DEFINITION

he evaluation of abnormal uterine

bleeding (AUB) requires characterization
and
quantification
of
the
bleeding,specifically the onset, duration,
frequency, amount,and pattern which is
occurring both within and outside the
menstrual cycle.

MENSTRUAL DIMENSIONS

MENSTRUAL DIMENSIONS
(2)

MENSTRUAL DIMENSIONS (3)

Duration of
menstrual bleeding

Prolonged
> 7 days

DIFFERENTIAL DIAGNOSIS OF
AUB

Ta
bel 1. Differential Diagnosis of AUB by Age Group
Perimenopaus Menopausa
Children
Adolescent
Reproductive
al
l
a.Physiologi a. Anovulatory
a. Pregnancy
a. Anovulatory
a. Atrophy
c
due
to
related
b. Endometrial
b. Endometri
b.Vulvovagin
immaturity of b. Anovulatory
hyperplasia
al
itis
hypothalamic- c. Vaginal/pelvic c. Endometrial
carcinoma
c. Trauma
pituitaryinfection
polyps
c. Endometri
d.Urethral
ovarian axis
d. Pelvic tumor
d. Leiomyomas
al
prolapse
b. Coagulopathy e. Endocrinopath e. Adenomyosis
hyperplasi
e.Endocrinop c. Pregnancy
ies
f. Genital tract
a
athies
d. Vaginal/pelvic f. Coagulopathy
neoplasm
d. Endometri
f. Precocious
infection
al polyp
puberty
e. Benign lesions
e. Leiomyom
g.Ovarian
f. Medications
as
cyst
g. Mllerian
f. Hormone
h.Genital
anomalies
replaceme
tract
h. Genetic
nt therapy
neoplasm
abnormality

Adapted from Shwayder JM. Pathophysiology of abnormal uterine bleeding. Obstet

DIFFERENTIAL DIAGNOSIS OF
AUB (2)

iagnostic Testing

O
rder laboratory serum testing for human chorionic
gonadotropin (-hCG), thyroid stimulating hormone (TSH),
follicle stimulating hormone (FSH), prolactin, and complete
blood count (CBC).

I
n women with risk factors for neoplastic processes a tissue
diagnosis is required.

I
f anovulatory bleeding and pregnancy have been ruled out,
evaluate for coagulation disorders.

EVALUATION OF AUB
ULTRASONOGRAFI
Transvaginal Ultrasonografi (TVUS)
TVUS is useful to evaluated for the presens of fibroids, intrauterine pregnancy and ectopic
pregnancy.
Saline Infusion Sonografi
It is the most sensitive non invasive method of diagnosis for endometrial polyps and
submucous myomata. But, it does not distinguish between benign and malignant processes.
HYSTE
ROSCOPY

The
advantage of this procedure is that it provide direct visualization of the endometrial cavity and
can be performed in the operating room.
MAGN
ETIC RESONANCE IMAGING (MRI)

Can be
useful in the diagnosis adenomiosis and can accurately localize and measure fibroids,
faciltating determination of the best treatment.

EVALUATION OF AUB (2)

ENDOMETRIAL SAMPLING

Recommended for a women over age 35 years with

anovulatory
bleeding and considered in younger women
with a history of
chronic anovulatory bleeding or risk
endometrial carcinoma.
he advantage is a rapid, safe, and cost effective.
potential drawback is that the biopsy does not sample the entire
endometrium and a localized lesion may be missed .

DILATION and CURRETAGE

an be both diagnostic and therapeutic,but incurs the cost of an operating room and
carries the risks of anasthesia.
ts also can be indicated in women with nondiagnostic endometrial biopsi.

C
I

Pregnancy Associated Bleeding

Pregnancy should be suspected in any woman in her
reproductive years.
If urine -hCG is positive, a pelvic examination must be
performed and an ultrasonographic study obtained.
Any patient who is hemodynamically unstable, bleeding
heavily, or septic requires surgical intervention.
Women with missed or incomplete abortions who are
stable and not bleeding heavily may be treated medically
with misoprostol

Dysfunctional uterine bleeding (DUB)

DEFINITION
Dysfunctional uterine bleeding (DUB) is a diagnosis of exclusion for AUB without a
demonstrable pathologic cause and is found in approximately one third of all patients
evaluated.

ETIOLOGY
The predominant causes of DUB are anovulation or oligoovulation.
Anovulation is multifactorial and related to alterations of the hypothalamic-pituitaryovarian axis.
long-term anovulation
estrogen production occurs without the progesterone
produced from the corpus luteum
thus creating an unopposed estrogen state
risk for endometrial hyperplasia
Anovulation is also associated with polycystic ovary syndrome, which also places
women at risk for endometrial hyperplasia.
Morbid obesity
Peripheral conversion of androstenedione to estrone occurs in adipose tissue
producing elevated estrogen levels
Occasionally, DUB may be associated with ovulatory cycles.

Dysfunctional uterine bleeding (DUB) (2)

MANAGEMENT
Administration of progestins
The levonorgestrel-releasing intrauterine system (Mirena)
OCPs also regulate menses and often decrease flow.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Danazol
Antifibrinolytic
Gonadotropin-releasing hormone (GnRH) agonists

SURGICAL TREATMENT

Endometrial ablation is designed to ablate the full thickness of the

endometrium.

Before performing endometrial ablation in a woman with anovulatory

bleeding, endometrial hyperplasia or carcinoma must be ruled out.

overall success rate is 80% to 90%, with 30% to 50% of women reporting
amenorrhea 6 months postprocedure. Still, within 5 years, 15% will have a
second ablation and 20% will have a hysterectomy.

