Abnormal Uterine

Bleeding
What the Medical Provider Needs to Know about Causes,
Work Up, and Treatment
Janis D. Fee, M.D.
Updated, 2018
 Overview
New Terminology

Causes: Hormonal, Medical, Physical abnormalities, and

Premalignant and Malignant Lesions. Remember:PALM-
COEIN

Work Up: Physical Exam, Labs, Ultrasound, other

diagnostics. D and C vs. EMB. Who needs it?

Treatment: Medical, surgical and other options

Questions
 Terminology
• A Revised Terminology System introduced in 2011 by International Federation
of Gynecology and Obstetrics (FIGO)
• Replaces poorly defined or confusing term, such as
“menorrhagia”,oligomenorrhea,etc.
• Abnormal Uterine Bleeding (AUB) refers to premenopause (reproductive age
as well as menopause transition) plus Postmenopausal Bleeding
• Acronym PALM-COEIN as reminder for causes
What is abnormal uterine
bleeding (AUB)?

Bleeding in any of the following situations is

abnormal:
•Bleeding between periods is Intermenstrual
Bleeding (IMB)
•Bleeding after sex (IMB)
•Spotting anytime in the menstrual cycle for
longer than 5 days (IMB)
•Bleeding heavier or for more days than
normal is Heavy Menstrual Bleeding (HMB)
>80ml blood loss/cycle
•Bleeding after menopause:
Postmenopausal Bleeding
Menstrual cycles that are longer than 35 days
or shorter than 21 days are abnormal. The
lack of periods for 3–6 months (amenorrhea)
also is abnormal.
Irregular Bleeding: most commonly
associated with Ovulatory dysfunction, or
iatrogenic cause
 Description by Heavy
Abnormal Uterine Bleeding Women

Bleeding Heavy
• Very common: 18-50 years old Moderate
prevalence is 53/1000 women
annually
Light-Mod
• AUB has a major impact on
women’s quality of life,
productivity, utilization of Light
healthcare resources
• Somewhat subjective. ¼ of
patients w normal periods
considered them excessive, 40%
of severe bleeders considered
periods normal or even light.
 What is a normal
menstrual cycle?

The menstrual cycle

begins with the first day of
bleeding of one period and
ends with the first day of
the next. In most women,
this cycle lasts about 28
days. Cycles that are
shorter or longer by up to 7
days are normal.
At what ages is abnormal uterine
bleeding more common?

Abnormal uterine bleeding can

occur at any age. However, at
certain times in a woman’s life it is
common for periods to be
somewhat irregular. They may not
occur on schedule in the first few
years after a girl has her first period
(around age 9–16 years). Cycle
length may change as a woman
nears menopause (around age 50
years). It also is normal to skip
periods or for bleeding to get lighter
or heavier at this time.
<21 day cycles are considered
abnormal
Usual Causes of Abnormal Bleeding
 Neonates: estrogen withdrawl
 Premenarche: Trauma, Infection, urethral Prolapse,
Sarcoma, precocious puberty, ovarian tumor
 Early postmenarche: Ovulatory dysfunction, Bleeding
diathesis, stress (psychogenic, exercise), Pregnancy,
Infection
 Reproductive age: Ovulatory dysfunction, Pregnancy,
Cancer, Polyps, Leiomyoma, Adenomyosis, etc
 Menopause transition: Anovulation, Polyps, Fibroids,
Adenomyosis, Cancer
 Menopause: Endometrial atrophy, Cancer, HRT
 Remember: PALM-COEIN
(nonpregnant, ages 20-60)
 Polyps
 Adenomyosis
 Leiomyomas / Fibroids
 Malignancy and Premalignancy/ Hyperplasia
 Coagulopathy
 Ovulatory Dysfunction
 Iatrogenic: IUDs, OCPs, HRT, other medications, etc
 Endometrial: Endometritis, AV abnormalities, etc
 Not classified…. Rarer causes, Csection Niche, etc.
 Endometrial
Polyps
• Common, may be transient
• May be associated with obesity,
high estrogenic states, hyperplasia
• Most are benign
• May represent a “focal” endometrial
lesion on sonography
 Adenomyosis
• Characterized by a tender,
enlarged uterus, with heterogenous
echotexture on sonography
• Often associated with cramping,
chronic pelvic pain
 Leiomyomata:
Fibroids
• The most common structural
abnormality causing increased
bleeding
• Submucous myomas more likely to
produce abnormal bleeding or
cramps
Medical disorders
• Coagulation Defects: need to rule
out, particularly in the younger
patient
• Ovulatory dysfuntion (AUB-O),
often called “dysfunctional
bleeding”
• May be due to PCO or other
causes of anovulation
• Thyroid disease: need to workup
but uncommon cause. AUB in 7%
of hypothyroid pts, vs 1% in normal
controls
 Iatrogenic
• Remember! possible
medication effects
• “breakthrough” on OCPs
• Progestin or steroid
effects
• Anticoagulation effects
• Common usually
temporary effect of
progestin IUDs
 Endometrial Ca
• The MOST common gynecologic
malignancy in the US and most
developed countries
• 2008: 287,000 worldwide,
• U.S. 52,000 cases in 2013, 8600
deaths
• Adenocarcinoma of the
Endometrium is the most common
type
• 75-90% present with AUB
• 68% of women present w/disease
confined to the uterus, with a 96%
5 year survival rate
Endometrial Ca Staging
 Endometrial Ca:  High Risk
Endometrial
Prognosis Cancer includes
Clear cell Ca,
120
deep myometrial
invasion, grade 3
100 disease, Serous
Carcinomas
80
 SEER study (
Grade1
60 1998-2001)
Grade 2
demonstrates
Grade 3
40 effect of grade,
stage on 5 year
20 survival

