AUB

• AUB


  Abnormal uterine bleeding
• Frequency of menstruation


  • 21 days to 35 days
  • Age 25: 40% between 25 and 28 days
  • Age 25-35: 60% are between 25 and 28 days
  • Teens and women over 40s: Cycles may be longer apart
• Duration of menstruation


  2 – 8 days (usually 4-6 days)
• Flow or amount of menstrual blood loss


  Normal volume is 30 cc
• Hypomenorrhea


  Abnormally reduced menstrual flow
• Oligomenorrhea


  Infrequent periods with normal flow
• Menorrhagia


  Regular periods, heavy flow
• Metrorrhagia


  Irregular periods, normal flow
• Menometrorrhagia


  Irregular heavy periods
• Heavy menstrual bleeding (HMB)

  Excessive menstrual blood loss that interferes with woman's physical, emotional, social, and material quality of life
• Acute AUB


  Episodes of heavy bleeding that result in hypovolemia (hypotension, tachycardia) or shock
• Chronic AUB


  Abnormal in volume, regularity, and/or timing, present for majority of the past 6 months, do not require immediate intervention
• Intermenstrual bleeding (IM)


  Occurs between clearly defined cyclic and predictable menses, at random times or in a predictable fashion
• Dysfunctional uterine bleeding (DUB)

  Term discarded by FIGO 2009 World Congress and POGS 2009 CPG
• Approach to patient with AUB

  1. Assess rapidly the clinical picture to determine patient acuity

  2. Determine etiology

  3. Choose appropriate treatment
• History and physical exam

  • Step 1: Rapid assessment of vital signs
  • Step 2: Simultaneous with step 1 - CBC and quantitative beta hCG
• Most common causes of reproductive tract AUB


  • Pre-menarchal: Foreign body
  • Reproductive age: Gestational event (abortions, ectopic pregnancy trophoblastic disease, IUP)
  • Post-menopausal: Atrophy
• Initial laboratory testing


  • CBC
  • Blood type and cross match
  • Pregnancy test
• Initial lab evaluation for disorders of hemostasis

  • Partial thromboplastin time
  • Prothrombin time
  • Activated partial thromboplastin time
  • Fibrinogen
• Initial testing for von Willebrand disease

  • Von Willebrand factor antigen
  • Ristocetin cofactor assay
  • Factor VIII
• Other laboratory tests to consider

  • Thyroid stimulating hormone
  • Serum iron, total iron binding capacity, and ferritin
  • Liver function tests
  • Chlamydia trachomatis
• Endometrial biopsy


  Considered for women over 45 years, those with hereditary non-polyposis colorectal cancer syndrome, and for persistent AUB that is unexplained or not adequately treated
• Sonography


  Identifies abnormalities like endometrial and endocervical polyps, transvaginal ultrasound is an appropriate screening tool
• FIGO classification system for causes of AUB

  • PALM (Polyp, Adenomyosis, Leiomyoma, Malignancy and hyperplasia)
  • COEI (Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic)
  • N (Not yet classified)
• Leiomyoma (AUB-L)


  Spectrum of size and location, asymptomatic and frequently not the cause of AUB, submucosal lesions are most likely to contribute to AUB
• Proposed etiologies of menorrhagia with leiomyoma

  • Increased vessel number
  • Increased endometrial surface area
  • Impeded uterine contraction with menses
  • Clotting less efficient locally
• Coagulation defects


  ITP, Von Willebrand's disease is the most common inherited coagulation defect
• Routine screening for coagulation defects should be reserved for the young patient who has heavy flow with the onset of menstruation
• Leiomyomas


  • Variable number of lesions in a given uterus require that they be afforded a separate categorization system
  • Asymptomatic and frequently not the cause of AUB
  • Primary classification system reflects only the presence or absence of 1 or more leiomyomas
  • Secondary system requires the clinician to distinguish leiomyomas involving the endometrial cavity (submucosal) because it is considered that submucosal lesions are the most likely to contribute to the genesis of AUB
• Proposed etiologies of menorrhagia with leiomyoma

  • Increased vessel number
  • Increased endometrial surface area
  • Impeded uterine contraction with mens
  • Clotting less efficient locally
• Systemic etiologies of abnormal uterine bleeding

  • Coagulation defects
  • ITP
  • Von Willebrand's
• Von Willebrand's Disease is the most common inherited bleeding disorder with a frequency of 1/800-1000
• Clinical Screening for an Underlying Disorder of Hemostasis in the Patient With Excessive Menstrual Bleeding


  • Initial screening should be structured by the medical history
  • A positive screening result comprises heavy menstrual bleeding plus one of the following: postpartum hemorrhage, surgery-related bleeding, bleeding associated with dental work, or two or more of the following: bruising 1-2x per month, epistaxis 1-2x per month, frequent gum bleeding, family history of bleeding symptoms
  • Patients with a positive screening result should be considered for further evaluation, including consultation with a hematologist and testing for von Willebrand factor and ristocetin cofactor
• Iatrogenic causes of abnormal uterine bleeding

  • Intra-uterine device
  • Oral and injectable steroids
  • Psychotropic drugs
• Categorized AUB-LSM;O


  Abbreviation option for the full notation in clinical practice
• Medical treatment options for abnormal uterine bleeding

  • NSAIDs
  • Oral progestins
  • Combined Oral Contraceptive pills
  • Estrogen
  • GnRH Agonists
  • Levonorgestrel Releasing Intrauterine System
  • Tranexamic Acid
• Surgical treatment options for abnormal uterine bleeding

  • Endometrial Destructive Procedures
  • Hysterectomy
• Menstrual bleeding stops if prostaglandins cause contractions and expulsion, or if endometrial healing and cessation of bleeding occurs with increasing estrogen
• Treatment goals for abnormal uterine bleeding

  • Control bleeding
  • Prevent recurrence
  • Preserve fertility
  • Correct associated conditions
  • Induce ovulation in patients who want to conceive
• Conjugated equine estrogen


  25mg IV every 4-6 hours for 24 hours