AUB Diagnosis and evaluation

1. AUB
Diagnosis and evaluation
BY: Dr. DIPTI NABH
Dr Sharda Jain

2. Abnormal Uterine Bleeding
2
ACOG1 NICE2Guideline Talk
• Bleeding from uterine corpus that is
abnormal in:
• Regularity
• Volume
• Frequency or
• Duration and
• Occurs in the absence of pregnancy
• When a woman experiences a change in:
• Her menstrual loss or
• The degree of loss or
• Vaginal bleeding pattern differs from
that experienced by the age-matched
general female population

3. Limitations of the current nomenclature
Terms associated with AUB
Inconsistently defined in
literature1,2
It also make it difficult to plan
and conduct studies and
compare results of different
studies2
Sub-optimal diagnosis of
patients
Impact the comprehensive
management of the condition
Terms abandoned in the FIGO nomenclature
system
Dysfunctional uterine bleeding
Epimenorrhagia
Epimenorrhea
Functional uterine bleeding
Hypermenorrhea
Hypomenorrhea
Menometrorrhagia
Menorrhagia (all usages: essential menorrhagia, idiopathic
menorrhagia, primary menorrhagia, functional menorrhagia,
ovulatory menorrhagia, anovulatory menorrhagia)
Metrorrhagia
Metropathica hemorrhagica
Oligomenorrhea
Polymenorrhagia
Polymenorrhea
FIGO, International Federation of Gynecology and Obstetrics.
Munro, FIGO system for abnormal uterine bleeding. Am J Obstet Gynecol, 2012.

4. Waves of change
• In 2006, FIGO identified as the appropriate body to provide supervision &
international credibility to the ongoing evaluation of new terminology
• In 2009, FIGO Menstrual Disorders Group was formed. FIGO World
Congress of Gynecology and Obstetrics , accepted the new terminology.
• In 2011, the PALM-COEIN Classification System created.
• In 2012, PALM-COEIN system was endorsed by ACOG

5. FIGO nomenclature
&
PALM-COEIN classification
•Simplified and unified terminology
•Allows clear focus of treatment concepts

6. AUB Validated Terminology
• Acute AUB
• Chronic AUB
• AUB – HMB (Heavy Menstrual Bleeding)
• AUB-IMB (Inter Menstrual Bleeding)

7. PALM-COEIN
FIGO Classification
•Polyp
•Adenomyosis
•Leiomyoma
• Submucosal
• Other
•Malignancy & hyperplasia
Coagulopathy
Ovulatory Dysfunction
Endometrial
latrogenic
Not Yet Classified
Structural Entities Non-Structural Entities

8. Structural Abnormalities
•P – Polyps – scored as Present or Absent
•A – Adenomyosis - scored as Present or Absent
•L – Leiomyoma
• Primary level – Present or Absent
• Secondary level – Distinguish between submucosal (SM) & others (O)
• Tertiary level – Detail location/size of uterine fibroids
• M – Malignancy & hyperplasia

9. AUB-P; Polyps (8-35 %)
•Diagnosis: US, SIS, hysteroscopy
•Further sub-classification: Present or Absent
•Present with : HMB, AUB, IMB, or post-coital bleeding

10. •AUB-A; Adenomyosis
Ectopic endometrial glands & stroma within the myometrium
Usual presentation: HMB, uterine enlargement, & dysmenorrhea
Diagnosis suspected by USG confirmed by MRI

11. •Adenomyosis
•Linear Striations
80% PPV
71% Accurate
•Heterogeneous
myometrium
•81% PPV
69% Accurate

12. •Asymmetric wall thickening Enlarged globular uterus
•Heterogeneous echotexture
•Pseudo-widening of endometrium Confluent echogenic
areas of tissue
AUB-A - Adenomyosis

13. AUB-L; Leiomyoma
• Primary classification-
Absent or present : AUB-L0,
AUB L1
• Secondary classification
• Submucosal – AUB-L(SM)
• Other – AUB-L (o)
• Tertiary classification
• Types 0-8

14. The three stage classification system for leiomyoma

15. •AUB-M; Malignancy & Hyperplasia
• WHO classification of endometrial hyperplasia – 2014
• Endometrial hyperplasia -with atypia( conversion to malignancy t2%)
Without atypia(25%-30%)
• Older classification
• Simple hyperplasia- with atypia/ without atypia
• Complex hyperplasia- with atypia/without atypia

16. Non-structural Abnormalities
• C – Coagulopathy
• O – Ovulatory Dysfunction
• E – Endometrial
• I – Iatrogenic
• N – Not yet classified

17. •AUB-C; Coagulopathy
• Prevalence 3% of women presenting with HMB
• Caused by systemic disease of haemostasis
• Von Willebrand’s disease (10%)
• Platelet Dysfunction
• Factor XI deficiency
• Factor X deficiency
•Category does not include patient’s taking anti-coagulants

18. DUB-Dysfunctional uterine bleeding or Anovulatory bleeding is also included in
this category.
Ovulatory DUB-
Idiopathic ovulatory menorrhagia
Luteal phase defect menorrhagia
Anovulatory DUB-
Puberty menorrhagia
Metropathia Hemorrhagica
•AUB-O-- Ovulatory Dysfunction

19. AUB-O
Occurs from menarche to menopause
•Various Causes
• Polycystic Ovarian Syndrome (PCOS)
• Hypothyroidism
• Hyper-prolactinemia
• Mental stress
• Obesity
• Anorexia
• Weight loss
• Extreme exercise
• Adolescence
• Menopausal transition

