Abnormal Uterine

Bleeding (AUB)
INA S. IRABON, MD, FPOGS, FPSRM, FPSGE
Obstetrics and Gynecology
Reproductive Endocrinology and Infertility
Reference:

´ Comprehensive Gynecology 7th edition, 2017 (Lobo RA,

Gershenson DM, Lentz GM, Valea FA editors) chapter 26,
pp 621-633.
To download this lecture deck:

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Outline: AUB

1. Definition
2. Classification and Pathophysiology
3. Diagnosis
4. Treatment of acute and chronic AUB
Abnormal uterine bleeding (AUB)

´ One of the most common

health concerns of women
´ can present in many ways,
from infrequent episodes
(oligomenorrhea) to
excessive flow (heavy
menstrual bleeding, or
prolonged duration of
menses and intermenstrual
bleeding)
´ This lecture will focus only on
heavy menstrual bleeding Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;
In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.
Review: Normal Menstrual blood flow

´ mean duration of the

menstrual cycle is 28 ± 7
days.
´ Average menstrual
blood loss (MBL) is 35
mL. (normal range: 10-
80ml)
´ Average number of
days of menses: 4 days
(normal range: 2-7
days)
Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;
In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.
Abnormal uterine bleeding (AUB)

´ Bleeding is abnormal/heavy
if:
´ it occurs at intervals of 21
days or less, or 35 days or
more;
´ Lasts longer than 7 days;
´ MBL of 80 mL or greater

´ the term dysfunctional

uterine bleeding (DUB) is
no longer favored and
Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;
should be discarded. In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.
 622 Part III GENERAL GYNECOLOGY
PALM-COIEN classification of AUB
Polyp Coagulopathy
Adenomyosis Ovulatory dysfunction
Anatomic Submucosal Non-anatomic
causes Leiomyoma Endometrial causes
Other
Malignancy and Iatrogenic
hyperplasia Not yet classified

Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;

Figure 26.1 PALM-COEIN Classification System for Abnormal
In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.
Uterine Bleeding. The basic system comprises four categories A
Diagnosis Nomenclature:

´ the acronym AUB is followed by the letters PALM-COEIN

and a subscript 0 or 1 associated with each letter to
indicate the absence or presence, respectively, of the
abnormality.
´ Example #1: A patient with abnormal bleeding due to a
polyp :

AUB-P1A0L0M0-C0O0E0I0N0

Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;

In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.
Diagnosis Nomenclature:

´ Example #2: A patient with abnormal bleeding that is

both irregular and heavy may have endometrial
hyperplasia due to anovulation.

AUB- P0A0L0M1- C0O1E0I0N0

Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;

In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.
 ENDOMETRIAL POLYPS (AUB-P)
´ localized overgrowths of endometrial
P tissue, containing glands, stroma, and
blood vessels, covered with epithelium.
A
´ Most commonly found in reproductive-
L age women

M ´ estrogen stimulation is thought to play a

key role in their development.
C ´ Usually benign.
O ´ Women with symptomatic polyps can
be treated safely and effectively with
I operative hysteroscopy

E
Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;
N In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.
 ADENOMYOSIS (AUB-A)
´ presence of endometrial glands and stroma in
P the uterine myometrium. à ectopic
endometrial tissue leads to hypertrophy of the
A surrounding myometrium.
L ´ Risk factors: Multiparity (most significant) and
any process that allows for penetration of
M endometrial glands and stroma past the basalis
layer (e.g., dilation and curettage, cesarean
C delivery, spontaneous abortion)
O ´ Enlarged, asymmetric uterus on ultrasound

I ´ Abnormal bleeding due to adenomyosis is

thought to be a result of altered uterine
E contractility and is associated with profound
dysmenorrhea.
N Ryntz T, Lobo R. Chapter 26. Abnormal Uterine Bleeding;
In Comprehensive Gynecology 7th edition, 2017;Lobo RA,
Gershenson DM, Lentz GM, Valea FA editors; pp 621-633.
 LEIOMYOMA (AUB-L)
´ Also called fibroids, are benign tumors of the uterine
P myometrium.
´ pathogenesis : myometrial injury leading to cellular
A proliferation, decreased apoptosis, increased production
of extracellular matrix, and overexpression of transforming
L growth factor beta that leads to fibrosis of these tumors.

