Insight AUB Management Guidelines on AUB in Reproductive Period

Insight AUB
Presentations based on
FOGSI
AUB GUIDELINES
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DGF
CME
15TH SEPTEMBER AT
LEMON TREE

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accuracy &/or veracity of the information or for any
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relying on the information contained in the
presentation or otherwise.

Evidence-based Guidance for Clinical
Decision Making and Approach to
Diagnosis of abnormal uterine bleeding
“An Indian Perspective”
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AUB-Spectrum of problem
11
Total women in
reproductive age group
Women
affected
with AUB
at any
given
point
17.9
Total women in
reproductive age group
Women
affected
with AUB
Women
not
affected
In world In India
Prevalence increases with age, reaching 24 percent in women aged 36 to 40. 1
1. Harlow SD, Campbell OM. BJOG. 2004;111:6– 16; 2. Omidvar S, Begum K. J Nat Sci Biol Med.
2011;2:174–9. 3. Chattopdhyay B, Nigam A, Goswami S. Eur Rev Medi Pharmacol Sci. 2011;15:764–768

Burden of HMB in India
Excessive bleeding has been reported in about 8-9%
women from India and neighboring countries.1
42-53% of women aged < 21 years and those > 21 years
complained of excessive bleeding.2
15% of all gynecology OPD visits and 25% of all
gynaecological surgeries3
1. Harlow SD, Campbell OM. BJOG. 2004;111:6– 16; 2. Omidvar S, Begum K. J Nat Sci Biol Med. 2011;2:174–9.
3. Chattopdhyay B, Nigam A, Goswami S. Eur Rev Medi Pharmacol Sci. 2011;15:764–768
8–9%
42–53%
15%

AUB impacts up to 30% of women at some time in their
lives
Behavior and Attitude of patients
• HMB isn’t clearly understood, it’s mostly associated to menopause &
Hormonal imbalance
• Several myths are associated to the same – kachra blood, spicy foods, a
sign of feminity.
• Heavy bleeding is sometimes viewed wrongly as ‘return to womanhood’
• Fear and anxiety is present to visit the doctor and several women function
in the zone of denial, hence delaying visitation or consistent follow-up,
check-up
• Treatment is a psychological block in itself to undertake as it will be
prolonged, painful, extended and result in hysterectomy
*Source: Independent market research funded by Bayer Zydus Pharma Pvt. India.
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Impact of AUB on Quality of life (QoL)
Major impact on a woman’s
quality of life
Over 60% of women
diagnosed with HMB ended
up having a hysterectomy
within 5 years from the
diagnosis4
About 1/3rd of
hysterectomies for HMB
result in removal of
anatomically normal
uterus5
Impact of HMB
Anxiety
Decreases
work
productivity2
Iron
deficiency
anaemia 1
Discomfort
1
Negative
impact on
relationship
with
partners3
Decreased
QOL1
1. Ghazizadeh S. Int J Women’s Health. 2011;3: 207–21. 2. Magon N. J Midlife Health. 2013;4(1):8–15; 3. Bitzer J.Open Access J Contracep.
2013; 21–28; 4. NICE 2007; can be accessed at: https://www.nice.org.uk/guidance/cg44 5.Roy SN, Bhattacharya S. Drug safety 2004

What is Abnormal Uterine Bleeding
(AUB)??

Abnormal Uterine Bleeding
1. ACOG: Obstet Gynecol. 2013;121(4):891-6. 2. NICE Guidance 2007
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

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
1. ACOG: Obstet Gynecol. 2013;121(4):891-6.
2. Munro et al. Am J Obstet Gynecol. 2012 Oct;207(4):259-65.

Role of FIGO Nomenclature
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Limitations of the current nomenclature
• Terms associated with AUB
– inconsistently defined in literature12
a) sub-optimal diagnosis of patients
b) Impact the comprehensive management of
the condition
– It also make it difficult to plan and conduct
studies and compare results of different
studies2
– Towards rectifying inconsistent terminologies,
FIGO developed a consistent and universally
accepted nomenclature a classification
system for clinicians, investigators, and patients
to facilitate communication, clinical care, and
research
1. Woolcock et al. Fertil Steril 2008;90:2269-80.

