Normal & Abnormal

Uterine Bleeding

Syamel Muhammad

Objectives Recognize the characteristics of Normal

Menstrual Bleeding (The LMP as the fourth vital sign!)

Describe the etiologies of Abnormal Uterine Bleeding (AUB.)

Understand etiologies of AUB with respect to the life stages of women.

Understand the diagnostic tools to identify the etiology of the AUB.

State the medical & surgical options available in primary care and gynecology settings.

Normal Menstruation

The Menstrual CycleIn the normal menstrual cycle, orderly cyclic

hormone production and parallel proliferation of the uterine lining prepare for implantation of the embryo.

Berek & Novak’s Gynecology, 2012, p.145

Normal Menstruation

“The menstrual cycle starts with the first day of bleeding of one period and ends with the first day of the next. In most women, the cycle last about 28 days. Cycles that are shorter or longer by 7 days are normal.”

ACOG Website: FAQ095

The Normal Menstrual Period

Blood loss < 80 ml (average 30-35 ml) Duration of flow 2-7 days (average 4 days) Cycle length 21 - 35 days (average 29 days)

(28 days +/- 7 days}

Phases of the Menstrual CycleReproductive Cycle

Follicular Begins with Menses ends with luteinizing (LH)

hormone surge Ovulation (30-36 hours)

Begins with LH surge and ends with ovulation Luteal (14 days)

Begins with the end of the LH surge and ends with onset of menses

The Normal Menstrual CycleAnother Way of looking at it

M. Manting; DUB LECTURE 2008

Phases of the Menstrual CycleEndometrium Proliferative

Begins with menses and ends at ovulation

Secretory Begins at ovulation and ends with menses

The Normal Menstrual CycleAnother Way of looking at it

M. Manting; DUB LECTURE 2008

Regulation:Hypothalamic Pituitary Axis

Hypothalamus is the pulse generator mediated through GnRH

GnRH cannot be directly measured

Negative Feedback

Abnormal Uterine Bleeding (AUB)

Definition: Any change in

menstrual periodFlowDurationFrequency Bleeding

between cycles

Prevalence:20 million office

visits/year25% of visits to

gynecologists

Old Terminology

Menorrhagia Metrorrhagia Menometrorrhagia Polymenorrhea

Dysmenorrhea Amenorrhea Oligomenorrhea Hypomenorrhea

New Terminology Heavy Menstrual Bleeding

Acute Chronic

Intermenstrual Bleeding

History for AUBOnset

Quantity : Spotting or heavydaily or intermittent

Duration

History for AUBAssociated

SymptomsPainDysmenorrheaMenstrual

ChangesTiming Flow (clots)Frequency

Fever/chills Changes in hair/

bodyBruising/bleedingRectal/urethral

bleedingNausea/vomiting

Gender Specific History

MenstrualContraception GynecologicObstetricSexualGenital Infections

Other Important Details Family History

Anyone else? Von Willebrand's PCOS

Nutrition and exercise Weight changes Exercise habits diet

Chronic conditions Liver disease Kidney disease

Anemia Drugs /medications Psychiatric

medications Thyroid Disorders Blood thinners

Differential Diagnosis Of AUBStructural: PALM-COEIN (Non Gravid

Women)

Life Cycles: Pre-menarche Menarche

Reproductive Post-Menopause

Anatomic: “Bottoms Up”

Pregnancy

Age is NotAn Issue!

NeverForget

Pregnancy

Assumptions can lead to death

PROVE IT!

PALM-COEIN FIGO Classification System (PALM-

COEIN) for causes of AUB in non gravid women of reproductive age

Structural vs. Non-Structural

Developed to create a universally accepted nomenclature

PALMStructural Causes

P- Polyp (AUB-P)A- Adenomyosis (AUB-A)L- Leiomyoma (AUB-L)

Submucosal myoma (AUB-LSM)Other myoma (AUB-LO)

M- Malignancy & hyperplasia (AUB-M)

COEINNon-Structural Causes

C- Coagulopathy (AUB-C)O-Ovulatory dysfunction (AUB-O)E- Endometrial (AUB-E)I- Iatrogenic (AUB-I)N- Not yet classified (AUB-N

AUB-O Abnormal Uterine Bleeding with

ovulatory dysfunction Heavy, irregular bleeding

Causes of Anovulation:

Physiologic

Adolescence Menopause Transition Lactation Pregnancy

Causes of Anovulation

Pathologic Hyperandrogeni

c anovulation (e.g., PCOS, CAH, or androgen-producing tumors)

Hypothalamic dysfunction

Hyperprolactinemia

Thyroid disease Pituitary

disease Premature

ovarian failure Iatrogenic

(Chemo) Medications

Liver Disease Patients known to have liver

disease manifest additional symptomatology because of abnormal hepatic function.

Evaluate patients for spider angioma, palmar erythema, splenomegaly, ascites, jaundice, and asterixis.