Endometrial ablation is not recommended in women who desire future

fertility.

Pharmacologic Management of
Abnormal Uterine Bleeding

Hormonal
Manageme
nt

Progestin
s

a. Medroxyprogesterone (Provera) 10 mg 3/d

for 14 d (days 12-25); or for 5-10 d
b. Norethindrone acetate (Aygestin) 5 mg
3/d for 14 d (days 12 and 25) for
anovulatory bleeding; or on days 5-25 for
ovulatory bleeding
c. Medroxyprogesterone
acetate
injection
(Depo Provera) 150 mg IM every 12 wk
d. Levonorgestrel-releasing
intrauterine
system (Mirena)

Combined
estrogen
and
progestin
s

a.
b.
c.
d.

Oral contraceptives
Transdermal preparations
Vaginal ring
Hormone replacement therapy

Androgeni Danazol 200 mg/d

c steroids
GnRH
agonists

a. Leuprolide (Lupron) 3.75 mg IM/mo or 11.25 mg

every 3 mo

Pharmacologic Management of
Abnormal Uterine Bleeding (2)
Nonsteroidal Anti-inflammatory a. Mefenamic acid 500 mg 3/d
Drugs (NSAIDs)
b. Ibuprofen 600-800 mg every
6 hr
c. Meclofenamate sodium 100
mg 3/d
d. Naproxen sodium 550 mg
1, then 275 mg every 6 hr
Antifibrinolytic Agents

Tranexamic acid 1 g 4/d on days 1

to 5; or 1.5 g 3/d

Coagulation Disorders
enorrhagia during adolescence should be attributed
to a coagulation disorder until proven otherwise.
Bleeding from multiple sites (e.g., nose, gingiva,
intravenous
sites,
gastrointestinal,
and
genitourinary tracts) may suggest coagulopathy.
here is a higher prevalence of bleeding disorders in
women with menorrhagia.

Von Willebrand Disease

Von
Willebrand disease is the most common inherited bleeding disorder,
affecting 1% to 2% of the population
In
women with vWD, menorrhagia is the most common manifestation,
occurring in 60% to 95% beginning at menarche.
Women
with vWD are also likely to report postpartum or postoperative bleeding.
Other
coagulopathies may also cause AUB, including platelet abnormalities,
idiopathic thrombocytopenic purpura, and hematologic malignancy (e.g.,
leukemia).
Testing
for vWD should be considered in women with a history of unexplained
menorrhagia beginning at menarche.
Screeni
ng for vWD in adolescents with severe menorrhagia before starting
hormonal therapy and in adult women with significant unexplained
menorrhagia.

ENDOCRINE DISORDERS
ndocrinopathies can cause anovulation, producing
an estrogen without progesteron.
he endometrium eventually breaks down, which
may or may not lead to the formation of
hyperplasia.

Hepatic Dysfunction
ecreased metabolism of estrogen and decreased
clotting factor synthesis are common ramifications
of liver failure.
novulation may also ensue. Menometrorrhagia is
common.
iver function tests are necessary to make the
diagnosis,
finding
of
jaundice,
ascites,
hepatosplenomegaly, palmar erythema, pruritus,
and spider angioma are suggestive of liver failure.

Medication Side Effects

Medications
medications used in the treatment of psychiatric patients

Psychotropic
a.Certain

b.Antipsychotic
medications (i.e., dopamine antagonists) Phenothiazines and antidepressants
Hormone
Medications
a.Medroxyprogestero
ne acetate
b.Combination OCPs
c.Progestational
agents
Other Medications
a.Anticoagulants
b.Digitalis,
phenytoin, and corticosteroids
Intrauterine
Devices
a.Copper-containing
intrauterine devices, unlike the levonorgestrel-releasing Mirena intrauterine system
b.Such bleeding is
often treated successfully with NSAIDs.

Benign Pathology
Leiomyomata
Leiomyomata (fibroids) are the most common uterine
neoplasm, and is the number one indication for
hysterectomy in the United States.
Endometrial Polyps
Generally, benign endometrial lesions tend to be
asymptomatic but may be present in 10% to 33% of
women with complaints of bleeding, typically
metrorrhagia.
Endometrial Hyperplasia
Endometrial hyperplasia, a precursor to endometrial
carcinoma, is classified into simple or complex, based on
architectural features, and typical or atypical, based on
cytologic features.

Malignancy
Endometrial Cancer
Endometrial
carcinoma is rare in patients younger than age 40. Postmenopausal bleeding,
should be assumed to represent endometrial cancer until proven otherwise.
Cervical
Cancer
a.Cervical
carcinoma is a disease of both the relatively young and the old it cause abnormal
bleeding.
b.The most
common bleeding patterns associated with cervical carcinoma are intermenstrual
and postcoital bleeding
Ovarian
Cancer
Estrogenproducing ovarian tumors, such as a granulosa-theca cell tumor, can produce
endometrial hyperplasia and AUB.

SUGGESTED READINGS

anagement of Anovulatory Bleeding. ACOG Practice Bulletin

Number 14. American College of Obstetricians and
Gynecologists. Int J Gynaecol Obstet 2001;72(3):263-271.

on Willebrand Disease in Women. ACOG Committee Opinion

Number 451. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2009;114:1439-1443.

acey JV Jr, Chia VM. Endometrial hyperplasia and the risk of

progression to carcinoma. Maturitas 2009;63(1):39-44.

asablanca Y. Management of dysfunctional uterine bleeding.

Obstet Gynecol Clin North Am 2008;35(2):219-234, viii.