FIGO System of Nomenclature
for the etiologies of AUB
Polyps (P)
Adenomyosis (A)
Leiomyoma (L)
Malignancy & Hyperplasia
(M)
Coagulopathy (C)
Ovulatory dysfunction (O)
Endometrial (E)
Iatrogenic (I)
Not defined (N)
Submucosal
Other
Structural causes
a) discrete in nature,
b) can be measured visually
with imaging techniques
and/or histopathology
Non- Structural causes
entities that are not defined
by imaging or histopathology
Munro et al. Am J Obstet Gynecol. 2012 Oct;207(4):259-65.

International guidelines on Management of AUB
Faculty of Family Planning and Reproductive Health Care (FFPRHC) Guidance
2004
National Institute for Health and Care Excellence (NICE) 2007
Clinical Practice Guideline: Management of Abnormal Uterine Bleeding
(France)
Finnish Society of Obstetrics and Gynecology, 2006
Cochrane Review:-Progesterone or Progestogen releasing Intra Uterine
systems for Heavy Menstrual Bleeding; 2005
Clinical Practice Guideline: Management of Menorrhagia (Ministry of Health –
Malaysia); 2004
ACOG Guidelines- Management of Acute Abnormal Uterine Bleeding in Non-
pregnant Reproductive-Aged Women, 2013 reaffirmed in 2015
SOGC Canadian Clinical Practice Guideline: Management of AUB in Pre-
Menopausal Women; 2013

Why India specific guidelines for
AUB??
Need
for AUB
GCPR
Inconsistency
in day to day
management
of AUB
Unavailability of
clear diagnostic
and therapeutic
criteria impact
overall standard
of health care
High prevalence
of AUB among
women in India
Diverse clinical
practices
Lack of good
clinical practice
guidelines
specific to
Indian context
1. The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB. Available
at http://www.fogsi.org/wp-content/uploads/2016/02/gcpr-on-aub.pdf Last accessed at 24 February, 2016
2. Rahnn et al. J Clin Epidemiol. 2011;64(3):293-300

Level of evidences
Strength of recommendation (adapted from AACE Task Force)
A Strongly recommended
B Intermediate
C Weak
D Not-Evidence based, Panel recommended
Scale of scientific support
1 Meta-analysis of randomized controlled trials and randomized controlled trials
2
Meta-analysis of non-randomized prospective or case-controlled trials, non-randomized
controlled trials, prospective cohort study, and retrospective case-control studies
3
Cross-sectional studies, surveillance studies (registries, surveys, epidemiologic studies,
retrospective chart reviews, mathematical modelling of database), consecutive case series,
single case reports
4 Opinion/consensus by experts or preclinical study
1. Handelsman et al. Endocr Pract. 2013;19:675-93

Methodology
Review of literature: Best evidence
Evidence reviewed by experts group
Variability in Indian context identified: cultural,
racial, socioeconomic background
Need identified to formulate GCPR in Indian
context
Draft recommendations framed : April 2014
Expert Panel meeting, 26.9.2015: Draft discussed
Where evidence was limited, the panel relied on
experience/ clinical judgement
Final version framed → Graded

Methodology
Current consensus guidelines in accordance with
AACE protocol
Recommendations organized etiology-wise
(PALM-COEIN)
Based on :
 Clinical importance and graded- A, B, C, and D
 Coupled with four intuitive levels of evidence-
1, 2, 3, 4 (quality of supporting evidence)

Evaluation, Investigations & Diagnosis
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Recommendations: History /
Examination
Use PALM-COEIN , Abandon old terminology
(Grade A; Level 4)
Thorough history, physical examination to direct
need for investigations/ Tt
(Grade A; Level 4)

Diagnosis and Evaluation
Thorough History
(Grade A; Level 4)
Preliminary
assessment (Grade A;
Level 4)
Investigations
(Grade A; Level 4)
Menstrual
Pattern
a) Duration,
b) amount,
c) cycle length,
d) regularity,
e) intermenstrual
bleed
Pain a) Dysmenorrhea,-
spasmodic or
congestive,
b) intermenstrual,
chronic pain,
c) dyspareunia
Concomitant
Medications
(Grade B;
Level 4)
a) Anticoagulants,
b) Tamoxifen
c) Hormonal
contraceptives
d) Anti depressants
and anti psycotics
e) Corticosteroids
History suggestive of bleeding
diathesis, PCOS or thyroid disorder
1) Laboratory
testing
2) Imaging
3) Specialized
tests
4) Endometrial
histopathology
Assess pallor, weight, features
suggestive of PCOS, thyroid
disorders
Abdominal
examination
Palpable
uterus
Per speculum
examination
cervical
lesions,
discharge
Per vaginum
examination
uterine size,
contour,
consistency,
tenderness,
adnexal mass
or tenderness
The Federation of Obstetric and Gynecological Societies of India. Good clinical practice
recommendations for AUB. Available at http://www.fogsi.org/wp-content/uploads/2016/02/gcpr-on-
aub.pdf Last accessed at 24 February, 2016 L.IN.MA.WH.02.2016.0746

