GYN 15

• Abnormal uterine bleeding (AUB)


  Any uterine bleeding outside the normal volume, duration, regularity or frequency
• Nearly 30% of all gynecological outpatient attendants are for AUB
• Normal menstruation


  • Cycle interval: 28 days (21–35 days)
  • Menstrual flow: 4–5 days
  • Menstrual blood loss: 35 mL (20–80 mL)
• PALM-COEIN


  Acronym that subdivides all the causes of AUB into nine main categories
• PALM categories

  • Polyp
  • Adenomyosis
  • Leiomyoma
  • Malignancy and hyperplasia
• COEIN categories


  • Coagulopathy
  • Ovulatory dysfunction
  • Endometrial
  • Iatrogenic
  • Not yet identified
• AUB notation


  AUB is followed by the letters PALM–COEIN and a subscript 0 or 1 associated with each letter to indicate the absence or presence in respect of the abnormality
• AUB examples


  • AUB: P0A1L0M0–C0O0E0I0N0
  • P1A0L0M0–C0O1E0I0N0
• Leiomyoma category


  Subdivided into patients with at least one submucosal myoma (LSM) and those with myomas that do not affect the endometrial cavity (L0)
• Menorrhagia


  Cyclic bleeding at normal intervals that is either excessive in amount (> 80 mL) or duration (>7 days) or both
• Organic causes of menorrhagia

  • Pelvic: Fibroid uterus, adenomyosis, pelvic endometriosis, IUCD in utero, chronic tubo-ovarian mass, tubercular endometritis, retroverted uterus, granulosa cell tumor of the ovary
  • Systemic: Liver dysfunction, congestive cardiac failure, severe hypertension
  • Endocrinal: Hypothyroidism, hyperthyroidism
  • Hematological: Idiopathic thrombocytopenic purpura, leukemia
• Functional causes of menorrhagia are due to disturbed hypothalamo-pituitary-ovarian-endometrial axis
• Diagnosis of menorrhagia


  Long duration of flow, passage of big clots, use of increased number of thick sanitary pads, pallor, and low level of hemoglobin
• Polymenorrhea


  Cyclic bleeding where the cycle is reduced to an arbitrary limit of less than 21 days and remains constant at that frequency
• Epimenorrhagia


  Polymenorrhea associated with excessive and/or prolonged bleeding
• Causes of polymenorrhea


  • Dysfunctional: Seen during adolescence, preceding menopause, following delivery and abortion
  • Ovarian hyperemia: Pelvic inflammatory disease, ovarian endometriosis
• Metrorrhagia

  Irregular, acyclic bleeding from the uterus with variable amount of bleeding
• Causes of contact bleeding

  • Carcinoma cervix, mucus polyp of cervix, vascular ectopy of the cervix, infections, cervical endometriosis
• Causes of acyclic bleeding

  • DUB, submucous fibroid, uterine polyp, carcinoma cervix and endometrial carcinoma
• Menometrorrhagia


  Irregular and excessive bleeding where the menses (periods) cannot be identified at all
• Causes of oligomenorrhea


  • Age-related, weight-related, stress and exercise related, endocrine disorders, androgen producing tumors, tubercular endometritis, drugs
• Hypomenorrhea


  Menstrual bleeding that is unduly scanty and lasts for less than 2 days
• Dysfunctional uterine bleeding (DUB)


  Abnormal uterine bleeding without any clinically detectable organic, systemic, and iatrogenic cause
• Heavy menstrual bleeding (HMB) is defined as a bleeding that interferes with woman's physical, emotional, social and maternal quality of life
• DUB is currently defined as a state of abnormal uterine bleeding following anovulation due to dysfunction of hypothalamo-pituitary-ovarian axis
• Structural causes of abnormal bleeding

  • Uterine: Leiomyoma, adenomyosis, endometrial hyperplasia or malignancy, arteriovenous malformation
  • Cervix: Polyp, cancer
  • Vagina: Cancer
  • Fallopian tube: Cancer
• Nonstructural systemic causes of abnormal bleeding

  • Ovarian tumors, anovulation, thyroid dysfunction, hyperprolactinemia, androgen excess, premature ovarian failure
  • Pregnancy complications: Miscarriages, gestational trophoblastic disease
  • Iatrogenic: Medications, IUCD, trauma
  • Infections: STIs, endometritis, tuberculosis
  • Systemic: Hepatic and renal dysfunction, coagulopathies
• Endometrial polyps (AUB-P)


  • Diagnosis is made by sonography. MRI is superior to USG.
• Adenomyosis (AUB-A)


  • Diagnosis is made by sonography. MRI is superior to USG.
• Leiomyoma (AUB-L)


  • Classification system includes submucosal, intramural and subserosal fibroids.
• Malignancy (AUB-M)


  • Includes female genital tract cancers. Malignancy is observed in 4.5% of postmenopausal women when they present with symptoms.
• Coagulopathy (AUB-C)


  • Includes von Willebrand disease, prothrombin deficiency, hemophilias A, B, ITP, leukemia, platelet deficiency, inherited coagulopathies due to deficiency of other clotting factors.
• Anticoagulation therapy


  • Women on heparin or LMWH may present with AUB. Nearly 20% of adolescent girls with AUB have been found to suffer from coagulation disorders.
• Ovulatory dysfunction (AUB-O)


  • Often seen in the premenarchal and premenopausal women due to abnormality of neuroendocrine function and anovulation.
• Iatrogenic (AUB-I)


  • Mostly due to medications like breakthrough bleeding following the use of combined oral contraceptives, erratic use of pills or any contraceptive steroids, use of IUCDs, or LNG-IUS.
• Endometrial (AUB-E)


  • Abnormal endometrial production of PGI2 and deficiency of PGF2a or excessive production of PGE, chronic inflammatory changes.
• Not otherwise specified (AUB-N)

  Includes trauma and foreign bodies
• Diagnostic criteria to detect coagulopathy

  • One of the following: PPH, surgical bleed, dental bleed
  • Two of the following: Bruising >5 cm, epistaxis 1–2 episodes/month, gum bleeding, family history of bleeding
• Treatment is directed to the underlying pathology and malignancy is to be excluded prior to any definitive treatment
• Oligomenorrhea


  Menstrual bleeding occurring more than 35 days apart and which remains constant at that frequency