Management guidelines for AUB

1. Guidelines for Management of
Abnormal Uterine Bleeding
Dr Nupur Gupta
Department of Obstetrics & Gynecology

2. AUB: Spectrum of Problem
Menarche to Menopause

3. Burden of HMB in India
• 15% of all Gynae visits &
• 25% of all Gynae surgeries

4. Impact of AUB on Daily Life
Anxiety,
pscychological
Decreased QOL
Negative impact
on relationship
with partners
Pain &
Discomfort
Dec Work
Productivity
Iron Deficiency
Anemia

5. Dysfunctional Uterine Bleeding (DUB)
• Epimenorrhagia
• Epimenorrhoea
• Functional Uterine Bleeding
• Hypermenorrhoea
• Hypomenorrhoea
• Menometrorrhagia
• Menorrhagia
• Metropathica
• Metropathica haemorrhagica
• Oligomenorrhoea
• Polymenorrhoea
• Polymenorrhagia
• Uterine haemorrhage
Amenorrhoea word is retained

6. Abnormal Uterine Bleeding
ACOG1 NICE2
Bleeding from uterine
corpus that is abnormal in
a) regularity,
b) volume,
c) frequency, or
d) duration and
e) occurs in the absence of
pregnancy
When a woman
experiences a change in
a) her menstrual loss, or
b) the degree of loss or
c) vaginal bleeding pattern
differs from that
experienced by the age-
matched general female
population
NICE Guidance 2007ACOG: Obstet Gynecol 2013; 121(4):891-6

7. Acute and Chronic AUB
• Acute uterine bleeding unrelated to pregnancy was defined in
as “that which is sufficient in volume as to, in the opinion of
the treating clinician, require urgent or emergent intervention.”
(FIGO definition)
• Chronic: AUB present for most of the previous 6 months
ACOG Obstet Gynecol 2013
Munro Am J Obstet Gynecol 2012

8. Establishing a Diagnosis

9. Menstrual History
• Age at menarche
• Cycle length
• Duration of bleeding
• Perception of flow: light, medium or heavy
• First day of LMP
• Dysmenorrhoea

10. Menstrual Calender

11. Blood Loss Assessment Tools
• Diagnostic tool
• Outcome (follow up tool)
1. Alkaline Haematin Method
2. Pictoral Blood Loss Assessment Chart

12. Pictoral Blood Loss Assessment Chart
A PBAC score of >150 points is most often used as an inclusion criterion in
HMB studies

13. Medical History
• Social History – social stressors, substance abuse,
exercise patterns or athlete
• Family History – bleeding or menstrual disorders,
diabetes & thyroid
• Past Medical History – systemic illness (hematologic or
renal disease), PCOD
• Drug History (current or recent medications, medical
abortion pill or ipill, drug induced hyperprolactinemia)

14. Medical History
Sexual History
• Contraceptive & condom use
• Number of partners
• H/o STIs (vaginal discharge, pelvic pain)
• Previous pregnancy loss or abortion
• H/o sexual abuse or assault

15. Physical Assessment
General Assessment
• Vital signs
• Weight/BMI
• Thyroid exam
• Skin pallor, bruising, striae,
hirsutism, petechiae
• Abdominal Exam – mass,
hepatosplenomegaly
Gynecological Assessment
• Inspection
• Bimanual exam (PS, PV)
• PR
• Pap smear, cervical culture

16. Laboratory Testing
• CBC
• Coagulation profile (adolescents)
• TSH, Prolactin
• Serum beta HCG
• Day 2 Hormonal profile (PCOD)

17. IMAGING
TVS
Doppler Ultrasonography (suspected AVM or malignancy)
3D USG (fibroid mapping)
Hysteroscopy/SIS (intracavitary lesion & type of myoma)
MRI (differentiate b/w fibroid & adenomyoma, fibroid mapping
pre surgery or prior to UFE)

18. Imaging: Transvaginal Ultrasound
• Evaluate uterus: Assessment of
myometrium, cervix, endometrial polyp,
adenomyosis, leiomyoma, uterine
anomalies & endometrial thickness
• Adnexa: any mass or cyst