Recommendations: History /
Examination
Criteria - Positive screen for coagulopathies :
 H/o heavy bleeding starting at menarche
 One of following:
 At least two of following:
Examination: Weight, BMI, pallor, thyroid, breasts, acne,
FG scoring (if hirsutism),
P/A, P/S, P/V examination (Grade A; Level 4)
PPH
Bld with dental work
Surgery-related bld
Bruising : ≥ 1 episode / mth
Epistaxis: ≥ 1 episode / mth
Frequent gum bleeding
F/H bleeding symptoms
(Grade B; Level 4)

Recommendations: Lab testing
CBC: Hb, platelets
UPT if s/o pregnancy
Bleeding time
Platelet count
Prothrombin time
Partial thromboplastin time
TSH test : when clinically indicated
Coagulopathy screen +
Adolescents
Hematologist Cx &
Further testing :
Von Willebrand antigen
vWB- Ristocetin cofactor
activity
Factor VIII activity

Imaging
Ultrasound
Imaging - Mandatory
Magnetic Resonance
Imaging - Optional
Hysteroscopy
Doppler
sonography
Suspected AV malformation,
malignancy cases and to
differentiate between fibroid
and adenomyomas (Grade B;
Level 3)
3D USG For evaluating intra
myometrial lesion in selected
patients for fibroid mapping
(Grade B; Level 4)
SIS If intracavitary lesion is
suspected and hysteroscopy
is not available (Grade A;
Level 1)
USG should be done in AUB to evaluate uterus,
adnexa and endometrial thickness (Grade A; Level 1)
a) Map exact location of
fibroids before planning
conservative surgery and
prior to therapeutic
embolization for fibroids
b) To differentiate
between fibroids and
adenomyomas
a) Direct visualization
of intracavitary lesion
(Grade A; Level 1)
b) Facilitates directed
biopsy
The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB. Available at
http://www.fogsi.org/wp-content/uploads/2016/02/gcpr-on-aub.pdf Last accessed at 24 February, 2016
Not indicated
for ALL AUB

GCPR- Endometrial Assessment and Biopsy
recommended in all
women with AUB
Older than 40
years of age
(Grade A; Level 2)
Less than 40 years
who are at risk of
endometrial cancer
(Grade A; Level 2)
Risk factors of endometrial cancer
• Irregular bleeding
• Obesity associated with hypertension
• Endometrial thickness > 12 mm
• Polycystic Ovarian syndrome (PCOS)
• Diabetes Mellitus
• History of malignancy of ovary/breast/
endometrium/colon
• Use of Tamoxifen for HRT or breast cancer
• AUB-unresponsive to medical management
• HNPCC syndrome (hereditary nonpolyposis
colorectal cancer or Lynch Syndrome)
Endometrial assessment (EA)
Endometrial histopathology Dilatation and curettage Hysteroscopy
Performed if
endometrium is
thick on imaging
but HPE is
inadequate, to
rule out polyps
(Grade A; Level 2)
Not be a procedure of choice
for EA (Grade A; Level 3)
Endometrial aspiration should be the
preferred procedure for obtaining
endometrial sample for histopathology.
The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB.
Available at http://www.fogsi.org/wp-content/uploads/2016/02/gcpr-on-aub.pdf Last accessed at 24 February, 2016

Algorithm for the Diagnosis of AUB
The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB. Available at http://www.fogsi.org/wp-content/uploads/2016/02/gcpr-on-aub.pdf Last accessed at
24 February, 2016

Evidence-based Approach for
Management of abnormal uterine
bleeding in Indian women of
reproductive period
“An Indian Perspective”