M ´ Mechanisms by which fibroids cause abnormal bleeding

are varied and depend on size, location, and number:
C ´ Intracavitary/submucous fibroids

O ´ intramural fibroids
´ Subserous fibroids
I ´ Management:
E ´ Medical management
´ Surgical : hysterectomy, myomectomy Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;

N In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,

G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.
 MALIGNANCY (AUB-M)
P ´ vulvar, vaginal, cervical, endometrial, uterine, and adnexal
(ovarian or fallopian tube) cancers.
A ´ Bleeding from cervical malignancy classically presents as coital
L bleeding or intermenstrual bleeding
´ Endometrial cancer is mostly secondary to prolonged exposure to
M hyperestrogenic state (chronic anovulation, PCOS, obesity,
nulligravidity, etc)
C
´ Lynch syndrome, or hereditary nonpolyposis colorectal cancer, is
O an autosomal dominant disease caused by a disruption in the
mismatch repair (MMR) genesà carries a 40% to 50% lifetime risk of
I endometrial cancer (mostly before the age of 45.)

E ´ estrogen-producing ovarian tumors (ex. Granulosa theca cell

tumors)
N Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;
In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.
 COAGULOPATHY (AUB-C)
P ´ disorders of blood coagulation such as von Willebrand
disease (most common), prothrombin deficiency, hemophilia,
A leukemia, severe sepsis, idiopathic thrombocytopenic
purpura, and hypersplenism
L ´ Routine screening mainly indicated for the adolescent who
M has prolonged heavy menses beginning at menarche.
´ In adults, screening for these disorders indicated by clinical
C signs such as bleeding gums, epistaxis, or ecchymosis.
O ´ Other disorders that produce platelet deficiency, such as
Chronic anticoagulation as a result of heparin, low-molecular-
I weight heparin, direct thrombin inhibitors, and direct factor
E Xa inhibitors

N
Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;
In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.
 Adults with HMB and h/o either

One of the following Two of the following

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n ratio of endogenous concentra-
d prostaglandin E and menstrual Figure 26.6 Diagnostic approach to adults with abnormal uterine
I The synthesis
endometrium; persistent endo-
H, Kelly RW, et al.
bleeding due to coagulopathy. (Data from Kouides PA, Conard J,
Peyvandi F, et al. Hemostasis and menstruation: appropriate investi-
proliferative endometrium. J Clin
-289.) E gation for underlying disorders of hemostasis in women with exces-
sive menstrual bleeding. Fertil Steril. 2005;84[5]:1345-1351.)

N Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;

In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
CH ristocetin cofactor should be obtained to rule out a coagula-
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.
 OVULATORY DYSFUNCTION (AUB-O)
P ´ the predominant cause of ovulatory
dysfunction postmenarchal and
A premenopausal women is secondary to
alterations in neuroendocrine function.
L
´ there is continuous estradiol production
M without corpus luteum formation and
progesterone production à continuously
C proliferating endometrium, which may
O outgrow its blood supply à necrosis.
´ uniform slough to the basalis layer does
I not occur, which produces excessive
E uterine bleeding.

