This document discusses abnormal uterine bleeding and provides information on evaluating and managing different types. It begins with definitions of normal menstruation and then defines abnormal uterine bleeding and classifications. The causes of abnormal uterine bleeding are covered across a woman's lifespan from neonatal to menopausal periods. Dysfunctional uterine bleeding is explored in more depth as a common cause. The document outlines evaluation and workup that should be performed for a patient presenting with abnormal uterine bleeding.
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Abnormal Uterine Bleeding -Update
1. Abnormal Uterine Bleeding in
Reproductive Age
“Evidence Based Management “
Dr Hassan A Nasrat FRCS, FRCOG
Professor of Obstetrics and Gynecology
Faculty of Medicine
King Abdelaziz University
1Tuesday, June 18, 13
2. The Jeddah Ultrasound Club For
Obstetrics and Gynecology
“JUCOG”
On “LinkedIn”
2Tuesday, June 18, 13
3. Vision:
Ultrasound skill is the backbone of safe and professional
practice of Obstetrics and Gynecology. But proper utilization
and understanding of its application must be well
appreciated.Aminimumstandardof skillisamustforevery
ObstetricianandGynecologist.
Mission:
To disseminate knowledge and promote interest in the
proper use and application of sonography in Obstetrics and
Gynecology.
“JUCOG”
3Tuesday, June 18, 13
4. The Normal Menstruation ....
Abnormal Uterine Bleeding
“AUB” Types and Terminology.
Causes of AUB
Work up in AUB
Management of AUB-o
4Tuesday, June 18, 13
5. NORMAL MENSTRUAL
CYCLE
D1 D28:D1
Normal Regularity
Normal Frequency
Normal Volume
Normal Duration
Normal Menstrual Cycle and Menstruation
MBL/Ml
Total MBL=37
Total MBL=41
5Tuesday, June 18, 13
6. NORMAL MENSTRUAL
CYCLE
D1 D28:D1
Normal Regularity
Normal Frequency
Normal Volume
Normal Duration
Normal Menstrual Cycle and Menstruation
MBL/Ml
Total MBL=37
Total MBL=41
Regular
5Tuesday, June 18, 13
7. NORMAL MENSTRUAL
CYCLE
D1 D28:D1
Normal Regularity
Normal Frequency
Normal Volume
Normal Duration
Normal Menstrual Cycle and Menstruation
MBL/Ml
Total MBL=37
Total MBL=41
Frequency
28 days
(24-35 days)
Regular
5Tuesday, June 18, 13
8. NORMAL MENSTRUAL
CYCLE
D1 D28:D1
Normal Regularity
Normal Frequency
Normal Volume
Normal Duration
Normal Menstrual Cycle and Menstruation
MBL/Ml
Total MBL=37
Total MBL=41
Volume
30-40 mL.
(Range 10-80 mL)
Frequency
28 days
(24-35 days)
Regular
5Tuesday, June 18, 13
9. NORMAL MENSTRUAL
CYCLE
D1 D28:D1
Normal Regularity
Normal Frequency
Normal Volume
Normal Duration
Normal Menstrual Cycle and Menstruation
MBL/Ml
Total MBL=37
Total MBL=41
Volume
30-40 mL.
(Range 10-80 mL)
Frequency
28 days
(24-35 days)
Duration
(5-7 days)
Regular
5Tuesday, June 18, 13
11. Cycle variability 5-7
years after menarche
Little Variability
between 20 and 40
years of age
cycle variability for the
10 years before
Menopause
50 % anovulatory.
Mean Length 34 days,
38 % exceed 40 days
7 percent occurring < 20 days
WHO Report
Normal Cycle Variablity
7Tuesday, June 18, 13
12. Establishment of regular ovulatory cycles and age of
menarche
WHO Report
Cycle Regularity
<12 years
Age at Menarche
12- 13years
>13 years
50% by
oneyear
Ovulatory Cycles
50% by
3 years
50% by
4.5 years
8Tuesday, June 18, 13
13. 25 % Of Women With
Normal Periods Considered
Their Blood Loss Excessive.
40 % With Excessive
B l e e d i n g ( > 8 0 M L )
Described Their Periods As
Light Or Moderate.