19. Endometrial Histopathology
• In women > 40 years
• In women < 40 years with risk of cancer endometrium
(irregular bleeding, obesity associated with hypertension,
PCOD, diabetes, endometrial hyperplasia >12mm, family history
of cancer ovary, breast, endometrium or colon, use of tamoxifen
for HRT or breast cancer, late menopause or HNPCC (hereditary
non polyposis colon cancer syndrome)
Endometrial Aspiration (Not D&C)

20. Hysteroscopy
• To rule out endometrial polyps
• To look for submucus myoma
• Suspicious for malignancy: Polypoid
proliferations, ulceration & necrosis, friable
mass with irregular vessels
• Retained fetal bones following abortion (2nd
trimester)

21. Goals of Treatment
• Establish/maintain haemodynamic stability
• Correct acute or chronic anemia
• Return to a pattern of normal menstrual cycle
• Prevent recurrence
• Prevent long-term consequences (anemia, infertility,
endometrial cancer)

22. Waves of Change
2009 – FIGO Menstrual Disorders Group
2011 – PALM-COEIN classification system created
2012 – PALM-COEIN system endorsed by ACOG
FOGSI GUIDELINES SEP 2015

23. PALM COEIN CLASSIFICATION
Etiopathogenesis Based
Nonstructural CausesStructural Causes

24. LEIOMYOMA CLASSIFICATION

25. MANAGEMENT OF ACUTE AUB
Diagnostic curettage

26. MANAGEMENT OF CHRONIC AUB

29. AUB-P (POLYPS)
• Symptoms – prolonged uncontrolled
bleeding or intermenstrual bleeding,
pallor or infertility
• Signs – Normal size uterus, cervical os
patulous if protruding fibroid polyp
• Imaging – Thickened endometrium

30. AUB-P (POLYPS)
• Single Polyp - Hysteroscopic polypectomy in women desirous
of fertility
• Multiple polyps – Hysteroscopic polypectomy f/b LNG IUS
insertion in women not desirous of fertility
HISTOPATHOLOGY if malignant, manage as AUB-M

31. AUB-A (ADENOMYOSIS)
• Symptoms – heavy bleeding, marked dysmenorrhoea
• Signs – uterus 12 weeks, uniformly enlarged & globular with or
without tenderness
• Imaging – Enlarged uterus not due to myoma, asymmetric
thickening of uterine wall, obscuring of endomyometrial
junction, heterogenous endometrium

32. AUB-A (ADENOMYOSIS)
• Depends on age and symptomatology
• Women desirous of preserving fertility
- First Line: LNG-IUS
- Second Line: GnRH agonist with add back therapy
• Women with infertility: adenomyomectomy
• Failure of medical management: Vaginal H/TLH
• Earlier: COCs, Danazol, NSAIDs or progesterone

33. AUB-L (LEIOMYOMA)
• Symptoms –
- Submucus (more prolonged uncontrolled
bleeding)
- Intramural (heavy menstrual bleeding)
- Subserous (maybe asymptomatic)
• Signs – uterus irregularly enlarged & firm
• Imaging – whorled appearance on USG,
selected cases (3D), fibroid mapping (MRI)

34. AUB-L (LEIOMYOMA)
• Individualised – age, parity, symptoms, fertility desire
• Symptomatic subserous/intramural myomas(2-6)
- Desirous of fertility (Tranexa, NSAIDs, COCs)
- Not desirous of fertility for 1 year – LNG IUS if medical
treatment fails
• Myomectomy if medical treatment fails or interfering with
fertility
• Hysterectomy if age >40 years & family complete
• GnRH agonists for short-term management

35. AUB-L (LEIOMYOMA)
• For long-term management, LNG-IUS except in type 0 &1
• Newer promising options:
- Mifepristone 5 to 10mg
- Ulipristal acetate 5mg

36. AUB-M (MALIGNANCY
• Symptoms – postmenopausal bleeding,
irregular perimenopausal bleeding
• Signs – normal to mildly enlarged, restricted
mobility
• Imaging – thickened endometrium on USG,
irregular endometrial lining, loss of
endomyometrial junction