N
Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;
In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.
 OVULATORY DYSFUNCTION (AUB-O)
P ´ Anovulatory bleeding is most common
during the extremes of reproductive life: in
A the first few years after menarche and
during perimenopause.
L ´ In the adolescent: anovulation is due to
M an immaturity of the hypothalamic-
pituitary- ovarian (HPO) axis and failure
C of positive feedback of estradiol to
cause a luteinizing hormone (LH) surge.
O ´ In the perimenopausal woman: lack of
synchronization between the
I components of the HPO axis occurs as
E the woman approaches ovarian decline
at menopause.
N Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;
In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.
 OVULATORY DYSFUNCTION (AUB-O)
P
´ the patterns of anovulatory bleeding may be
A oligomenorrhea, intermenstrual bleeding, or heavy
menstrual bleeding.
L
´ What are the causes of anovulation?
M 1. extremes of reproductive life
C 2. polycystic ovary syndrome (PCOS)
O 3. hypothalamic dysfunction (related to weight loss,
severe exercise, stress, or drug use
I
4. abnormalities of other nonreproductive hormone
E (thyroid hormone, prolactin, and cortisol)
N Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;
In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.
 IATROGENIC(AUB-I)
P ´ abnormal bleeding resulting from medications
A ´ most common of these are hormonal preparations, including
selective estrogen receptor modulators, and gonadotropic
L releasing hormone agonists and antagonists.
´ Hyperprolactinemia can result from central nervous system
M dopamine antagonism of certain antipsychotic drugs (eg
risperidone)
C ´ combined and progesterone-only oral contraceptives may result in
O breakthrough bleeding (BTB).
´ interactions between oral contraceptives and other medications,
I such as antibiotics and anticonvulsants may alter circulating levels
of steroids, allowing follicular recruitment and increased
E endogenous levels of estro- gen.
N Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;
In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.
 ENDOMETRIAL (AUB-E)
P ´ heavy menstrual bleeding in the
A absence of other abnormalities are
thought to have underlying disorders of
L the endometrium or are otherwise
unclassified.
M
´ In the past, this category has been
C called “ovulatory dysfunctional uterine
bleeding.”
O
´ the primary line of defense to excessive
I bleeding during normal menses is the
formation of the platelet plug, followed
E by uterine contractility, largely mediated
N by prostaglandin F2α (PGF2α).
Ryntz T, Lobo R. Chapter 26. Abnormal Uterine Bleeding;
In Comprehensive Gynecology 7th edition, 2017;Lobo RA,
Gershenson DM, Lentz GM, Valea FA editors; pp 621-633.
 ENDOMETRIAL (AUB-E)
´ thus prolonged and heavy bleeding can
P occur with abnormalities of the platelet plug
A or inadequate uterine levels of PGF2α.
´ In some women with heavy menstrual
L bleeding, there is excessive uterine
M production of prostacyclin, a vasodilatory
prostaglandin that opposes platelet
C adhesion and may also interfere with
uterine contractility.
O ´ Deficiency of uterine PGF2α or excessive
I production of PGE (vasodilatory
prostaglandin) may also explain ovulatory
E DUB

N ´ Low PGF2α/PGE à increase menstrual

blood loss
Ryntz T, Lobo R. Chapter 26. Abnormal Uterine Bleeding;
In Comprehensive Gynecology 7th edition, 2017;Lobo RA,
Gershenson DM, Lentz GM, Valea FA editors; pp 621-633.
 NOT OTHERWISE SPECIFIED (AUB-N)
P ´ Abnormal bleeding not classified in the previous
A categories is considered AUB-N.
´ Examples of such conditions may include foreign bodies
L or trauma. Treatment is tailored to the specific cause.
M
C
O
I
E
N Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;
In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.
Diagnostic approach
History, Physical examination, and Laboratory exams
 1. Medical History

´ Menstrual history: frequency, duration, and amount of

bleeding
´ inquire whether and when the menstrual pattern changed.
´ Describe the menstrual abnormality as oligomenorrhea,
polymenorrhea, heavy menstrual bleeding, or intermenstrual
bleeding.
´ Menstrual calendar to record her bleeding episodes à helpful
way to characterize definitively the bleeding episodes.
´ Symptoms present for the majority of the preceding 6 months
are considered chronic Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;
In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.
 The menstrual history
For all patients:
• Age at menarche
• Cycle length
• Duration of bleeding
• Perception of flow: heavy, medium or light
• Menstrual product use
• First day of LMP
• Dysmenorrhea

Holland-Hall C. Heavy menstrual bleeding in adolescents:Normal variant or a bleeding disorder.http://contemporaryobgyn.modernmedicine.com/

THE MENSTRUAL CALENDAR
 The menstrual history
For patients reporting heavy menstrual bleeding:

• Lasts more than 7 days

Holland-Hall C. Heavy
menstrual bleeding in
adolescents:Normal
• Soaking through pads/tampons in 1h for 2-3h in a variant or a bleeding

row disorder.http://contempor
aryobgyn.modernmedicin
e.com/
• Require frequent pad or tampon changes (soaking
more than one every 1-2 hour. M enstruation in girls and
adolescents: using the
• Passing blood clots > 1 inch in diameter (“about menstrual cycle as a vital
sign. Committee Opinion
the size of a quarter”) No. 651. American
College of Obstetricians
and Gynecologists.
Obstet Gynecol
2015;126:e143–6
The menstrual history
For patients reporting heavy menstrual bleeding:

• Using “double protection” (pad plus tampon or 2

pads together) Holland-Hall C. Heavy
menstrual bleeding in
• Flooding or gushing sensation adolescents:Normal variant
or a bleeding

