An overview on AUB classification, causes and management.

1. ABNORMAL UTERINE BLEEDING
(AUB)
Dr Joyce MWATONOKA
INTERN DOCTOR
May 2018

2. Outline
• Introduction
• Definition of terms
• Etiological classification
• Diagnosis; history and physical examination
• Differential diagnoses
• Management
• Complications
• References

3. Introduction
• The FIGO definition of AUB is; 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
• Normal menstruation cycle interval 28 days (21–
35 days) menstrual flow 3–7 days menstrual
blood loss 35 ml (20–80 ml)
• Affects 5-10% of females
• Most patients are adolescents or are older than
40 years

4. Definition of terms
• The bleeding can be excessive in amount (> 80
mL) or duration (>7 days) or both –
menorrhagia/hypermenorrhoea
• Unduly scanty and lasts for less than 2 days –
hypomenorrhoea
• Cyclic, the cycle is reduced to an arbitrary limit
of less than 21 days and remains constant at
that frequency – polymenorrhoea/
Epimenorrhea

5. Cont…
• If the frequent cycle is associated with
excessive and or prolonged bleeding, it is
called epimenorrhagia
• Menstrual bleeding occurring more than 35
days apart and which remains constant at that
frequency - Oligomenorrhea
• Metrorrhagia; irregular, acyclic bleeding from
the uterus. Amount of bleeding is variable

6. FIGO classification system (PALM-COEIN) for
causes of abnormal uterine bleeding in
nongravid women of reproductive age

7. Etiological classification
• PALM group includes five entities with structural
etiologies of AUB that can be diagnosed with
imaging techniques and/or histopathology (polyp,
adenomyosis, leiomyoma, malignancy, and
hyperplasia)
• COEIN group includes non-structural entities that
are not diagnosed by imaging or histopathology
• Formerly, dysfunctional uterine bleeding [DUB] is
irregular uterine bleeding that occurs in the
absence of recognizable pelvic pathology, general
medical disease, or pregnancy

8. Cont…
• The term “dysfunctional uterine bleeding,
which was previously used when there was no
structural cause for AUB, has been discarded
• Women who fit this description should,
actually, be distinguished according to FIGO
classification, in one or in a combination of
the following three etiologies: coagulopathy
(AUB-C), disorder of ovulation (AUB-O), or
primary endometrial disorder (AUB-E)

9. Diagnosis
• Diagnosis of exclusion
• AUB should be suspected in patients with
unpredictable or episodic heavy or light
bleeding despite a normal pelvic examination
• Exclude the diagnosis of pregnancy first

10. History
• Confirmed the bleeding is through the vagina
and not from the urethra or rectum
• Excessive bleeding is assessed by number of
pads used, passage of clots, and duration of
bleeding
• Cyclic or acyclic, its relation to puberty,
pregnancy events and last normal cycle

11. Cont…
• Use of steroidal contraceptives, IUCD or
hormone replacement therapy
• Any emotional upset or psychosexual problem
should be elicited tactfully
• History of abnormal bleeding from the injury
site, epistaxis, gum bleeding

12. General and Physical examination
• Pallor, LL edema, tachycardia, BP
• PCOS; hirsutism with or without
hyperinsulinemia, and obesity
• Thyroid enlargement or other manifestations of
hyperthyroidism or hypothyroidism
• Galactorrhea: May suggest hyperprolactinemia
• Ecchymosis, purpura: Signs of bleeding disorder
• Visual field deficits: Raise suspicion of
intracranial/pituitary lesion

13. Ddx
In young women < 20 years; A study by
Maslyanskaya et al (June 2017) revealed;
• PCOS 33%
• Hypothalamic pituitary ovarian axis
immaturity (31%)
• Endometritis (13%)
• Bleeding disorders (10%)

14. Cont…
In older women;
• Fibroids
• Endometrial polyps
• Thyroid problems
• Polycystic ovary syndrome
• Bleeding disorders

15. Management; investigations
• Blood or urinary Bhcg
• FBP (RBC indices, plateles)
• Prothrombin time (PT), activated partial
thromboplastin time (APTT), INR-international
normaized ratio & LFT
• Hormonal assay (progestin level)
• In suspected cases of thyroid dysfunction, serum
TSH, T3, and T4 estimation
• Prolactin

16. Excluding structural causes;
• USS, transvaginal/transabdominal
• Hysteroscopy —better evaluation of
endometrial lesion, to take biopsy (if required)
from the offending site under direct vision
• Saline Infusion Sonography (SIS) is found very
helpful to diagnose endometrial polyps,
submucous fibroids and uterine abnormality

17. Treatment
General;
• Assurance and sympathetic handling are
helpful particularly in adolescents
• Anemia should be corrected by diet,
hematinics or by blood transfusion
• In structural etiology, treat the cause

18. Cont…
• In case of AUB-C, AUB-O, or AUB-E (once
malignancy and other pelvic pathologes are ruled
out), medical treatment is the first-line therapy
• It includes hormonal therapy;
• Physiological mechanism of hemostasis in normal
menstruation are: (1) Platelet adhesion
formation. (2) Formation of platelet plug with
fibrin to seal the bleeding vessels (3) Localized
vasoconstriction. (4) Regeneration of
endometrium (5) Biochemical mechanism: In
increased endometrial ratio of PGF2α/PGE2.
PGF2α causes vasoconstriction and reduces
bleeding

19. Cont…
• Progestin; increases the level of PGF2α from
arachidonic acid. Given during luteal phase or in
an extended regimen (medroxyprogesterone
acetate (MPA)/Depo-Provera 10 mg or
norethisterone 5 mg is used from 5th/15th to 25th
day of cycle for 3-6 cycles)
• Oral contraceptive pills (OCP) – high dose first
then taper
• Levonorgestrel intra-uterine device (L-IUD)
• Gn-RH agonist

20. Non-hormonal medical therapies;
• Antifibrinolytic agents; Tranexamic acid
• Prostaglandin synthetase inhibitors (PSI);
Fenamates (Mefenamic acid)
• Hemostatic drug; Sylate – restores capillary
endothelial resistance and improves platelet
adhesion. Contraindicated in fibroids??
• NSAIDs

21. Surgical management;
• Endometrial ablation/resection; alternative
to hysterectomy; laser, uterine thermal
balloon, Microwave
• Hysterectomy
• Uterine curettage (not done anymore)

22. Complications,
• Anemia
• Heart failure
• Endometrial cancer (2% anovulatory cycles,
excessive estrogen exposure)
• etc

23. References;
• Khrouf M, Terras K. Diagnosis and management of
formerly called "dysfunctional uterine bleeding"
according to PALM-COEIN FIGO classification and the
new guidelines. J Obstet Gynaecol India. 2014 Dec. 64
(6):388-93
• Maslyanskaya S, Talib HJ, Northridge JL, Jacobs AM,
Coble C, Coupey SM. Polycystic Ovary Syndrome: An
Under-recognized Cause of Abnormal Uterine Bleeding
in Adolescents Admitted to a Children's Hospital. J
Pediatr Adolesc Gynecol. 2017 Jun. 30 (3):349-355.
• Dutta Text Book of Gynecology
• MedScape