Abnormal Uterine Bleeding

Dr.Bülent Urman

Definition and Prevalence

• Abnormal uterine bleeding (AUB) refers to menstrual bleeding of abnormal quantity, duration, or schedule.

• A common gynecological complaint (1/3 of visits)

• A United States population-based survey of women ages 18 to 50 years reported an annual prevalence rate of 53 per 1000 women

• Caused by a wide variety of local and systemic diseases or related to medications

Terminology

• Structural causes

• Hormonal causes-Dysfunctional uterine bleeding

• Systemic diseases that cause abnormal uterine bleeding

Terminology

• A revised terminology system for abnormal uterine bleeding (AUB) in non-gravid reproductive age women was introduced in 2011 by the International Federation of Gynecology and Obstetrics (FIGO)

• Goal was to avoid poorly defined or confusing terms used previously (eg, menorrhagia, menometrorrhagia, oligomenorrhea)

Normal Menses

• Frequency: every 21 to 35 days

• Occurs at fairly regular intervals

• Volume of blood ≤80 mL• Volume of blood is difficult to measure. In clinical

practice, heavy menses are generally defined as:• soaking a pad or tampon more than every two hours, or• a volume of bleeding that interferes with daily activities (eg,

wakes patient from sleep, stains clothing or sheets).

• Duration is 2-5 days

• Normal menstrual bleeding is a estrogen-progesterone withdrawal bleeding

Patterns of Abnormal Bleeding

• Hypermenorrhea (menorrhagia): Heavy/prolonged bleeding

• Hypomenorrhea: light menstrual flow• Obstruction: cervical or hymenal stenosis

• Oral contraceptives, LNG-IUD

• Uterine synechia (Asherman’s syndrome)

• Polymenorrhea: Periods that occur less than 21 days apart

• Oligomenorrhea: Periods that occur more than 35 days apart

Patterns of Abnormal Bleeding

• Metrorrhagia (intermenstrual bleeding): bleeding that occurs at any time between menstrual periods

• Menometrorrhagia: bleeding that occurs at irregular intervals. Amount and duration may vary

• Contact bleeding (Postcoital bleeding)

Differential diagnosis of AUB

Initial Evaluation-History

• Gynecologic and obstetric history• Menstrual history, LMP• Sexual intercourse? Trauma? (Bleeding after trauma

usually suggests vaginal or cervical etiology)• Contraceptive use (IUD, OCP, progestin-only pill use)

• Other medical history• Systemic diseases (especially endocrine, liver, renal, and

hematological diseases)• Family history (esp. bleeding disorders) • Medication use (hormonal, drugs that ↑PRL,

anticoagulants)• Excessive exercise, eating disorders

Initial Evaluation-History

• Is the patient pregnant?• All patients with AUB should have pregnancy testing

• It should also be performed in women who report no sexual activity and in those who report use of contraception.

• Is the patient premenarchal or postmenopausal?• The differential diagnosis of AUB for reproductive-age

women differs from that of premenarchal or postmenopausal patients

Initial Evaluation-Symptoms

• Are there any associated symptoms?• Lower abdominal pain, fever, and/or vaginal discharge

could indicate infection (pelvic inflammatory disease [PID], endometritis)

• Dysmenorrhea, dyspareunia or infertility suggest endometriosis and possible adenomyosis.

• Changes in bladder or bowel function suggest extrauterine uterine bleeding or a mass effect from a neoplasm.

• Galactorrhea, heat or cold intolerance, hirsutism, or hot flashes suggest an endocrinologic issue.

Initial Evaluation-Physical Exam• Vital signs should be assessed first

• A general examination should be performed to look for signs of systemic illness, such as • Anemia• Fever• Ecchymoses• Enlarged thyroid gland• Evidence of hyperandrogenism (hirsutism, acne,

clitoromegaly, or male pattern balding)• Acanthosis nigricans may be seen in women with polycystic

ovarian syndrome (PCOS)• Galactorrhea (bilateral milky nipple discharge) suggests the

presence of hyperprolactinemia

Initial Evaluation-Physical Exam

• A complete pelvic examination should be performed

• Abnormal findings along the genital tract (mass, laceration, ulceration, friable area, vaginal or cervical discharge, foreign body)

• An enlarged uterus → pregnancy, leiomyoma, adenomyosis,malignancy

• Limited uterine mobility → pelvic adhesions or a pelvic mass

• Pelvic adhesions → prior infection, surgery, or endometriosis

• A boggy, globular, tender uterus is typical of adenomyosis.