Agenda • Management Algorithms for PALM COEIN causes of
AUB
• Current treatment options for AUB
a) Management of AUB-PALM
 Clinical evidences
 India specific clinical recommendations-treatment
algorithms
b) Management of AUB-COEIN
Clinical evidences
 India specific clinical recommendations-treatment
algorithms
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Management Algorithms for
Patients with AUB
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Treatment Options
Medical
Non-
hormonal
Non-
steroidal
Surgical
Certain
clinical
situations
Hormonal
Depends on
• Clinical condition,
• Overall acuity
• Suspected aetiology,
• Desire for future fertility and
• Underlying medical problem
Preferred
Depends on
• Clinical stability,
• Severity of bleeding,
• Contraindications/ lack of
response to medication,
• Desire for future fertility
1. ACOG: Obstet Gynecol. 2013;121(4):891-6.

Current Treatment Options
• Pharmacological
– Levonorgesterol -
Intrauterine System
(LNG-IUS)
– Antifibrinolytics
– NSAIDS
– GnRH analogues
– Oral contraceptives
– Cyclic progestins
 Surgical
 Endometrial ablation (EMA)
 Considered appropriate only for patients
who have completed their family.
 It is also not suitable for women with a
large uterus
 Hysterectomy
 Remains the definitive treatment for
HMB
 Should not be used as first-line
treatment in cases with primary HMB
unless all other treatments are
contraindicated or refused by the
patient.
 Uterine fibroid embolization
 New and still experimental

Patients with AUB-PALM
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Treatment Algorithm: AUB-P
In women with AUB
diagnosed with
Single endometrial
polyp
Multiple endometrial polyps and
women is not desirous of
continued fertility
Suggested to perform
hysteroscopic
polypectomy for younger
women.(Grade A; Level 1)
Suggested to perform
hysteroscopic polypectomy
(Grade A; Level 1)
LNG IUS insertion (Grade A;
Level 1)
Histopathology examination
If benign
lesion on
HPE
If HPE suggest
malignancy
Further management
should as AUB-M.
The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB. Available

Recommendations for AUB-A
For managing AUB-A: Individualize
Age
Symptoms (AUB, pain and infertility)
Associated leiomyomas, polyps,
endometriosis
Fertility desire

Treatment Algorithm: AUB-A
LNG IUS is
recommended
as 1st line
therapy (Grade
A; Level 1)
In women with AUB due to
Adenomyosis
Women desirous of fertility
Unwilling for
immediate
conception
Resistant or
unwilling to use
LNG IUS
Gonadotropin releasing
hormone (GnRH) agonists
with add back therapy is
recommended as 2ndline
therapy (Grade A; Level 1)
GnRH agonists cannot be
indicated for symptomatic relief
Combined oral contraceptives,
Danazol, NSAIDS and progestogens
are recommended (Grade B; Level 4)
Women not desirous of fertility
Vaginal or laparoscopic
hysterectomy / Trans-
cervical resection of
endometrium is
recommended (Grade A;
Level 3)
long-term GnRH agonists and add-
back therapy can be initiated/ LNG
USG
Medical management
Failure or refusal for medical
management
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The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB. Available at http://www.fogsi.org/wp-content/uploads/2016/02/gcpr-on-aub.pdf Last accessed at
24 February, 2016
Adenomyomectomy  conservative surgery that may be offered in selected cases
presenting with infertility or with strong desire to retain uterus. (Grade B; Level 2).

Leiomyoma sub-classification

Recommendations: AUB-L
 Individualized : Age, parity, symptoms, fertility desire
 Type 0-1
 Hysteroscopic myomectomy (<4 cm)
 Abdominal myomectomy (>4 cm) (Grade B; Level 4)
 First generation ablation (TCRE / REA)- in selected cases
undergoing hysteroscopic myomectomy in pts not desiring
pregnancy