37. AUB-M (MALIGNANCY &
ENDOMETRIAL HYPERPLASIA)
• Ca endometrium: standard protocol
• Endometrial hyperplasia with atypia: Hysterectomy
• Endometrial hyperplasia without atypia: LNG-IUS or oral
progestins

38. AUB- C (Coagulopathy)
• Heavy menstrual bleeding since menarche
• One of the following:
- Postpartum haemorrhage (PPH)
- Surgical site bleeding
- Bleeding associated with dental work
• Two or more of the following:
- Bruising/epistaxis 1 to 2 times per month
- Frequent gum bleeding
- family history of bleeding symptoms

39. AUB- C (Coagulopathy)
• Symptoms – puberty menorrhagia, heavy bleeding at
menarche, H/o bleeding diathesis, family history
• Signs – uterus normal size, pallor, easy bruisability,
petechiae
• Imaging – thickened endometrium on USG, irregular
endometrial lining, loss of endomyometrial junction

40. AUB-C (Coagulopathy)
AUB due to
coagulopathy
Secondary
Option
(Hormonal
treatment)
COCs/LNG-
IUS
Tranexemic
acid
Primary
option (Non
Hormonal
treatment)
After consultation with Haematologists
Specific Factor Replacement CI – NSAIDS & IM prep

41. AUB-O (Ovulatory Dysfunction)
• Symptoms – of PCOD, irregular cycles, insulin
resistance
• Signs – uterus normal size
• Imaging – PCOD on ultrasound, thickened
endometrium

42. AUB-O (Ovulatory Dysfunction)
Etiology
• Polycystic ovaries
• Hypothyroidism
• Hyperprolactinemia
• Mental stress
• Obesity
• Anorexia
• Weight loss
• Extreme exercise
• Adolescence
• Menopausal transition

43. AUB-O
• Not planning conception: COCs for 6-12 months (Grade A Level 1)
• Cyclical luteal phase progesterone (x 10-14 days) (Grade A, Level 1)
• In acute episode of bleeding - Norethisterone cyclically for 21
days for 3 months (Grade B, Level 4)

44. AUB-O
• Surgical intervention: if persistent AUB or failure of medical
treatment
• LNG-IUS, if patient is unwilling for COCs or they are
contraindicated

45. AUB-E (Endometrial)
• Symptoms – intermenstrual spotting, prolonged spotting
• Signs – Discharge per vaginum, Cervical erosion
• Imaging – Uterus normal, fluid in endometrial cavity

46. AUB-E (Endometrial)
• Primary disorder of the endometrium
• Secondary to endometrial inflammation or infection
• Abnormalities in local inflammatory response
• Abnormalities in endometrial vasculogenesis
- Deficiency of vasoconstrictors (PGF2alpha & Endothelin 1)
- Increased production of vasodilators (PG E2 & PGI2)
- Increased production of plasminogen activators
Management similar
to AUB-O

47. AUB –I (Iatrogenic)
• Symptoms – H/o use of CuT
• Signs – No abnormality
• Imaging – Uterus normal, CuT in
situ

48. AUB –I (Iatrogenic)
• Unscheduled endometrial bleeding or
Breakthrough bleeding (BTB)
– Using OCs, P, E, androgens
– Use of GnRH agonists, SERMs, heparin or
anticoagulants
– IUD or implant related bleeding
• Cigarette smoking
Recommendation:
LNG IUS

49. AUB –N (Not Yet Classified)
• Symptoms – heavy menstrual bleeding
• Imaging – ultrasound, doppler USG to rule out AVM

50. AUB –N (Not Yet Classified)
• Disorders that would be identified only by biochemical or
molecular biology assays
• AVM (Arteriovenous malformation)
• Myometrial hypertrophy

51. AUB –N (Not Yet Classified)
• Women who desire effective contraception: LNG-IUS or
COCs
• Women with predictable or cyclical bleeding: Tranexa
or NSAIDs