• Frequent “accidents” or leaking through disorder.http://contempora

ryobgyn.modernmedicine.c
protection om/

• Hemorrhage from a corpus luteum M enstruation in girls and

adolescents: using the
• Diagnosed with anemia menstrual cycle as a vital
sign. Committee Opinion
• Associated with history of excessive bruising or No. 651. American

bleeding or a family history of bleeding disorder

College of Obstetricians
and Gynecologists.
Obstet Gynecol
2015;126:e143–6
 MEDICAL history
For patients reporting personal history of >1 of the
following symptoms:
• Epistaxis (>10min, or requiring medical attention), Holland-Hall C. Heavy

spontaneous bruising (>2cm), or minor wound

menstrual bleeding in
adolescents:Normal variant

bleeding (>5min) or a bleeding

disorder.http://contempora
ryobgyn.modernmedicine.c
• Bleeding from oral cavity or GI tract without an om/
obvious anatomic lesion M enstruation in girls and

• Prolonged or excessive bleeding after dental adolescents: using the

menstrual cycle as a vital
extraction or surgery sign. Committee Opinion
No. 651. American

• Hemorrhage that required transfusion College of Obstetricians

and Gynecologists.
Obstet Gynecol
2015;126:e143–6
 MEDICAL history
´Social history –social stressors, substance use,
and exercise patterns, and athletic
competition.
´Family history –bleeding disorders, menstrual
disorders, diabetes and thyroid
´Past medical history – systemic illness, including
hematologic or renal disease, and current or
recent medications
Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;
In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.
 MEDICAL history
´ Sexual history
´contraception and condom use
´number of partners
´history of sexually transmitted infections or
current symptoms (eg, vaginal discharge,
pelvic pain);
´previous pregnancy or abortion
´history of sexual abuse or assault

De Silva N. Abnormal uterine bleeding in adolescents: Evaluation and approach to diagnosis. August 2016. www.uptodate.com
Physical Exam

´Vital signs
´tachycardia and
hypotension may signal
acute hemodynamic
instability and the need for
rapid intervention
´The presence of
tachycardia, pallor, or a
heart murmur suggests
anemia
Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;
In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.
 Physical Exam

´Petechiae or excessive
bruising: may suggest a
platelet defect or another
bleeding disorder.
´Obesity, acne, hirsutism, and
acanthosis nigricans : may be
present in a patient with PCOS.

Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;

In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.

Rydz N and Jamieson M A. M anaging heavy menstrual bleeding in adolescents. 2013. http://contemporaryobgyn.modernmedicine.com/
 Physical Exam

´ Palpation of the thyroid gland for

enlargement or other abnormalities.
´ Examination of the optic fundi and visual
field testing (pituitary tumor)
´ Sexual maturity rating of the breasts and
assessment for galactorrhea.
´ Palpation of the abdomen (pregnancy,
uterine/ovarian mass).
Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;
In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.
Rydz N and Jamieson M A. M anaging heavy menstrual bleeding in adolescents. 2013. http://contemporaryobgyn.modernmedicine.com/
 Physical Exam
´ External inspection of the
genitalia is sufficient for
diagnosis in most patients.
´ A sexually active patient may
warrant a complete pelvic
examination (speculum and
bimanual exams).

Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;

In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.

Rydz N and Jamieson M A. M anaging heavy menstrual bleeding in adolescents. 2013. http://contemporaryobgyn.modernmedicine.com/
 Laboratory evaluation
´ Pregnancy test
´ Complete blood count
including differential and
platelet count; blood typing
´ Measure of iron stores
´ prothrombin time and
activated partial
thromboplastin time

Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;

In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.
 Laboratory evaluation

´ von Willebrand studies (factor VIII,

von Willebrand factor antigen
(VWF:Ag), and ristocetin cofactor
(VWF:RCo) activities.)
´ TSH
´ Test for Chlamydia trachomatis and
Neisseria gonorrhea
´ pelvic ultrasound

Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;

In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.
Laboratory evaluation
´ Patients with a history of
amenorrhea or irregular
bleeding prior to the onset of
heavy bleeding should have:
´FSH and LH
´total and free testosterone
levels
´Dehydroepiandrosterone
´prolactin level

Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;

In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.
TREATMENT
 Management

´ The management of AUB depends

on:
´assessment of whether or not the
patient is hemodynamically stable
´determination of the underlying
cause
´medical management based on
etiology and the severity of
anemia.
Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;
In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.
The goals of treatment are to:
´Establish and/or maintain hemodynamic
stability
´Correct acute or chronic anemia
´Return to a pattern of normal menstrual
cycles
´Prevent of recurrence
´Prevent long-term consequences of
anovulation (eg, anemia, infertility,
endometrial cancer)
Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;
In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.
 Medical treatment
´ The goal of medical therapy is to stabilize the
endometrium with estrogen that will provide initial
hemostasis, followed by progestins for endometrial
stability.