<4 cm
diameter
Hysteroscopic
myomectomy
(Grade B;
Level 4)
Leiomyoma
Sub-mucosal
(Type 0-1)
Depending
on size
Women desirous of
preserving
fertility/uterus
If treatment fails, or if
myoma is causing infertility
Tranexamic acid or COCs
or NSAIDS – 2nd line
(Grade A; Level 1)
Women >40 years and
not desirous of fertility
Hysterectomy is
definitive
treatment or
medical
management / LNG-
IUS before resorting
to Sx
(Grade B; Level 3)
Treatment Algorithm: AUB-L
Site
Intramural/Sub-serous
(symptomatic)
(type II-VI)
>4 cm
diameter
Abdominal
myomectomy
(Grade B;
Level 4)
LNG-IUS
(Grade A; Level 1)
Abdominal (open or laparoscopic)/ Hysteroscopic
myomectomy is recommended (Grade A; Level 3)
The Federation of Obstetricand Gynecological
Societies of India. Good clinicalpractice
recommendations for AUB. Availableat
http://www.fogsi.org/wp-
content/uploads/2016/02/gcpr-on-aub.pdf Last
accessed at 24 February, 2016
Immediate
conception desired
and LNG IUS failure
Conception
not desired for
at least 1 year

Treatment Algorithm: AUB-L contd.
Leiomyoma – not desirous of
fertility
Improving
general
condition,
anaemia
Long term managementShort term management (up to 6 months):
In all AUB-L (III-VI)
except (AUB-L type 0 &
1) and selected cases of
AUB –(LII)
LNG-IUS is
recommended
(Grade A; Level 1)
In selected
patients
prior to
myomectomy
In selected
perimenopausal
women so that
they can tide over
menopause
GnRH agonists with add back
therapy is recommended
(Grade A; Level 1)
In younger
patients to
delay/avoid
early surgical
intervention

Newer promising options :
PRMs: Ulipristal acetate (5 mg/D) (Grade A; Level 1)
Mifepristone (5-10 mg/D), low doses
N/A (Grade A; Level 1)
 Endometrial ablation:
- HMB with small uterine fibroids (< 3 cm), uterus <10
wks
- 2nd gen. ablation techniques should be used (TBEA,
MEA)
Recommendations: AUB-L

Revised classification of
Endometrial hyperplasia WHO 2014
New Term Coexistent Invasive
Endometrial Cancer
Progression To
Invasive
Cancer
Hyperplasia without
Atypia
<1% RR:1.01-1.03
Atypical
Hyperplasia
25-33% RR:14-45

Standard protocol for
management of malignancy to
be followed (Grade B; Level 4)
Endometrial hyperplasia
(AUB-M)
AUB-M
If LNG IUS is contraindicated or
patient unwilling to use LNG IUS
Hysterectomy-
definitive
treatment
(Grade B; Level 2)
Hyperplasia without
atypia
LNG IUS is recommended
as 1st line therapy
(Grade A; Level 1)
Treatment Algorithmfor AUB-M
Endometrial
malignancy
Oral Progesterones
can be used(Grade A;
Level 1)
Atypical endometrial
hyperplasia
Conservative treatment with high-dose
progestins and close histological
monitoring should only be considered in
exceptional cases
Preventive hysterectomy should
only be considered in
exceptional cases (e.g., extreme
obesity without any prospect of
weight loss).

Recommendations for AUB-M
Endometrial Hyperplasia with Atypia
• EA to be repeated 6 monthly for close monitoring
• Endometrial ablation not recommended-
complete destruction not ensured, histological
follow up difficult

Management of AUB-PALM
Key recommendations for Treatment of AUB-PALM
AUB-P  Single Polyps: Hysteroscopic polypectomy
 Multiple Polyps: Hysteroscopic polypectomy followed by LNG IUS placement
if benign lesion on HPE.
AUB-A  Women desirous of fertility: and immediate conception not desired: LNG
IUS 1st line of treatment
 Women not desirous of fertility: Long term GnRH agonists with add back
therapy
AUB-L  Submucosal: Hysteroscopic/abdominal resection depending on size
 Intramural/subserosal: Immediate conception not desired LNG IUS 1st line
of treatment and immediate conception desired Tranexmic acid
 Women >40 years and fertility not desired: Hysterectomy
 Women >40 years and fertility desired
a) Long term management of AUB-L(III-VI) LNG IUS 1st line of treatment
b) Short term management GnRH agonists with add back therapy
AUB-M Atypical Hyperplasia fertility not desired: hysterectomy
Hyperplasia without atypia LNG IUS is 1st line of treatment. If contraindicated
then progesterone receptor modulators