Coagulation Disorders

In h eritedvon W illib ran d 's

h em op h ilia

A cq u iredITP

leu kem ia

D ru g In d u cedcou m ad in /h ep arin

asp irin

C oag u la tion D iso rd ers

Rule out von Willebrand'sin any girl who

requirestransfusion for excessive

bleeding when first

starting periods

Bleeding from ther Sites GI

Neoplasia or hemorrhoids GU

Urethral caruncle or diverticulum Renal lithiasis or hemorrhagic cystitis

GYN Labia, cervix, or vagina Trauma, infection, or neoplasia

RememberHemoccult

& Urinalysis

Differential Diagnosisof AUB: Life Cycles Pre-Menarche

Menarche

Reproductive

Postmenopausal

Etiology of AUB

Life Cycles Approach

• E2 withdrawal @birth

• Foreign Body• Sarcoma

• Ovarian Tumor• Trauma

• Coagulation Defects

• Hypothalamic Immaturity

• Psychogenic

• Pregnancy• Anovulation• Endogenous• Exogenous • Anatomic

• Carcinoma• Vaginal Atrophy• E2 Replacement

• Anatomic

Premenarchal Menarche Reproductive Post-Menopausal

Differential Diagnosis of AUB: Structural “Bottoms Up”

Vulva Vagina Cervix Ovary Brain

Contiguous Anatomy GU GI

Non-Pelvic Etiology Endogenous Iatrogenic

Vulvar Infections HPV Atrophy Benign Lesions Cancerous lesions Dermatologic Causes

PHYSICAL EXAM: INSPECTION IS IMPORTANT

Vagina Malignancy :

Carcinoma Sarcoma

Infections

Foreign bodies Diaphragm, Pessary Tampon other

Laceration/trauma

Atrophic changes

Granulomatous tissue formed after

surgery post hysterectomy

Physical Exam: Inspection is important

Cervix Neoplasia

Cancer Polyps Myomas

Cervical Eversion (Ectropion) Infection

Cervicitis Condyloma Acuminata

IMPORTANT: Visualize the Cervix!

Uterus Myomas Polyps Endometrial Hyperplasia Endometrial Carcinoma Atrophy

PHYSICAL EXAM: Bimanual Exam checks enlargement

Postmenopausal Bleeding

is consideredendometrial cancer

until proven otherwise

Postmenopausal bleeding

is evaluatedby an

Endometrialbiopsy

Most PMB Is due to Atrophy

Ovary Anovulation PCOS Menopause Transition

PathophysiologyEtiologies Of AUB Estrogen Withdrawal

Estrogen Breakthrough

Progesterone Withdrawal

Clinical Management of Abnormal Uterine Bleeding: APGO Educational Series, May 2002, p. 8.

Initial Assessment of AUBAcute

Sub-Acute

Chronic

Initial Assessment of AUB

History & Physical Vital Signs Shock Signs

Laboratory Pregnancy Test Complete Blood Count

EVALUATION OF AUB

Pregnant?

Evaluate for complications

IUP, SAB, Ectopic

Structural (PALM)

VS.

Non-Structural (COEIN)

YES NO

Evaluation of AUB Evaluation of the Endometrium

Pregnancy test Endometrial Biopsy Transvaginal &/or abdominal Ultrasound

(TVS/AUS) Saline Sono-hysterocopy (SIS) Hysteroscopy

Evaluation of the Uterus TVS SIS Hysteroscopy

Endometrial Biopsy (EMB)

Evaluation of the Endometrium Pipelle

Transvaginal Ultrasound To assess for thickened endometrium In 92% of abnormal endometrial

biopsies, ultrasound showed >5mm endometrium

In 96% of endometrial cancer by biopsy result, ultrasound showed >5mm endometrium

Therefore, ultrasound measured endometrium <5mm is likely benign uterine condition

TVS & SIS

TVS

SIS

Hysteroscopy

MRI Precisely localizes sub-mucosal fibroids

MRI is not superior to TVS & SIS in overall diagnostic potential

Dueholm M, et al. Fertil Steril. 2001;76(2):350357

Treatment of AUB Observation Medical Minimally invasive surgery Major surgery

Medical Management

Iron Anti-fibrinolytics Progestins Estrogen +

progestins (OCP)

Parenteral estrogens Androgens GnRH agonists Anti-progestational

agents

Minimally Invasive Surgery

Intrauterine Device (IUD) with progesterone

Dilation & Curettage

Endometrial Ablation

Major Surgery Myomectomy Total Abdominal Hysterectomy (TAH) Total Vaginal Hysterectomy (TVH) Laparoscopic Hysterectomy

LSH (laparoscopic supra-cervical) TLH (total laparoscopic) LAVH (laparoscopically assisted vaginal

hysterectomy) Robotic (TLH or LSH)

Management of Acute AUB Can be a life-threatening emergency

Monitor Vital signs, Start oxygen IV fluids (wide bore IV catheter) Type and Cross 2-4 units of blood

IV Estrogen IM Progesterone NSAIDS (Anti-prostaglandins vs. Anti-

fibrinolytics) Emergency Dilatation and Curettage

(D&C)

Treatment in Chronic, Stable AUB

High dose OCP’s to slow the bleeding Anovulatory Bleeding can be treated

with progesterone alone Endometrial sampling is indicated

prior to starting hormones in older women

Clinical Pearls

Age is Not an Issue!

Never Forget

Pregnancy!

Assumptions CanLead to Death!

PROVE IT!

References ACOG Practice Bulletin No. 136, July 2013 Beckmann, et al., Obstetrics & Gynecology, 7th ed.,

Chapters 37, 39 Clinical Management of Abnormal Uterine

Bleeding: APGO Educational Series, May 2002 Dueholm M, et al. Fertil Steril. 2001;76(2):350357 Fritz, MA, Speroff et al, Clinical and Gynecologic

Endocrinology and Infertility, 8th ed. 2011. Manting M., AUB Lecture 2008 Munro, MG, et al, FIGO Classification System

(PALM-COEIN) for causes of AUB in non gravid women of reproductive age. Int J Gynaecol Obstet 2011; 113:3-13