´ Typically, this is achieved with combined oral

contraceptive pills (OCPs) taken continuously for
several months until hemodynamically stable, as
withdrawal of either hormone will cause recurrent
bleeding.
Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;
In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.
Medical treatment
´Episodes of moderate-to-severe
bleeding can typically be treated
effectively with frequent dosing of
combined oral contraceptive pills.

Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;

In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.

Bennet AR and Gray SH. W hat to do when she’s bleeding through: the recognition, evaluation, and
management of abnormal uterine bleeding in adolescents. Curr Opin Pediatr 2014, 26:413–419
Treatment

´ In the absence of an organic cause for excessive uterine

bleeding, it is preferable to use medical instead of
surgical treatment, especially if the woman desires to
retain her uterus for future childbearing or will be
undergoing natural menopause within a short time.
´ the type of treatment depends on whether it is used to
stop an acute heavy bleeding (acute AUB) episode or is
given to reduce the amount of MBL in subsequent
menstrual cycles (Chronic AUB)

Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;

In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.
´A definitive diagnosis is required before
instituting long-term treatment, and should be
made on the basis of hysteroscopy,
sonohysterography, or directed endometrial
biopsies

Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;

In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.
ABNORMAL UTERINE BLEEDING: OVULATORY
DYSFUNCTION

A.Adolescents:
´ after ruling out coagulation disorders, the main direction
of therapy is to temporize because once the HPO axis
matures, the problem will be corrected.
´cyclic progestogen (medroxyprogesterone acetate,
10 mg for 10 days each month for a few months) to
produce reliable and controlled menstrual cycles.
´oral contraceptive (OC)may be an option if the
problem persist beyond 6 months.
Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;
In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.
ABNORMAL UTERINE BLEEDING: OVULATORY
DYSFUNCTION

B. Perimenopausal woman:
´ low-dose (20-µg) combined oral contraceptives( in a
nonsmoking woman).
´ Cyclic Progestogens

C. Reproductive-aged women:
´ chronic anovulatory bleeding is primarily caused by
hypothalamic dysfunction or PCOS.
´ Combined oral contraceptives
Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;
´ cyclic progestogens In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.
 ABNORMAL UTERINE BLEEDING:
ENDOMETRIAL

´ For women with heavy menstrual bleeding, for whom

there is no known cause and anatomic lesions have
been ruled out, the aim of therapy is to reduce the
amount of excessive bleeding.
´ some women with AUB-E have abnormal prostaglandin
production and some have alterations of endometrial
blood ow.
´ Options for treatment to reduce blood loss include:
´ prolonged regimen of progestogens (3 weeks each month);
´ Oral contraceptive pills will reduce the blood loss by at least 35%
in women with AUB
Ryntz T, Lobo R. Chapter 26. Abnormal Uterine Bleeding;
´ levonorgestrel intrauterine system (LNG-IUS) In Comprehensive Gynecology 7th edition, 2017;Lobo RA,
Gershenson DM, Lentz GM, Valea FA editors; pp 621-633.
 NONSTEROIDAL ANTI-INFLAMMATORY
DRUGS
´ prostaglandin synthetase inhibitors that inhibit the biosynthesis of the
cyclic endoperoxides, which convert arachidonic acid to
Ryntz T, Lobo R.
Chapter 26. prostaglandins.
Abnormal
Uterine
Bleeding;
´ block the action of prostaglandins by interfering directly at their
In
Comprehensive
receptor sites..
Gynecology 7th
edition, ´ All NSAIDs are cyclooxygenase inhibitors and thus block the
2017;Lobo RA,
Gershenson DM,
formation of both thromboxane and the prostacyclin pathway.
Lentz GM, Valea
FA editors; pp
Nevertheless, NSAIDs have been shown to reduce MBL, primarily in
621-633. women who ovulate.
´ Examples:
´ mefenamic acid (500 mg, three times daily)
Given in the first 3 days of
´ ibuprofen (400 mg, three times daily), menses or whole duration of
´ naproxen sodium (275 mg, every 6 hours bleeding

after a loading dose of 550 mg)