• Uterine tenderness → pelvic inflammatory disease (PID)

• Presence of an adnexal mass or tenderness

Structural causes of AUB

Polyps

• Cervical

• Endometrial

Adenomyosis

Anovulatory uterine bleedingDUB• Anovulatory uterine bleeding and DUB are

interchangeable terms

• DUB occurs with the disruption of cyclic hormonal changes that regulate the normal menstrual cycle

• In up to 90% of cases it is a manifestation of anovulation leading to estrogen breakthrough bleeding

Causes of DUB

• Polycystic ovary syndrome

• Immaturity of the HPO axis• Postpubertal adolescents shortly after menarche• Perimenopausal women

• Dysfunction of the HPO Axis• Hyperprolactinemia• Stress and anxiety• Rapid weight loss• Anorexia nervosa• Hypothyroidism• Perimenopause

• Abnormalities of normal feedback signals• Liver disease, hypothyroidism• Obesity• Estrogen producing ovarian tumors

Evaluation of DUB

Laboratory Evaluation- Initial Tests

• Pregnancy test• Repeat if positive

• Blood test if urine is negative

• Repeat in 1 week if negative

• Complete blood count• Hemoglobin and/or hematocrit for anemia → women

with heavy or prolonged bleeding

• Platelet count → bleeding disorders

• White blood cell count for infection

Laboratory Evaluation- Endocrine

• Thyroid function tests -Hypo and hyperthryoidism

• Prolactin

• Androgens levels

• FSH or LH – Poor nutrition, exercise, perimenopause

• Estrogen levels – estrogen secreting tumor (very rare)

• Assessment of ovulatory function – Anovulation

Diagnostic procedures

• Ultrasound• Transvaginal examination should be performed, unless there is a

reason to not perform the vaginal study (virginal patient) • Transabdominal sonography should also be performed if

transvaginal imaging does not allow adequate assessment of the uterus or adnexa or if a large pelvic mass is present.

• SIS if intracavitary pathology is suspected• Polyps• SM fibroids

• Endometrial biopsy

• DC

• Hysteroscopy

Endometrial Sampling

• Once pregnancy has been excluded, endometrial sampling should be performed in women with AUB if there is: • increased risk of endometrial hyperplasia or cancer

• Suspicion of endometritis

• Retained products of conception in women with PP bleeding

Saline Infusion Sonography

Treatment

• Treatment is planned according to the etiology

• Any medicine that may be responsible for AUB should be stopped, if possible

• Polyps →polypectomy

• Fibroids and Adenomyosis →• Medical:

• Tranexamic acid• Estrogen-progestin pills• Progestin implants-injections-pills• Gonadotropin-releasing hormone agonists• Levonorgestrel-releasing IUD (LNG-IUD)

• Surgical or invasive: • Myomectomy • Hysterectomy• Embolization• MR guided focused ultrasound

Treatment

• Endocrine disorders → Thyroid disease treated as indicated, cabergoline for hyperprolactinemia

• Von Willebrand Disease and other coagulation disorders →Desmopressin, tranexamic acid, estrogen-progestin contraceptives, LNG-IUD

• Infection→Antibiotics according to suspected agent

• Endometrial hyperplasia → High-dose long-term progestins, LNG-IUD, hysterectomy

• Genital cancer → Treated as indicated

Treatment of Acute, Heavy Bleeding in Dysfunctional Uterine Bleeding

• If endometrium is denuded or attenuated, the best initial treatment is estrogen therapy. When endometrium is normal or thickened, high dose estrogen-progestin or progestin alone may help.

• High-dose IV estrogen(25 mg conjugated E2 every 4 hrs) gives rapid response

• In hemodynamically stable patients, oral conjugated E2 2.5 mg every 4-6 hrs for 2-3 wks

• Alternatively, OCPs 3-4 times the usual dose may be preferred and tapered gradually

• Once bleeding has stopped, medroxyprogesterone acetate 5mg once or twice a day for 7-10 days

• Endometrial curettage is warranted when bleeding is acute or fails to respond promptly to intensive medical therapy

Treatment Options for Dysfunctional Uterine Bleeding

• OCPs regulate menses and decrease flow

• Progestins may be an alternative in patients who can not use OCPs (eg, smokers over age 35)

• NSAIDs reduce mentstrual volume

• Tranexamic acid

• GnRH agonists + add back therapy with progesteron+low dose E2 or progestin alone

• Danazol- effective but has side effects

• LNG-IUD