abnormal uterine bleeding

2. ABNORMAL
UTERINE
BLEEDING
‫کوونکی‬ ‫ترتیب‬:‫منلـــــــــــــــــــــــــی‬ ‫زبـــــیــــر‬ ‫محمد‬
‫الر‬‫استادان‬ ‫ښود‬:‫او‬ ‫سهاک‬ ‫حفیظه‬ ‫دوکتورس‬ ‫پوهندوی‬
‫احمدی‬ ‫وحیــــــده‬ ‫دوکتورس‬ ‫پوهیالـــــــــــــــــــــــي‬
‫ترتیـــــــب‬‫کوونکی‬:‫محمدزبیرمنلـــــــــــــــــــــــــی‬
‫الرښود‬‫استادان‬:‫پوهندوی‬‫دوکتورس‬‫حفیظه‬‫سهاک‬
‫او‬‫پوهیالۍ‬‫دوکتورس‬‫وحیده‬‫احمــــــــــــــــــــــــــدی‬
Nangarhar Medical University

3. Defined as any abnormalities of
cycle length, duration of flow, and
amount of menstrual bleeding.
•It can occur in women of all age
•Common especially in both extreme of
age
ABNORMAL UTERINE
BLEEDING (AUB)

4. Menstrual Period Characteristics
Normal Abnormal
Duration 4-6 days <2d, >7d
Volume 30-35cc >80cc
Cycle length 21-35d <21d, >35d
Average Iron loss: 16mg

5. INCIDENCE
 AUB affects 10-30 % of reproductive-aged women and up to 50 %
of perimenopausal women .
 Factors that impact the incidence most greatly are age and
reproductive status.
 For example, uterine bleeding is uncommon in prepubertal girls
and menopausal women, whereas rates of abnormal bleeding
increase significantly in adolescent, perimenopausal, &
reproductive-age groups

6. Causes of this bleeding may include
1. neoplastic growth,
2. hormonal dysfunction,
3. reproductive-tract trauma,
4. infection,
5. coagulopathies, and
6. complications of pregnancy.
7. * As a result, abnormal uterine bleeding is a common
gynecologic complaint that may affect females of all ages

7. Classification of AUB
1. Functional uterine bleeding (organic origin)
A. Associated with pregnancy
B. Not Associated with pregnancy
2. Dysfunctional uterine bleeding (non-organic origin)
A. Anovulatory (90% DUB)
B. Ovulatory (10% DUB)

8. Pattern of AUB
:Menorrhagia.1
‫دور‬ ‫یو‬ ‫د‬‫یی‬‫خونریزی‬ ‫میاشتنی‬‫د‬ ‫مقدار‬ ‫وینی‬ ‫د‬ ‫چی‬ ‫دی‬ ‫عبارت‬ ‫څخه‬۸۰‫او‬ ‫زیات‬ ‫څخه‬ ‫لیتره‬ ‫ملی‬
‫له‬ ‫یی‬ ‫دوام‬۸‫ور‬‫وی‬ ‫زیات‬ ‫څخه‬ ‫ځو‬
causes
 complication of pregnancy
 submucous myoma
 Adenomyosis
 IUDs
 endometrial hyperplasia & malignancy
 dysfunctional uterine bleeding

9. Cont…
: metrorrhagia.2
‫کیږی‬ ‫واقع‬ ‫ترمنځ‬ ‫سایکلونو‬ ‫ددو‬ ‫چی‬ ‫دی‬ ‫عبارت‬ ‫څخه‬ ‫خونریزی‬ ‫نورمال‬ ‫غیر‬ ‫یوه‬
causes
 endometrial polyps
 endometrial & cervical ca
 IUDs
breakthrough bleeding (BTB) Unscheduled endometrial bleeding
that occurs during the use of contraception
Withdrawal bleeding – refers to the predictable bleeding that often
results from abrupt progestin cessation (hormonal contraceptives)

10. Contd…
Menometrorrhagia.3
‫زیاته‬ ‫هم‬ ‫یی‬ ‫اندازه‬ ‫او‬ ‫کیږی‬ ‫واقع‬ ‫ترمنځ‬ ‫سایکلونو‬ ‫دوه‬ ‫د‬ ‫چی‬ ‫دی‬ ‫عبارت‬ ‫څخه‬ ‫خونریزی‬ ‫نورمال‬ ‫غیر‬
‫وی‬
causes
 malignant tumor
 complication of pregnancy
‫دی‬ ‫عبارت‬ ‫څخه‬ ‫بهیدنی‬ ‫وینی‬ ‫متقطع‬ ‫غیر‬ ‫ددوامداره‬ : Metrotaxis.4

11. Continue..
:polymenorhea.5
‫د‬ ‫سایکل‬ ‫کی‬ ‫حالت‬ ‫پدی‬۲۱‫تکراریږی‬ ‫کی‬ ‫فاصلو‬ ‫کمو‬ ‫په‬ ‫څخه‬ ‫ورځو‬
‫اسباب‬:
Shortened luteal phase
An ovulation

12. Contd…
: Oligomenorrhea .6
‫د‬ ‫سایکل‬ ‫میاشتنی‬ ‫چی‬ ‫دی‬ ‫عبارت‬ ‫څخه‬ ‫خونریزی‬ ‫نورماله‬ ‫غیر‬ ‫هغه‬۳۵‫کی‬ ‫ورځو‬ ‫زیاتو‬ ‫په‬ ‫څخه‬ ‫ورځو‬
‫تکراریږی‬
causes
 endocrine cause
 systemic cause