Anti-fibrinolytic Agents
´ε-Aminocaproic acid (EACA), tranexamic acid
(AMCA), and para-aminomethyl benzoic acid
(PAMBA) are potent inhibitors of fibrinolysis
´their use is somewhat limited by side effects
´ mainly GI side effects and can be minimized by reducing the
dose and limiting therapy to the first 3 to 5 days of bleeding.
´ Due to the increased risks of thrombosis and myocardial
infarction, antifibrinolytic agents should not be combined with
oral contraceptives. Combined treatment with tranexamic acid
and the oral contraceptive pill has been implicated in coronary
ulcerated plaque and acute myocardial infarction

Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;

In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.
 Gonadotropin-Releasing Hormone Agonists
´ GnRH agonists may be used to inhibit ovarian steroid
production, as estrogen production is necessary for
endometrial proliferation.
Ryntz T, Lobo R.
Chapter 26.
Abnormal
´ Because of the expense and menopausal side effects of
Uterine
Bleeding;
these agents, their use is limited to women with severe
In
Comprehensive MBL who fail to respond to other methods of medical
Gynecology 7th
edition, management and wish to retain their childbearing
2017;Lobo RA,
Gershenson DM,
Lentz GM, Valea
capacity.
FA editors; pp
621-633. ´ More commonly, GnRH agonists are an effective means
of bridging patients to surgical treatment, allowing for
correction of anemia.
´ Use of an estrogen or progestogen (add-back therapy)
together with the agonist will help prevent bone loss.
MANAGEMENT OF ACUTE BLEEDING
Acute AUB

´ In women who are bleeding heavily and are

hemodynamically unstable, the quickest way to stop
acute bleeding is with curettage.
´ Curettage should also be the preferred approach for
older women and those with medical risk factors for
whom high-dose hormonal therapy may pose a great
risk.
´ May also be managed medically (pharmacologic
agents)…

Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;

In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.
PHARMACOLOGIC AGENTS FOR ACUTE
BLEEDING

´ To stop acute bleeding that does not require curettage,

the most effective regimen involves high-dose estrogen.
´ High-dose estrogen is aimed at stopping acute
bleeding, and is merely a temporary measure.

Ryntz T, Lobo R. Chapter 26. Abnorm al Uterine Bleeding;

In Com prehensive G ynecology 7 th edition, 2017;Lobo RA,
G ershenson DM , Lentz G M , Valea FA editors; pp 621-633.
Estrogens
´ estrogen in pharmacologic doses causes rapid growth
of the endometrium.
´ a rapid growth of endometrial tissue occurs over the
denuded and raw epithelial surfaces
´ large doses of estrogen may alter platelet activity, thus
promoting platelet adhesiveness.
1. oral conjugated equine estrogen (CEE) 10 mg/day, in four divided
doses

2. IV conjugated estrogen: 25 mg q4-6h until the bleeding stops. (No

more than six doses should be administered)
3. combination oral contraceptive (both estrogen and progestin). Four
tablets of an oral contraceptive containing 30 to 35 µg of estrogen
taken every 24 hours in divided doses.
Ryntz T, Lobo R. Chapter 26. Abnormal Uterine Bleeding;
In Comprehensive Gynecology 7th edition, 2017;Lobo RA,
Gershenson DM, Lentz GM, Valea FA editors; pp 621-633.
 Progestogens
´ For patients with contraindication to estrogen (e.g., those with prior
thrombosis, certain rheumatologic diseases, estrogen-responsive
cancer).
´ Progestogens not only stop endometrial growth but also support and
organize the endometrium so that an organized slough occurs after
their withdrawal.
´ With progestogen treatment, an organized slough to the basalis layer
allows a rapid cessation of bleeding.
Ryntz T, Lobo R.
´ progestogens stimulate arachidonic acid formation in the
Chapter 26.
Abnormal Uterine
endometrium, increasing the PGF2α/PGE ratio.
Bleeding;
In Comprehensive ´ medroxyprogesterone acetate (MPA) at a dose of 60 mg daily (20
Gynecology 7th
edition, 2017;Lobo mg three times daily) for 7 days followed by 20 mg per day for 3
RA,
Gershenson DM, weeks
Lentz GM, Valea
FA editors; pp 621- ´ Depo-MPA 150 mg intramuscularly followed by oral MPA 60 mg (20
633.
mg three times daily) for 3 days
´ norethindrone acetate (30 mg per day)
ANDROGENS