20. •AUB-E; Endometrial
•Infection and inflammation of endometrium
• Disorders of endometrial repair (inflammation) – Chlamydia, TB
Dysfunction of endometrium imbalance of vasoconstrictors & vasodilators
Prostaglandin F2a / Prostaglandin E2
Disturbed fibrinolytic activity at the endometrial level

21. •AUB-I; Iatrogenic
• Etiology:
• Breakthrough bleeding (BTB) using gonadal steroids is the major component of
AUB-I :
• Oral contraceptives
• Continuous or cyclic progesterone
• IUD or implant related bleeding
• GnRH agonist/ antagonist
• SERMS/SPRMS
• Cigarette smoking : reduces the level of steroids because of enhanced hepatic
metabolism
• Systemic agents : (that interfere with dopamine metabolism) : Serotonin
uptake inhibitors
•Use of anti-coagulant drugs

22. AUB-N; Not Yet Classified
•Rare cases of AUB due to ill defined causes
•AVMS
•Caesarian scar defects
•Endometrial pseudo aneurysm
•Myometrial hypotrophy

23. Notation for AUB
• A patient may be found to have more than one potential entity
contributing to symptoms of AUB. A notation approach has been designed
to enable categorization.
• For example, if a patient is found to have endometrial hyperplasia and
ovulation dysfunction with no other abnormalities, she would be
categorized as follows:
• AUB P0 A0 L0 M1-C0 O1 E0 I0 N0
•May be abbreviated as : AUB – M,0

24. Example : Fibroid / Adenomyosis / Polyp
Single entity

25. Example: more than 2 Entities
Submucosal fibroid & hyperplasia
Polyp & adenomyosis
Polyp & Leiomyoma Subserosal
Coagulothapthy Adenomyosis & Leiomyoma Subserosal

26. DIAGNOSIS & EVALUATION
• THOROUGH HISTORY
• PRELIMINARY ASSESSMENT
• General assessment
• Gynaecological examination
• INVESTIGATIONS
• Laboratory Testing
• Imaging
• Specialized Tests
• Endometrial histopathology

27. THOROUGH HISTORY
Menstrual Pattern
• Duration
• Amount
• Cycle length
• Regularity
• Intermenstrual bleed
Pain
• Dysmenorrhea, spasmodic or
congestive,
• Intermenstrual, chronic pain,
• Dyspareunia
Concomitant
Medications
(Grade B; Level 4)
• Anticoagulants,
• Tamoxifen
• Hormonal contraceptives
• Anti depressants and anti-
psychotics
• Corticosteroids
• History suggestive of bleeding diathesis
• One of following:
• PPH
• Bleeding with dental work
• Surgery-related bleeding
• At least two of following:
• Bruising : ≥1 episode / month
• Epistaxis: ≥1 episode / month
• Frequent gum bleeding
• F/H bleeding symptoms

28. Physical Assessment
General assessment
 Vital signs
 Weight/BMI
 Thyroid exam- Nodule
 Signs of PCOS
 Signs of IR
 Sings of hemorrhagic
disorder
 Abdominal exam (mass,
hepatosplenomegaly)
 Breast examination
 Inspection vulva, vagina, cervix, anus, and
urethra
 Bimanual examination uterus and
adnexal structures
 PR if bleeding from rectum suspected or risk
of concomitant pathology
 Testing:
 Pap smear
 cervical cultures - if risk for
sexually transmitted infection
Gynecological examination

29. Laboratory testing
Laboratory Evaluation Specific Laboratory Tests
 Initial laboratory testing  CBC
 Blood group
 Pregnancy test
 Initial laboratory evaluation for
disorders of hemostasis
 PTT & PT
 Activated partial thromboplastin time
 Fibrinogen
 Testing for von
Willebrand disease
 VWF antigen
 Ristocetin cofactor assay
 Factor VIII
 Other laboratory tests to
consider
 TSH
 Serum Fe, total Fe binding
capacity, and ferritin
 Liver function tests
 Chlamydia trachomatis

30. Imaging
Ultrasonography
• Most Important diagnostic modality:
• TVS is prefered.
• Doppler USG- Suspected AV malformation, differentiate
between fibroid and adenomyomas
• 3D USG – For structural malformation, non invasive
alternative to hysteroscopy

31. •Ultrasound is performed after introduction of saline
into the uterine cavity
•Improves the diagnosis of intra cavitary pathology –
polyps and fibroids
Imaging
Saline infusion Sonography

32. • Rarely indicated
• Helps mapping the exact location of fibroids in planning surgery and
•prior to embolization
• When TVS or instrumentation of the uterus (i.e. congenital anomalies)
•cannot be performed
• Confirmation of Adenomyoma
• Before focused USG treatment
Imaging
MRI

33. Hysteroscopy
• Considered a primary tool for all cases of AUB
• A 3mm rigid Hysteroscope is inserted into the
uterine cavity using saline as a distension medium
allowing direct visualization of cavitary pathology
• Indications
• Intermenstrual spotting
• S/O Intracavitary lesion
• Dysynchronicity between symptoms & HPE
(Grade A, Level2)
• ET on TVS but HPE inadequate/atrophic
• No response to medical management
• Directed biopsy (main benefit over "blind" D&C)

34. Endometrial Biopsy
34
• Office Procedure using Karman Cannula, Probet
• Recommend in all women with AUB >45 years
• Women <40 years :
• With persistent AUB
• Failed Medical Management
• H/o unopposed estrogen exposure
• With risk of endometrial cancer
• Post Menopausal bleed with ET > 4mm

35. Take Home Message
• The terms DUB/ FUB/ Menorrhagia/ Polymenorrhoea should be
replaced by the PALM-COEIN Method.