Estimation of MB Loss
9Tuesday, June 18, 13
15. For Women: 1/3 Of Outpatient Visits To The
Gynecologist.
For Gynecologists: > 70% Of All Gynecologic
Consults.
Abnormal Uterein Bleeding
“AUB”
Epidemiology
11Tuesday, June 18, 13
16. APGO educational series on women's health issues. Clinical management of abnormal uterine bleeding. Association of Professors of Gynecology
and Obstetrics, 2006.
What Is Abnormal Uterein
Bleeding “AUB”?
12Tuesday, June 18, 13
17. APGO educational series on women's health issues. Clinical management of abnormal uterine bleeding. Association of Professors of Gynecology
and Obstetrics, 2006.
What Is Abnormal Uterein
Bleeding “AUB”?
Abnormal Uterine Bleeding Can Occur When A
Woman Experiences:
A Change In Her Menstrual Loss
Or
Develop Vaginal Bleeding Pattern (Regularity,
Frequency, Volume, Duration) Differs From
That Experienced By The Age- Matched General
Female Population.
12Tuesday, June 18, 13
18. Disturbances of
Regularity
Infrequent Menstrual
Bleeding
One or two episodes in a 90
days period.
Frequent menstrual
bleeding
> 4 episodes in a 90 days
(including erratic
intermenstrual bleeding)
Oligomenorrhea Polymenorrhea
13Tuesday, June 18, 13
20. Irregular Non-
Menstrual Bleeding
•Premenstrual and postmenstrual spotting (or staining):
•Intermenstrual bleeding:
Normal Regularity
Normal Frequency
Normal Volume
Normal Duration
Inter-menstrual bleeding
D1 D28:D1
Total MBL=39 ml
Total MBL=8 ml
Total MBL=6 ml
Total MBL=39 ml
Total MBL=7 ml
Metrorrhagia
14Tuesday, June 18, 13
21. Irregular Non-
Menstrual Bleeding
•Premenstrual and postmenstrual spotting (or staining):
•Intermenstrual bleeding:
Normal Regularity
Normal Frequency
Normal Volume
Normal Duration
Inter-menstrual bleeding
D1 D28:D1
Total MBL=39 ml
Total MBL=8 ml
Total MBL=6 ml
Total MBL=39 ml
Total MBL=7 ml
14Tuesday, June 18, 13
22. Disturbances of Heaviness of
Flow
Heavy Menstrual
Bleeding (HMB)
HOMB is less common and may have different etiologies and
therapeutic modalities than HMB
Heavy and Prolonged
Menstrual Bleeding
(HPMB)
Light
R a r e l y
pathological,
usually a cultural
complaint I
Heavy
Heavy, Regular ± Prolonged Normal Regularity
Normal Frequency
Normal Volume
Normal DurationTotal MBL=106 ml
Total MBL=110 ml
D1 D28:D1
Menorrhagia
Menorrhagia
15Tuesday, June 18, 13
23. Disturbances of Heaviness of
Flow
Heavy Menstrual
Bleeding (HMB)
HOMB is less common and may have different etiologies and
therapeutic modalities than HMB
Heavy and Prolonged
Menstrual Bleeding
(HPMB)
Light
R a r e l y
pathological,
usually a cultural
complaint I
Heavy
Heavy, Regular ± Prolonged Normal Regularity
Normal Frequency
Normal Volume
Normal DurationTotal MBL=106 ml
Total MBL=110 ml
D1 D28:D1
Menorrhagia
15Tuesday, June 18, 13
24. Disturbances Of Duration
Of Flow
Prolonged
Menstrual
Bleeding
Shortened
Menstrual
Bleeding
"Menstrual Periods That
Exceed 8 Days In Duration
On A Regular Basis."
"Menstrual Bleeding Of No
Longer Than 2 Days In
Duration. The Bleeding Is
Also Usually Light In
Volume And Is Uncommonly
Associated With Serious
P a t h o l o g y ( s u c h A s
Intrauterine Adhesions And
Endometrial Tuberculosis"
16Tuesday, June 18, 13
26. APGO educational series on women's health issues. Clinical management of abnormal uterine bleeding. Association of Professors
of Gynecology and Obstetrics, 2006.
Abnormal uterine bleeding (AUB)
✴Genital Tract Diseases.