´ Danazol is a synthetic androgen used in doses of 200 mg

daily for the treatment of heavy menstrual bleeding
´ Limited use because of the side effects of weight gain
and skin problems

Ryntz T, Lobo R. Chapter 26. Abnormal Uterine Bleeding;

In Comprehensive Gynecology 7th edition, 2017;Lobo RA,
Gershenson DM, Lentz GM, Valea FA editors; pp 621-633.
 Indications for hospitalization
´Hemodynamic instability (eg, tachycardia, hypotension)
´Hemoglobin concentration <7 g/dL or <10 g/dL with active
heavy bleeding
´Symptomatic anemia (eg, fatigue, lethargy)
´Need for intravenous conjugated estrogen (eg, cannot take
oral medications, continued heavy bleeding after 24 hours of
estrogen-progestin combination therapy)
´Need for surgical intervention (rare)
Ryntz T, Lobo R. Chapter 26. Abnormal Uterine Bleeding;
In Comprehensive Gynecology 7th edition, 2017;Lobo RA,
Gershenson DM, Lentz GM, Valea FA editors; pp 621-633.
De Silva N. Abnormal uterine bleeding in adolescents: M anagement. M arch 2017. www.uptodate.com
Surgical management of Acute
AUB
1. Dilatation and curettage (D&C)

´ Both diagnostic and is therapeutic for the immediate

management of severe bleeding.
´ For women with markedly excessive uterine bleeding
who may be hypovolemic, a D&C is the quickest way to
stop acute bleeding à treatment of choice in
hypovolemic women
´ D&C may be preferred as an approach to stop an
acute bleeding episode in women older than 35 when
the incidence of pathologic findings increases.

Ryntz T, Lobo R. Chapter 26. Abnormal Uterine Bleeding;

In Comprehensive Gynecology 7th edition, 2017;Lobo RA,
Gershenson DM, Lentz GM, Valea FA editors; pp 621-633.
1. Dilatation and curettage (D&C)

´ D&C is only indicated for women with acute bleeding

resulting in hypovolemia and for older women who are
at higher risk of having endometrial neoplasia.
´ All other women, after having an endometrial biopsy,
sonohysterography, or diagnostic hysteroscopy to rule
out organic disease, are best treated with medical
therapy, without D&C.

Ryntz T, Lobo R. Chapter 26. Abnormal Uterine Bleeding;

In Comprehensive Gynecology 7th edition, 2017;Lobo RA,
Gershenson DM, Lentz GM, Valea FA editors; pp 621-633.
2. Endometrial Ablation

´ if medical therapy is not effective or is contraindicated.

´ Exceptions are women who have very large uteri
caused by fibroids or abnormal pathology, such as
endometrial hyperplasia or cancer.
´ Alternative to hysterectomy

Ryntz T, Lobo R. Chapter 26. Abnormal Uterine Bleeding;

In Comprehensive Gynecology 7th edition, 2017;Lobo RA,
Gershenson DM, Lentz GM, Valea FA editors; pp 621-633.
3. Hysterectomy

´ Surgical removal of the uterus.

´ reserved for the woman with other indications for
hysterectomy, such as leiomyoma or uterine prolapse.
´ Usually offered to women with completed family size (no
longer desirous of pregnancy)
´ used to treat persistent abnormal uterine bleeding after
all medical therapy has failed, or medical therapy is
contraindicated.

Ryntz T, Lobo R. Chapter 26. Abnormal Uterine Bleeding;

In Comprehensive Gynecology 7th edition, 2017;Lobo RA,
Gershenson DM, Lentz GM, Valea FA editors; pp 621-633.
 Chronic AUB
´Multiple treatment options are available for long-
term treatment of chronic AUB:
´levonorgestrel intrauterine system
´OCs (monthly or extended cycles)
´progestin therapy (oral or intramuscular)
´tranexamic acid
´NSAIDs

De Silva N. Abnormal uterine bleeding in adolescents: M anagement. M arch 2017. www.uptodate.com