1. Abnormal Uterine Bleeding
Khalid Sait FRCSC
Professor, Faculty of Medicine
King Abdulaziz University

4. NORMAL MENSES
Frequency: 21-35 d
Duration: 3-7 d
Volume: 30-80 ml

5. Polymenorrhoea: frequent (<21 d) menstruation, at
regular intervals
Menorrhagia: Excessive (>80 ml) & / or prolonged
menstruation, at regular intervals
Metrorrhagia: Excessive (>80 ml) & / or prolonged
menstruation at irregular intervals.
Menometrorrhagia: both.
Intermenstual bleeding: episodes of uterine bleeding
between regular menstruations
Hypomenorrhoea: scanty menstruation.
Oligomenorrhea: infrequent menstruation (>35 d)

6. Abnormal Uterine Bleeding
• More than 10 millions women in the USA suffer
from abnormal Uterine bleeding (AUB)
• World wide AUB affects about 50 % of
menstruating women
• The majority occur in peri-menopousal and after
menarche when the ovaries are in the unstable
responsive state.

7. AUB
• It is a debilitating and common medical
problem that:
adversely impacts a women s health,
daily activity and responsibility
( quality of life )

8. AUB
• Approx. 4 out of 5 women with AUB have
no anatomic pathologic condition
• About 50 % of patient with abnormal
uterine bleeding will have fibroid or polyp
• 10 % of post menopausal bleeding women
will have cancer

9. Common presentation
• 40 years old women , Para 3 + 1
• Presented with the complain of abnormal
vaginal bleeding for the last 2 days

10. Abnormal Uterine Bleeding
Anatomic/Organic Pregnancy
Systemic conditions DUB

11. DUB
• Uterine bleeding that occurs
outside of normal menstruation,
or disruptions in cyclic
menstruation

12. DUB
• Ovulatory
• Unovulatory

13. Ovulatory AUB
• Regular heavy period
• Unknown etiology( Mostly an endocrine abnormality: -
ALTERED PROSTAGLANDIN SYNTHESIS IN
FAVOUR OF E2 THAN F2α
• The ratio of PGE2:PGF2alpha and level of PGI 2
are increase lead to lead to vasodiltation
• In addition the fibroinolytic activity is
significantly elevated in most women

14. Anovulatory AUB
• usually caused by : ESTROGEN -
PROGESTERONE IMBALANCE (mostly
estrogen dominance)
1- Bleeding due to estrogen –withdrawal
2-Bleeding due to estrogen breakthrough
3-Bleeding due to progesterone –
breakthrough.

15. Anovulatory AUB
Bleeding due to estrogen –withdrawal
• Recurrent mid cycle bleeding or spotting
just before ovulation during the normal
menstrual cycle due to pronounced dip in
levels of estradiol at that time

16. Anovulatory AUB
Bleeding due to estrogen breakthrough
• Occur in women with PCO with no
influence from progesterone on the
endometrium

17. Anovulatory AUB
Bleeding due to progesterone - breakthrough
• Occure when the progeterone to estrogen
ratio is relatively high
• Lead to frequent irregular bleeding

18. Abnormal Uterine Bleeding
• History and Physical Examination
• Pregnancy test
• Blood work: FSH.LH.Prolactine, TSH
• Uterine cavity assessment: Endometrial
biopsy, TVS ,Hysteroscopy , saline infusion
sonography , MRI

19. D & C
• Diagnostic and therapeutic technique,
diltation and curttage ( D&C) is now
considered obsolete for the evaluation and
treatment of abnormal uterine bleeding, but
it is unfortunately still used by many
physicians for this purpose

21. TVS

23. 11.SAG Uterus (Transvaginal)
Endometrial Polyps
12. SAG Uterus (Transvaginal)
Endometrial Polyp
11 12

24. COR Uterus (3D Reconstruction)
Endometrial Polyp

25. Endometrial Biopsy
• Pipelle cathter
• Accurette
• Z sampler
• Tis – u- trap
• Novak curatte
• Randall curatte
• Vabra aspiration
• Two studies shown that pipelle and novak has
same sensitivity with pipelle cause less discomfort
to the patient

27. Saline infusion sonography

29. HYSTEROSCOPY

30. Hysteroscopy
• Gold standard

32. MRI
• Powerful non invasive
• Sub mucus fibroid
• Adenomyosis
• But not polypi

34. Treatment
• Medical
• Surgical

35. Ø Treatment has to be indivisualised
Ø Not suitable for all ages
Ø Response is erratic and unpredictable
Ø SIDE EFFECTS - Discontinuation and
noncompliance
Ø Failures are common
Ø Cost effectiveness ?
Medical Treatment for DUB
Problems: -