✴Non-genital Tract Diseases.
✴Systemic Disorders.
✴Medications.
18Tuesday, June 18, 13
33. Dysfunction Uterine Bleeding
“Coagulopathy, Ovulatory, and
Endometiral (AUB)”
A Spectrum Of Disorders, Can Be Associated With
Amenorrhea, Heavy Menstrual Bleeding Or Irregular
Bleeding.
Ovulatory (AUB-O)
Condition of Edocrinopathy e.g.
PCO, adolescent and menopausal
transition
Endometiral Disorders
(AUD-E)
(Diagnosed After Exclusion Of
Other Abnormalities In The
Presence Of Normal Ovulatory
Function)
• E.g. Abnormal Prostaglandin Synthesis
• Receptor Upregulation,
• Increased Local Fibrinolytic Activity
• Increased Tissue Plasminogen Activator
Activity.
Coagulopathy
(AUB-C)
Occur in 13% of women
with heavy menstrual
bleeding
21Tuesday, June 18, 13
34. Anovulatroy Dysfunctional
Uterine Bleeding (DUB)
Noncyclic Endometrial Bleeding Unrelated To
Anatomical Lesions Of The Uterus Or To
Systemic Disease
22Tuesday, June 18, 13
35. Anovulatroy Dysfunctional
Uterine Bleeding (DUB)
Noncyclic Endometrial Bleeding Unrelated To
Anatomical Lesions Of The Uterus Or To
Systemic Disease
Diagnosed By
Exclusion
22Tuesday, June 18, 13
38. Failure of LH
Surge in Response
to E2 Production
Endometiral
Proliferation under
E2 Level
The CL is not
Formed and
Progesterone level
remains low
Irregular
Endometrial
Shedding
Prolonged and Heavy Bleeding
“E2 BreakthroughBleeding”
Decline in Ovarian
Follicular Function
Variable Level of
E2
Variable Degree of
Bleeding
“Light or Heavy” E2
Withdrowal bleeding”
Climacteric Adolescene
Pathophysiology Of DUB
24Tuesday, June 18, 13
39. Chronic Stimulation By
Higher Levels Of E2
Lead To Episodes Of
Heavy Bleeding
Non-cycling E2 Secretion
Endometrial Proliferation Without Periodic Shedding.
The Endometrium Outgrow Its Blood Supply.
Tissue Breaks Down With Irregular Healing.
Chronic Stimulation By
Low Levels Of E2 Result
In Infrequent Light
Bleeding
Anovualtory AUB
Clinical Presentation
25Tuesday, June 18, 13
40. Morbidity and Mortiality
“DUB”
Iron deficiency anemia: occur in 30% of cases. Adolescents are
particularly vulnerable. Up to 20% of patients in this age group presenting with
menorrhagia might have a disorder of hemostasis.
Endometrial adenocarcinoma: About 1-2% of women with
improperly managed anovulatory bleeding eventually might develop endometrial cancer.
Infertility:associated with chronic anovulation, with or without excess androgen
production.
Patients (e.g. PCO, older age, Obese..etc are
particularly at risk.
26Tuesday, June 18, 13
45. Examination
+
Initial
Investigations
Ancillary
Investigat
ions
Structural
History
Chronic AUB
•Menstrual history: Menarche,
Frequency, duration, severity, regularity
Duration of current problem
•Associated Symptoms:
•Medical History:
•Medications:
•Family history:
•Social Factors:
•Systemic Review:
social stressors, weight
change, athletic
competition, substance use.
bleeding disorders, PCO,
age of menarche in mother
and sisters .
29Tuesday, June 18, 13
46. Examination
+
Initial
Investigations
Ancillary
Investigat
ions
Structural
History
Chronic AUB
•Menstrual history: Menarche,
Frequency, duration, severity, regularity
Duration of current problem
•Associated Symptoms:
•Medical History:
•Medications:
•Family history:
•Social Factors:
•Systemic Review:
social stressors, weight
change, athletic
competition, substance use.
bleeding disorders, PCO,
age of menarche in mother
and sisters .
hirsutism, acne, visual
changes, and headaches,
bleeding from other sites,
symptoms of acute or chronic
anemia.
