Bleeding/item/293#6711
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1952557/

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