0
Stage I Stage II Stage III Stage IV
 Risk Factors for Endometrial Cancer
Risk Factor Relative Risk

Increased age Women 50-70 1.4 % risk

Unopposed estrogen 2-10

Late menopause >55) 2

Nulliparity 2

PCO syndrome 3
Obesity 2-4
Diabetes 2

Lynch syndrome 22-50% lifetime risk

Cowden syndrome 13-19% lifetime risk

Tamoxifen 2-4
 Basic Workup for AUB
 Initial Evaluation: Is the uterus the source? Evaluate for
other sources
 Pre or postmenopause? Pregnant or non-pregnant?
 History and Physical : bleeding pattern, symptoms, general
medical, surgical history, meds, risk factors, family history.
Physical exam, targeted as needed.
 Initial labs: HCG if needed, Hgb and Hct.
 Next: Ultrasound, further labs as indicated ( pap,
GCT/culture on cervix, coagulopathy workup if indicated,
iron stores, other metabolic workup such as TSH, CMP.
 Endometrium
thickness on
Sonography
• A normal endometrium thickness
may vary substantially
• “Normal” endometrial thickness is 8-
14mm during midcycle
• Use of a <5mm “threshold” for risk of
endometrial Ca good for
Postmenopausal bleeding.
Sensitivity 96%, Specificity61%
• Less predictive for asymptomatic
postmenopause. Recommended
cutoff of 11mm
• Premenopause: NO standard
threshold. Base decision on
regularity of lining, clinical
situation.TVS on day 4-6
 Next: Endometrial
Assessment: Who needs it?
 Postmenopause: any uterine bleeding, regardless of volume.
Further evaluation of sonographic endometrium of >4mm.
 45 to menopause: any AUB, including intermenstrual bleeding in
ovulatory women. AUB that is frequent, heavy, or prolonged.
 Menarche to 45: AUB that is persistent, failed medical
management or risk factor(s), including obesity, chronic
anovulation.
 AGC on pap- all ages
 Pap with endometrial cells ( nl) when not on period, >40 with AUB
or risk factors
 Lynch syndrome, previous history of hyperplasia of endometrium
Pipelle office Biopsy
 Pipelle biopsy
 This has become the first line of assessment since minimal
to no cervical dilation, local or no anesthesia needed, low
cost
 Less than 50% of the endometrium is sampled
 A large meta-analysis (39 studies) showed this to be
superior in initial sampling to other techniques
 99.6% sensitivity postmenopause, 91% premenopause,
81% specificity for atypical hyperplasia
 Best for global pathology, not a localized lesion
 If insufficient, the clinical situation should dictate further
testing.
 Dilation and
Curettage/Hysteroscopy
• Best for localized
pathology. The “gold”
standard, along with
Hysteroscopy
• When a patient not able to
tolerate a EMB or stenotic
cervix
• Insufficient tissue on EMB
with risk factors or
persistent symptoms
• Additional procedures
(LSC) are needed
• Benign EMB but
persistent AUB noted.
 Abnormal Uterine Bleeding:
Treatment Options
 After an appropriate workup, a trial of medical therapy is ok for low
risk women<45, no risks, or <40 with some, not high risk

 Medical therapy: OCPs, Progestin ( Provera or Norethindrone most

effective), short or longer term

 Progestin IUD an option for those not wanting daily medication.

 Endometrial ablation appropriate for AUB, benign EMB, persistent
symptoms, tried conservative therapy, <12 weeks size uterus, nl
cavity

 Directed therapy for fibroids, including HSC morcellation

 Further surgical therapy, including hysterectomy, UAE, myomectomy,
especially for patients with rapid growth, persistent symptoms
 Important Points:
 Abnormal Uterine Bleeding in the Reproductive Age
group is a common gynecologic complaint, the most
common etiologies being pregnancy, structural uterine
abnormalities, cancer or ovulatory abnormalities
 The initial approach is to confirm that the bleeding is
from the uterus, confirm if possible pregnant and
confirm menopause status.
 Direct further workup to suspected etiology, while
assessing possible risk for malignancy and need for
endometrial assessment
 Important Points (cont)
 Endometrial Cancers are common. Cure rate highly
dependent on Stage at Diagnosis. Most are > 40 years,
not all. Most present with AUB.

 EMB and/or D&C, hysteroscopy important for all PMB,

peri or premenopause with clinical suspicion,
postmenopause with endometrium 5 or above, or
persistent AUB. EMB procedure of choice, but may
require also D and C in focal lesions

 Evaluate for other sources!

 Thank you

Questions: Janis.Fee@stjoe.org or preferred office (714)282-1892