13. Continue..
cervical eversion
polyps, ca
cervical/vaginal infection
atrophic vaginitis
: contact/post-coital bleeding.7
‫کیږی‬ ‫پیدا‬ ‫کبله‬ ‫له‬ ‫تماس‬ ‫د‬ ‫چی‬ ‫ده‬ ‫خونریزی‬ ‫نورماله‬ ‫غیر‬ ‫هغه‬

14. Continue…
(concealed bleeding)Hypo menorrhea.8
:(cryptomorrhea(
‫وی‬ ‫نورمال‬ ‫اوږدوالی‬ ‫سایکل‬ ‫د‬ ‫خو‬ ‫وی‬ ‫کم‬ ‫ډیر‬ ‫مقدار‬ ‫وینی‬ ‫د‬ ‫کی‬ ‫حالت‬ ‫دی‬ ‫په‬
 Cervical obstruction
 Hymen obstruction( imperforated hymen)
 uterine synechia or Asher man's syndrome
:Amenorhea.9
‫نشتوالی‬ menses ‫د‬۶‫لپاره‬ ‫میاشتو‬ ‫شپږو‬‫د‬

15. Causes of AUB
The cause or DDx of AUB can be classified as
• Pregnancy related
• Infection
• Neoplasm
• Uterine condition
• Systemic illness
• Iatrogenic causes
• DUB

16. Organic causes of AUB
1. Pregnancy related causes
– Abortion
– Ectopic pregnancy
– GTD
2. Genital tract infection
– cervicites
– Vaginitis
– Endometritis

17. Cont...
3. Neoplasm
– cervical neoplasia, polyps, ca
– Endometrial hyperplasia, polyps, ca
– Leiomyoma (submucous, intra mural)
– Ovarian (estrogen producing tumor)
4. Systemic coagulation disorder
– Thyroid
– Liver
– sepsis

18. Cont...
5. Iatrogenic
– COC
– HRT
– Anti coagulation
– Steroid
– Tamoxifen

19. Causes of AUB by specific
category of AGE
A. Pre pubertal ( CHILDHOOD)
 Vulvo-vaginal & external lesion Eg...trauma
 Foreign body in vagina
 Precocious puberty
 Trauma ..... sexual abuse

20. ADOLECENCE
B. Adolescence
– Anovulation
– Pregnancy related causes
– Exogenous hormone use
– Coagulopathy
– other,...cervicitis, PID

21. Cont...
C. Reproductive age
 pregnancy related causes
 Anovulation
 Exogenous hormones
 Myomma
 Cervical and endometrial polyp

22. D. Perimenopause
– Anovulation
– Myoma
– Cervical & endometrial polyp
– Thyroid dysfunction

23. POST MENOPAUSAL
BLEEDING
– Def :- any vaginal bleeding 6 or more month after menopause
 Etiology
– Atrophic endometritis or vaginitis..... common cause
– Exogenous estrogen (HRT)
– Endometrial or cervical polyp
– Endometrial hyperplasia
– Endometrial cancer
– Cervical ca, uterine sarcoma

24. CONT..
– Bleeding after menopause typically originate from benign disease.
– majority of cases resulted from atrophy of the endometrium.
– Benign endometrial polyps may also cause bleeding in this pop/n.
– malignant neoplasms, especially endometrial carcinoma, are
found more frequently in this age group than in others.

25. Excessive weight gain
• Look for signs of PCOS: Hirsutism & acne
• Sign of thyroid disease & evidence of insulin resistance
In suspected bleeding disorder
• Look for petechiae, ecchymosis, skin pallor or swollen joints
• In a suspected case of thrombocytopenic purpura, tourniquet test is performed
Pelvic Examination
• Bimanual examination including speculum examination to assess the size and
contour of the uterus
PHYSICAL EXAMINATION

26. LAB EVALUATION
A complete blood count (CBC) is recommended for women with AUB to
look for anemia
It is recommended to perform a sensitive urine pregnancy test whenever
indicated, or if pregnancy is suspected.
Bleeding time, platelet count, prothrombin time, and partial thromboplastin
time are recommended in all adolescents and in adults with a positive
screen for coagulopathies.
TSH test is done when clinically indicated

27. LAB EVALUATION
Imaging Recommendations on imaging
 Ultrasonography is mandatory in AUB to evaluate uterus, adnexa and
endometrial thickness
 Doppler ultrasonography: In suspected arteriovenous malformation,
malignancy cases and to differentiate between fibroid and adenomyomas
 Hysteroscopy: For diagnosis and characterization of intrauterine
abnormalities
 MRI: To differentiate between fibroids and adenomyomas and for mapping
exact location of fibroids while planning conservative surgery and prior to
therapeutic embolization for fibroids
 Endometrial Biopsy – to rule out endometrial hyperplasia or endometrial
cancer
 Suggested for women > 40 years old who have the risk factors such as
obesity & diabetes.

28. Treatment
1.Medical treatment of AUB
1. Control of heavy bleeding
A. High dose estrogens
B. High dose coc pills
– Hemodynamic instability
 Establish ABC
 Open iv line
 Prepare cross mach blood

29. 2. prevent recurrence
a) Anovulatory DUB
 progestrone treatment
 coc pills
b) Ovulatory DUB
 NSAID+Coc
– Surgical treatment
1.D&C 2.Endometrial ablation 3.hysterescopy

30. References
1.American College of Obstetricians
and Gynaecologists (ACOG)
2.Ten Teachers 19th Edition
3.Federation of Obstetric and
Gynaecological Societies of India
(FOGSI)