29Tuesday, June 18, 13
50. Examination
+
Initial
Investigations
Ancillary
Investigat
ions
Structural
History
Chronic AUB
General
Examination
Ht., Wt. And Arm Spam.
Body type and Fat distribution
Vital sings.
Thyroid examination
Sings of androgen excess.
Optic Fundi and visual fields
Tanner staging of breasts and
Galactorrhea
Acanthosis nigricans
Sing of abnormal bleeding
Abdomen for masses
Pelvic
Examination
External and
Internal including
Pap smear
Uterine Evaluation
•TV Ultrasonography
•Saline Sononhystrography (SIS)
•MRI
•Endometrial Biopsy
30Tuesday, June 18, 13
51. Risk Factor Relative Risk (RR)
Increasing age
Age 50-70 years have a 1.4%
RUDJ of endometiral cancer
Unopposed estrogen therapy 2-10
Late menopause (>55 years) 2
Nulliparity 2
PCO 3
Obesity 2-4
Diabetes mellitus 2
Lynch Syndrome (hereditary non-polyposis
colorectal cancer )
22-50 % life-time risk
Tamoxifen Therapy 2
Early menarche NA
Estrogen secreting tumor NA
Family history of endometrial, ovarian, breast
or colon cancer
NA
Smith RA,Von Eschenbach, Ender R et al American Caner Society Guideline for early endometiral cancer
Detection: 2001
31Tuesday, June 18, 13
54. TV Ultrasound Vs. SIS
SIS Is Superior To TV US In
Detection Of Intracavitary Lesions.
TV Sonography: Sensitivity 55-75% in exclusion of
uterine & endometiral pathology
34Tuesday, June 18, 13
55. The risk of endometrial hyperplasia and
carcinoma by age setting
★Persistent AUB in setting of unopposed
E2 (e.g. obesity, chronic anovulation)
★Failed medical management
★High risk of endometrial cancer (e.g.,
tamoxifen, Lynch syndrome).
When Should Endometiral Sampling be
Performed?
45yearsto
menopause
> 45 year
★First Line test
(ACOG) guidelines
0
5
10
15
20
<45 >45
19
6T h e P r i m a r y R o l e O f
Endometrial Sampling Is To
Determine Whether Carcinoma
Or Premalignant Lesions Are
Present
35Tuesday, June 18, 13
56. Cancer can be missed (If it
occupies less than 50% of the
surface area)
How Good is Endometiral Sampling?
0
22.5
45
67.5
90
Positive Negative
0.9
81.7
Post-test Probability of endometiral
cancer after
36Tuesday, June 18, 13
57. Cancer can be missed (If it
occupies less than 50% of the
surface area)
How Good is Endometiral Sampling?
0
22.5
45
67.5
90
Positive Negative
0.9
81.7
Post-test Probability of endometiral
cancer after
➡Endometrial Sampling is only an
endpoint when they reveal cancer or
atypicalcomplexhyperplasia.
➡Persistent bleeding with a previous
benign pathology, such as proliferative
endometrium, requires further testing
suchasHysteroscopy.
36Tuesday, June 18, 13
58. Hystroscopy ?
Hysteroscope
•Allows direct visualization of
e n d o m e t r i a l c a v i t y
abnormalities and the ability
to take directed biopsies.
•Hysteroscopy is highly
accurate in diagnosing
endometrial cancer but less
us eful for d etectin g
hyperplasia
37Tuesday, June 18, 13
60. Age-Based Common Differential Diagnosis
13-18 Years
•Persistent Anovulation Due To
The Immaturity Of The H-P-O
Axis
•Other Causes: OCP,
Pregnancy, Pelvic Infection,
Coagulopathies,OrTumors
(20 % Of As Many As 19% Of
Adolescents With AUB Who
Require Hospitalization May
H a v e A n U n d e r l y i n g
Coagulopathy)
19-39 Years
•Pregnancy.
•Structural Lesions (e.g.,
LeiomyomasOrPolyps.
•Anovulatory Cycles (e.g.,
PCOS).
•UseOfOCP
•Less Common: Endometrial
Hyperplasia. Endometrial
Cancer
40 Years To
Menopause
•Anovulatory Bleeding In
Response To Declining
Ovarian Function.
•Endometrial
Hyperplasia Or
Carcinoma.