Patients with AUB-COEIN
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After consultation with haematologists
Tranexamic acid 1g
QID (Grade A; Level 2)
coagulopathy (AUB-C)
Hormonal treatment-
secondary option
COCs/LNG IUS is
recommended (Grade A;
Level 2)
Treatment Algorithm: AUB-C
Following considerations have to be taken care of:
• In refractory cases von-willebrand disease with uncontrolled uterine bleeding with above
medical management, specific factor replacement where possible or desmopressin to be given
in consultation with haematologist.
• When surgical interventions are indicated, for appropriate pre-, intra- and post-operative
management of bleeding – Factor replacement /desmopressin
Non hormonal treatment-
primary options
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The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB. Available at http://www.fogsi.org/wp-
content/uploads/2016/02/gcpr-on-aub.pdf Last accessed at 24 February, 2016

Treatment Guidelines: AUB-O
• In women not desiring conception presently, COCs can be
used as first-line therapy for 6-12 months (Grade A; Level
1).
• Cyclic luteal-phase progestins (for 10-14 days) can not be used
as a specific treatment in women with AUB-O (Grade A; Level 1)
• Norethisterone cyclically (for 21 days) is given as initial
therapy in acute episodes of bleeding for short-term
management of 3 months (Grade B; Level 4).

Treatment Guidelines: AUB-O
• It is suggested to assess response after 1 year of medical
management and judge to continue/discontinue existing
therapy (Grade B; Level 4).
• Surgical intervention is not recommended unless, there is
evidence of persistent AUB or failure of medical
management to alleviate the condition (Grade A; Level 4).
• If COCs are contraindicated or patient is unwilling for COCs,
LNG-IUS is recommended if she wishes to use it for at least 1
year (Grade A; Level 1).
• In adolescents with AUB-O, both hormonal and non-
hormonal therapies can be prescribed. (Grade A; Level 4).

Endometrial (AUB-E)
1. Management of AUB-E can be similar to the management
of AUB-O (Grade A; Level 4).
AUB that occurs due to a primary disorder of the
endometrium and secondary to endometrial
inflammation or infection, abnormalities in the local
inflammatory response or endometrial vasculogenesis, in
the context of predictable and cyclic menstrual bleeding
with no other definable causes

Iatrogenic (AUB-I), Definition
and recommendations
• Patients with unscheduled endometrial bleeding due to:
– Using gonadal steroid (eg, estrogens, progestogens, androgens) or
– gonadal steroid-related therapy (eg, GnRH agonists, aromatase
inhibitors, selective estrogen receptor modulators, or progesterone
receptor modulators, heparins and anti-coagulants)
Treatment Algorithm: AUB-I
• Whenever feasible, medications causing AUB should be changed to other
alternatives, if no alternatives are available
• LNG-IUS is recommended for treatment (Grade A; Level 1).
The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB. Available

In women with AUB (not
yet defined-N)
Medical management
If fails or
contraindicated
If LNG IUS is
contraindicated
Women desires contraception
For AUB that is mainly cyclic or
has predictable
Treatment Algorithm: AUB-N
LNG IUS is
recommended as
1st line therapy
(Grade A; Level 1)
COCs are
recommended as 2nd
line therapy
(Grade A; Level 1)
GnRH agonists
along with add-
back hormone
therapy are
recommended
(Grade B; Level 4).
Surgical treatment
(such as ablation) – if
fails or is
contraindicated
Non hormonal options such NSAIDS and
Tranexamic acid are recommended
(Grade A; Level 1)
1) Uterine Artery
embolization is
recommended.
2) Hysterectomy is the
last resort (Grade
B; Level 4).
In women with AUB
(not yet defined-N)-
AV Malformation

Management of AUB-COEIN
Key recommendations for Treatment of AUB-COEIN
AUB-C  Nor-hormonal is primary treatment: Tranexmic acid
 Hormonal treatment: secondary treatment LNG IUS/COCs
AUB-O  Women not desirous of fertility: COCs for 1st 6 months. If COCs are
contraindicated then LNG IUS is preferred as 1st line treatment
 Surgical treatment not a choice of treatment unless failure of medical
management.
AUB-E  Similar to AUB-O
AUB-I  LNG IUS is preferred choice of treatment
AUB-N  Women not desirous of contraception: LNG IUS is 1st line of treatment
 If medical and surgical treatment fails: or is contraindicated :GnRH
agonists are preferred