36. Medical
• Iron
• Hemopiotin
• Blood transfusion

37. Antifibrolynitcs
• Antifibrolynitcs Transxamic acid
Cyklokopron
• Side effect leg cramps and nausia
• Reduce menst cycle by 45% to 54 %(10
RCT placebo control)

38. Antifibrolynitcs
• Competitively inhibits the activation of
plasminogen to plasmin and counter acts the high
fibrinolytic activity in the endometrium which
may be one of the causes
• Dose :1 gm every 6 hour po for 3 days of heavy
period

39. Cyclo oxygenase inhibitor
• With endometriun cycooxygenase convet arachidonic acid into PGS and lead
to vasoditation
• Inhibit cyclooxygenase
• 21 RCT decrease blood loss by 20-50 %
• Nsaids
• Mefenemic acid
• Diclofenac
• Flurbiprofen
• Indomethacine
• Naproxen
• Side effect
• GI upset
• Dose
• 500 mg q 6 hours for 3 days of period
• C/I renal faliure and peptic ulcer

40. Progesteron
• It will lead to predictable bleeding but heavy unless the therapy used
for several months
• May increase flow by 20 % coulter et al 1995
• Benefit in anovulatory uterine bleeding as in PCO
• Progestrone ( 5 mg bid on luteal phase northindrone for 7 days led to
increase menstrual loss

41. IUCD caoted progeteron
mirena( levonorgesteral)
• Anderson et al 1990
Reduction in MBL after 3 month by 86 %
and 97 % after 12 month of use

43. Combined birth control pills
• Ovul and unovul AUB
• Suppress ovulation, and over time , thin the
endometrium lining to an inactive state
• In unovulation it level out the fluctuation in
estrogen which often initiate breakthrough
bleeding
• C/I
• Side effect

44. Combined birth control pills
• Excessive bleeding
• Ovral 1 tab tid for 1 week
Bid for 2nd weeks and once per week for
third week then follow with microgynon 30
for 3 months

45. Estrogen
• Acute excessive bleeding
• Conjugated equine estrogen (cees)
• Ovu and unovu
• Stop bleeding in 71 % of women compare to
placebo
• 25 mg IV every 4 hours
• Or 2.5 mg adminstered orally every 4-6 hours for
2-3 weeks
• Once bleeding stop please give progesterone for 7
days

46. Androgen
• Danazol+ a synthetic derivastive of 17 alpha
– ethinyl testosterone
• Ovul AUB
• Danazol resduce blood flow in 50 % -80 %
200-400 mg/d > 100 mg /d for three month
• Side effect

47. GnRh agonist
• Act by produce unovulation
• Ovul and unovu
• Second week of injection bleeding increase
due to gondotrophine flare
• Cost
• Side effect
• With add back therapy can continue therapy
beyond 12 months

48. antiprogesterone
• Mifepristone
• 50 mg/day
• Induce ammenorrhae

49. Cost per cycle
• Nsaid 16$
• Provera 16 $
• Ocp 16 $
• Cyclokopron 60 $
• Danazol 70 $

50. ENDOMETRIAL ABLATION: -
• TCRE – Tran Cervical Resection Of
Endometrium
• ELA – Endrometrial Laser Ablation
• HTEA – Hydrothermal Endrometrial Ablation
v HYSTEROSCOPIC METHODS: -
Surgical Treatment of DUB

54. • TBEA – Thermal Balloon Endometrial Ablation
ENDOMETRIAL ABLATION: -
v NON HYSTREOSCOPIC METHODS: -
Surgical Treatment of DUB

57. • VAGINAL HYSTERECTOMY
• LPAROSCOPICALLY ASSISTED V H
• Lap Hys.- Total / Subtotal
• Abdominal / MINILAP Hysterectomy- Total /
Subtotal
HYSTERCTOMY: -
Surgical Treatment of DUB

58. Hysterectomy

59. • Hystrectomy is a commonly used and
effective treatment for AUB , but it is the
most expensive surgical option avaliable
and is often medically unnecessary due to
the absence of pathological uterine
conditions in a large percentage of these
women( 40 % )

60. Summary
§ Dysfunctional Uterine Bleeding is a very common
disorder at all ages from menarche to menopause.
§ Though its pathophysiology is still unclear, Estrogen-
Progesterone imbalance is usually the basis of
bleeding.
§ Available medical treatment modalities are far from
satisfactory.
The perfect SERM for DUB