•Endometrial Atrophy.
•Leiomyomas.
39Tuesday, June 18, 13
63. What Are The Goals Of Management Of DUB?
41Tuesday, June 18, 13
64. Confirm The Diagnosis Of DUB.
What Are The Goals Of Management Of DUB?
41Tuesday, June 18, 13
65. Confirm The Diagnosis Of DUB.
Prevent Short And Long Term Complications ( Acute Or
Chronic Anemia, Long-term Consequences Of
Anovulation)
What Are The Goals Of Management Of DUB?
41Tuesday, June 18, 13
66. Confirm The Diagnosis Of DUB.
Prevent Short And Long Term Complications ( Acute Or
Chronic Anemia, Long-term Consequences Of
Anovulation)
Return To A Pattern Of Normal Menstrual Cycles
What Are The Goals Of Management Of DUB?
41Tuesday, June 18, 13
67. Confirm The Diagnosis Of DUB.
Prevent Short And Long Term Complications ( Acute Or
Chronic Anemia, Long-term Consequences Of
Anovulation)
Return To A Pattern Of Normal Menstrual Cycles
Prevention Of Recurrence
What Are The Goals Of Management Of DUB?
41Tuesday, June 18, 13
68. The Choice Of Management
Depends On:
Age, Past History, And Bleeding
Amount.
42Tuesday, June 18, 13
70. ➡Exclusion of Pregnancy (including ectopic pregnancy) and
pelvic infections.
General principles in Management OF DUB
43Tuesday, June 18, 13
71. ➡Exclusion of Pregnancy (including ectopic pregnancy) and
pelvic infections.
➡Use of Menstrual Calendar for All adolescents.
General principles in Management OF DUB
43Tuesday, June 18, 13
72. ➡Exclusion of Pregnancy (including ectopic pregnancy) and
pelvic infections.
➡Use of Menstrual Calendar for All adolescents.
➡Monitoring patients for iron deficiency anemia.
General principles in Management OF DUB
43Tuesday, June 18, 13
73. ➡Exclusion of Pregnancy (including ectopic pregnancy) and
pelvic infections.
➡Use of Menstrual Calendar for All adolescents.
➡Monitoring patients for iron deficiency anemia.
➡Long-term monitoring and follow-up are necessary to
prevent the potential sequelae of DUB (eg, anemia, infertility,
endometrial cancer).
General principles in Management OF DUB
43Tuesday, June 18, 13
74. ➡Exclusion of Pregnancy (including ectopic pregnancy) and
pelvic infections.
➡Use of Menstrual Calendar for All adolescents.
➡Monitoring patients for iron deficiency anemia.
➡Long-term monitoring and follow-up are necessary to
prevent the potential sequelae of DUB (eg, anemia, infertility,
endometrial cancer).
➡Additional evaluation and consultation should be obtained if
bleeding cannot be controlled despite hormonal therapy.
General principles in Management OF DUB
43Tuesday, June 18, 13
75. Medical Therapy
•Oral Contraceptives
•Estrogen
•Progestin
Surgical Care
•D&C
•Endometrial Ablation
•Hysterectomy
Haemostatic
agents
Options for Management of
DUB
NSAIDHormonal
Therapy
•Aminocaproic acid
•Tranexamic Acid
•Desmopressin
Mostcases of DUBcan betreated medically. Surgical
measures arereserved forsituations when medicaltherapy
has failed oris contraindicated
44Tuesday, June 18, 13
77. ➡longer than normal
➡Shorter than normal
for > two months
Moderate DUB Severe DUBMild DUB
Management of DUB
45Tuesday, June 18, 13
78. ➡longer than normal
➡Shorter than normal
for > two months
Moderate DUB
✓hormonal therapy to
stabilize endometrial
p r o l i f e r a t i o n a n d
shedding.
✓Iron supplementation
Severe DUBMild DUB
Management of DUB
45Tuesday, June 18, 13
79. ➡longer than normal
➡Shorter than normal
for > two months
Moderate DUB
✓hormonal therapy to
stabilize endometrial
p r o l i f e r a t i o n a n d
shedding.