Endometrial Ablation in AUB
Benign lesions (All except AUB-M)
As primary Tt if intolerant/ no response to
medical Tt
Medical Tt fails, & poor surgical candidates for
hysterectomy
Pt preference
(Grade A, Level 1)
SOGC Clinical practice Guidelines 2015Initial cost of ablation- significantly lower than hysterectomy
Since re-treatment is often necessary, the cost difference
narrows over time
Cochrane 2010

Uterine artery embolization
Indications
 AV Malformations (Grade A, Level 1)
 Symptomatic fibroid with significant symptoms
 No desire for fertility but want to preserve uterus
 Poor surgical risks
 Severely anemic & require immediate intervention
RESULTS
 Symptomatic improvement : 84% at 6 mths
 83% at 24 mths
 Reduction in fibroid volume: 40–70%
 Reintervention:15-28%(Hysterectomy, Myomectomy, Rpt. UAE)
NICE GUIDELINES for UAE, 2010
(Grade A, Level 1)

MRI- Guided High intensity Focused
Ultrasound (HIFU)
Mechanism:
 High intensity USG waves → specific target point
→ temp rise (55-90oC) → Coagulative Necrosis
 Concurrent MRI - Accurate tissue mapping &
- Real time temperature feedback
Adv:
 Noninvasive
 OPD based Tt
 No radiation
Kim YS, Am J Roentgenol, 2014

Ultrasound (HIFU)..
Limitations
 Too large (upto 10 cm), too deep and multiple myoma
 Presence of scar tissue, bowel loops in sonication path
 Excessive thick subcutaneous layer of ant abd wall
 Vascular myoma
 Inability to withstand stationary position
 Not recommended for women wishing to preserve fertility
 Cost
Kim YS, Am J Roentgenol, 2014
Response: 71% at 6 mth, 51% at 12 months (Zhao WP, Eur Radiol, 2014)
Re intervention > 12 months: 35% (Stewart, Fertil Steril, 2006)

Ultrasound (HIFU)..
FDA approved in 2004
NICE 2011 : Use only in research and audit
settings
Ongoing FIRSTT trial comparing UAE v/s
HIFU
(Ending in Aug 2016)

Summary-Clinical recommendations
Key recommendations for Diagnosis of AUB
1) For proper Evaluation
a) Thorough history of bleeding patter, pain and concomitant
medication
b) Preliminary assessment- Abdomen, vaginal and cervical
examinations for any structural distortions
c) Investigations
 Laboratory testing: for coagulopathies, pregnancy and thyroid
disorder
 Imaging: TVUS for endometrial thickness, doppler USG for
AVM, 3D USG for myometrial lesions and SIS for intracavitary
lesions
 MRI: to map exact location of fibroids and differentiate
between fibroids and adenomyomas.
 Hysteroscopy: diagnosis of uterine abnormalities.
2) Endometrial Assessment and Biopsy
 Endometrial histopathology: performed in all women >40
years and <40 years at risk of endometrial carcinoma.
Endometrial aspiration is preferred method for EA.
 Hysteroscopy: performed if endometrium is thick but
inadequate to rule out polyps.
Key recommendations for
Management of AUB
1) LNG IUS is recommended as 1st
line of treatment for:
a) AUB due to multiple polyps after
hysteroscopic polypectomy if benign
lesion on HPE
b) AUB-A women desirous of fertility
but not immediate conception
c) Intramural/subserosal leiomyoma
d) Type III-VI leiomyoma in peri-
menopausal women
e) Hyperplasia without atypia
f) In women with ovulatory
dysfunction and COCs are
contraindicated
g) AUB due to iatrogenic causes
h) AUB-N, when women are not
desirous of fertility.
The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB. Available at http://www.fogsi.org/wp-
content/uploads/2016/02/gcpr-on-aub.pdf Last accessed at 24 February, 2016

Take home message
 AUB is a common problem from menarche to
menopause
 PALM-COIEN system- simplified the clinical
classification and provided an organized approach for
diagnosis and evaluation of AUB.
 Individualized / Cafeteria approach
 Newer drugs are promising but need to be evaluated
carefully
 Evidence based management can avoid number of
unnecessary hysterectomies

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Insight AUB Management Guidelines on AUB in Reproductive Period

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