✓Iron supplementation
Severe DUBMild DUB
Management of DUB
45Tuesday, June 18, 13
80. ➡longer than normal
➡Shorter than normal
for > two months
Moderate DUB
✓hormonal therapy to
stabilize endometrial
p r o l i f e r a t i o n a n d
shedding.
✓Iron supplementation
Severe DUBMild DUB
Management of DUB
45Tuesday, June 18, 13
81. ➡longer than normal
➡Shorter than normal
for > two months
Moderate DUB
✓hormonal therapy to
stabilize endometrial
p r o l i f e r a t i o n a n d
shedding.
✓Iron supplementation
Severe DUBMild DUB
Management of DUB
45Tuesday, June 18, 13
82. ➡longer than normal
➡Shorter than normal
for > two months
Moderate DUB
➡Moderately Prolonged Or
Frequent Menses Every One To
Three Weeks.
➡Menstrual Flow Is Moderate To
Heavy.
➡MildAnemia (Hb 10 To 12 G/dL)
But Without Signs Of
Hypovolemia
✓hormonal therapy to
stabilize endometrial
p r o l i f e r a t i o n a n d
shedding.
✓Iron supplementation
Severe DUBMild DUB
Management of DUB
45Tuesday, June 18, 13
83. ➡longer than normal
➡Shorter than normal
for > two months
Moderate DUB
➡Moderately Prolonged Or
Frequent Menses Every One To
Three Weeks.
➡Menstrual Flow Is Moderate To
Heavy.
➡MildAnemia (Hb 10 To 12 G/dL)
But Without Signs Of
Hypovolemia
✓hormonal therapy to
stabilize endometrial
p r o l i f e r a t i o n a n d
shedding.
✓Iron supplementation
Not currently
bleeding
✓ COPs or
✓ progesterone-only
hormonal
Severe DUBMild DUB
Management of DUB
45Tuesday, June 18, 13
84. ➡longer than normal
➡Shorter than normal
for > two months
Moderate DUB
➡Moderately Prolonged Or
Frequent Menses Every One To
Three Weeks.
➡Menstrual Flow Is Moderate To
Heavy.
➡MildAnemia (Hb 10 To 12 G/dL)
But Without Signs Of
Hypovolemia
✓hormonal therapy to
stabilize endometrial
p r o l i f e r a t i o n a n d
shedding.
✓Iron supplementation
Not currently
bleeding
✓ COPs or
✓ progesterone-only
hormonal
currently
bleeding
✓OC pills: 3 three times
per day until the bleeding
ceases (48 h) then
tapered gradually for 21
days of hormone therapy.
✓Alternatively progestin
therapy
Severe DUBMild DUB
Management of DUB
45Tuesday, June 18, 13
85. ➡longer than normal
➡Shorter than normal
for > two months
Moderate DUB
➡Moderately Prolonged Or
Frequent Menses Every One To
Three Weeks.
➡Menstrual Flow Is Moderate To
Heavy.
➡MildAnemia (Hb 10 To 12 G/dL)
But Without Signs Of
Hypovolemia
✓hormonal therapy to
stabilize endometrial
p r o l i f e r a t i o n a n d
shedding.
✓Iron supplementation
Not currently
bleeding
✓ COPs or
✓ progesterone-only
hormonal
currently
bleeding
✓OC pills: 3 three times
per day until the bleeding
ceases (48 h) then
tapered gradually for 21
days of hormone therapy.
✓Alternatively progestin
therapy
Severe DUB
➡ heavy bleeding that
causes a decrease in
hemoglobin (to <10
mg/dL) and may or
m a y n o t c a u s e
h e m o d y n a m i c
instability
Mild DUB
Management of DUB
45Tuesday, June 18, 13
86. ➡longer than normal
➡Shorter than normal
for > two months
Moderate DUB
➡Moderately Prolonged Or
Frequent Menses Every One To
Three Weeks.
➡Menstrual Flow Is Moderate To
Heavy.
➡MildAnemia (Hb 10 To 12 G/dL)
But Without Signs Of
Hypovolemia
✓hormonal therapy to
stabilize endometrial
p r o l i f e r a t i o n a n d
shedding.
✓Iron supplementation
Not currently
bleeding
✓ COPs or
✓ progesterone-only
hormonal
currently
bleeding
✓OC pills: 3 three times
per day until the bleeding
ceases (48 h) then
tapered gradually for 21
days of hormone therapy.
✓Alternatively progestin
therapy
Severe DUB
➡ heavy bleeding that
causes a decrease in
hemoglobin (to <10
mg/dL) and may or
m a y n o t c a u s e
h e m o d y n a m i c
instability
✓ ? hospitalization for
stabilization of
hemodynamic status,
✓ blood transfusion.
✓ pharmacologic therapy,
✓ Rarely, surgical therapy.
Mild DUB
Management of DUB
45Tuesday, June 18, 13
87. COC Pills
•High-dose Combination
Pill Every Four Hours
U n t i l T h e B l e e d i n g
Subsides (usually Within 24
Hours),
•Then Four Times Per Day
For Four Days, Then
Three Times Per Day For
Three Days.
•Then Two Times A Day
For Two Weeks.
•I f H i g h - d o s e E s t r o g e n I s
Contraindicated (eg, Arterial Or Venous
Thromboembolic Disease, Estrogen-
dependent Tumors, And Hepatic
Dysfunction Or Disease). Progestin E.g.
Norethindrone Acetate (5- To 10 Mg) Or
Micronized Progesterone (200 Mg) Every
Four Hours Until The Bleeding Stops.
•Then One Pill Four Times A Day For
Four Days
•Then Three Times A Day For Three
Days, Then Twice A Day For Two
Weeks.
If Estrogen Is Contraindicated And Progestin-only Regimens Fail To Control
The Bleeding, Aminocaproic Acid Or Desmpressin May Be Initiated.
•Intravenous Conjugated
Equine Estrogen, 25 Mg
Every Four To Six Hours
Until The Bleeding
Stops.
•No More Than Six Doses
Should Be Administered.
•Anti-emetics Should Be
Prescribed.
Management Of Acute Severe DUB
Hospitalization For Stabilization Of Hemodynamic Status, Blood
Transfusion, Pharmacologic Therapy, And, Rarely, Surgical Therapy.
IV Conjugated
Estrogen
Progestins
46Tuesday, June 18, 13
91. Use Simple Descriptive Terminology For AUB.
AUB-O Is The Most Common At Extreme Of
Reproductive Age.
48Tuesday, June 18, 13
92. Use Simple Descriptive Terminology For AUB.
AUB-O Is The Most Common At Extreme Of
Reproductive Age.
Workup Aims To Differentiate Structural From
Non-Structural Causes (PALM & COIEN).
48Tuesday, June 18, 13
93. Use Simple Descriptive Terminology For AUB.
AUB-O Is The Most Common At Extreme Of
Reproductive Age.
Workup Aims To Differentiate Structural From
Non-Structural Causes (PALM & COIEN).
Appreciate The Place, Sensitivity Of Various
Diagnostic Tools.
48Tuesday, June 18, 13
94. Use Simple Descriptive Terminology For AUB.
AUB-O Is The Most Common At Extreme Of
Reproductive Age.
Workup Aims To Differentiate Structural From
Non-Structural Causes (PALM & COIEN).
Appreciate The Place, Sensitivity Of Various
Diagnostic Tools.
Appreciate High Risk Subjects (risk Of Cancer).
48Tuesday, June 18, 13
95. Use Simple Descriptive Terminology For AUB.
AUB-O Is The Most Common At Extreme Of
Reproductive Age.
Workup Aims To Differentiate Structural From
Non-Structural Causes (PALM & COIEN).
Appreciate The Place, Sensitivity Of Various
Diagnostic Tools.
Appreciate High Risk Subjects (risk Of Cancer).
Treatment Is Highly Influenced By Age, Severity Of
Bleeding.
48Tuesday, June 18, 13
96. Use Simple Descriptive Terminology For AUB.
AUB-O Is The Most Common At Extreme Of
Reproductive Age.
Workup Aims To Differentiate Structural From
Non-Structural Causes (PALM & COIEN).
Appreciate The Place, Sensitivity Of Various
Diagnostic Tools.
Appreciate High Risk Subjects (risk Of Cancer).
Treatment Is Highly Influenced By Age, Severity Of
Bleeding.
In All Cases Follow Up Is Essential Part Of
Management.
48Tuesday, June 18, 13
