ABNORMAL

UTERINE BLEEDING AND

DYSFUNCTIONAL UTERINE BLEEDING (AUB/DUB)

The mean amount of menstrual blood loss in
once cycle is 35-60mL with an average loss of 13
mg of iron
Abnormal uterine bleeding can take many forms:
o Infrequent episodes
o Excessive flow
o Prolonged duration of menses
o Intermenstrual bleeding.
Alterations in the pattern or volume of blood flow of
menses are among the most common health
concerns of women.
Infrequent uterine bleeding:
o Oligomenorrhea (35 days to 6 months)
o Amenorrhea (no menses for at least 6
months)
Normal Menstrual Flow
o Mean interval of 28 days (7 days)
Interval of 21 days or less is
abnormal
o Mean duration of 4 days
o Few women with normal menses bleed
more than 7 days, so bleeding for longer
than 7 days is considered to be abnormally
prolonged (menorrhagia)
It is useful to document the duration and frequency
of menstrual flow with the use of menstrual diary
cards
Difficult to determine the amount of menstrual blood
loss (MBL) by subjective means

CAUSES

Abnormal Bleeding

Organic Abnormal
Bleeding (AUB)

Systemic
Disease

Reproductive
Tract Disease

Dysfunctional Uterine
Bleeding (DUB)

Anovulatory
Bleeding

Ovulatory
Bleeding

ORGANIC ABNORMAL BLEEDING (AUB)

A. Systemic disease
Disorders of blood coagulation
o Von Willebrand disease and prothrombin
deficiency may present as abnormal uterine
bleeding
Disorders that produce platelet deficiency
o Leukemia, severe sepsis, idiopathic
thrombocytopenic purpura and
hyperspenism can also cause excessive
bleeding

Routine screening for coagulation defects is

indicated for the adolescent who has prolonged
heavy menses beginning at menarche, (unless
clinical signs like petechiae or ecchymosis are
present)
Abnormal bleeding in adults frequently encountered
in women receiving anticoagulation
o Menorrhagia or abnormal intracycle
bleeding
Chronic systemic diseases
o Hepatitis, renal disease, cardiac disease,
coronary vascular disorders
Mechanism: anovulation related to hypothalamic
causes or problems with estrogen metabolism
Endocrine Disorders
Thyroid hormones, prolactin (PRL) and cortisol

B. Reproductive Tract Disease
Accidents of pregnancy in women of reproductive
age
o Threatened, incomplete or missed abortion,
ectopic pregnancy
o Trophoblastic diseasedifferential
diagnosis of abnormal bleeding in a woman
who had a recent pregnancy
o -human chorionic gonadotropin (-HCG)
assay should be performed as part of the
diagnostic evaluation
Malignancy of the genital tract
o Endometrial and cervical cancer
o Vaginal, vulvar and fallopian tube cancer
o Estrogen producing ovarian tumors
Granulosa theca cell tumors
Infection of the upper genital tract-endometritis
Prolonged menses or
intermenstrual spotting (more
common)
Entometriosis- premenstrual spotting
Anatomic uterine abnormalities
o Submucous myomas, endometrial polyps,
adenomyosis
Secondary to abnormal vascular
and blood flow; inflammatory
changes
Cervical Lesions
Erosions, polyps, cercicitis-
postcoital spotting
Diagnosed by visualization of the
cervix
Traumatic vaginal lesions, severe vaginal infections
and foreign bodies
Foreign bodies in the uterus- Intrauterine device
(IUD)
Iatrogenic causes include oral and injectable steroid
use for contraception and hormonal replacement, OR
for the management of dysmenorrhea, hirsutism,
acne or endometriosis

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Tranquilizers and other psychotropic drugs may

interfere with the neurotransmitters responsible for
releasing and inhibiting hypothalamic hormones

DYSFUNCTIONAL (HORMONALLY RELATED)
UTERINE BLEEDING (DUB)
The predominant cause of DUB in the postmenarchal
and premenopausal years is anovulation secondary
to alternations in neuroendocrinologic function

A. Anovulatory bleeding (most common)
Continuous estradiol production without corpus
luteum formation and progesterone production
The steady state of estrogen stimulation leads to a
continuously proliferating endometrium, which may
outgrow its blood supply or lose nutrients with
varying degrees of necrosis
Uniform slough to the basalis layer does not occur,
which produces excessive uterine blood flow
Occurs mostly during the extremes of reproductive
life (first few years of menarche and perimenopause)
Adolescent: immaturity of the HPO axis and failure of
positive feedback of estradiol to cause an LH surge
Perimenopausal: lack of synchronization between
the components of the HPO axis as the woman
approaches ovarian failure
Pattern of anovulatory bleeding
o Oligomenorrhea
o Menometrorrhagia
o Metrorrhagia
o Menorrhagia- most have a normal
duration of menses
20% of women reporting normal menses are
anovulating
Causes:
o Extremes of reproductive life
o Polycystic ovary syndrome (PCOS)- acne,
hirsutism, increased body weight
o Hypothalamic dysfunction- no known cause
or related to weight loss, severe exercise,
stress or drug use
o Abnormalities of non-reproductive
hormones (hypothyroidism,
hyperprolactinemia, hypercortisolism)

B. Ovulatory bleeding (most difficult to treat)
Menorrhagia without uterine lesions, polyps, fibroids
Important to understand how menses ceases each
month to appreciate what can go wrong in ovulatory
DUB:
1. Primary defense- platelet plug
Excessive uterine production of
prostacyclin, a vasodilatory
prostaglandin that opposes platelet
adhesion and interfere with uterine
contractility
2. Uterine contractility mediated by PGF2
Deficiency of PGF2

Excessive production of PGE

(vasodilatory prostaglandin)
Ratio of PGF2/PGE is inversely
related to menstrual blood loss

DIAGNOSTIC APPROACH
Take a thorough history regarding frequency,
duration, amount of bleeding, menstrual pattern
History and PE provide clues about the diagnosis of
PCOS and other disorders
Objective criteria should be used to determine if
menorrhagia (blood loss > 80mL) is present
Indirect assessment by measuring hemoglobin
concentration, serum iron levels, serum ferritin
o Serum ferritin provides a valid indirect
assessment of iron stores in the bone
marrow
-HCG level determination
Sensitive TSH assay and PRL
Androgen level measurements for PCOS is suspected
Coagulation profile
Serum progesterone level determination- ovulation
o Ovulatory DUB- pattern of repetition with
heavy bleeding
Endometrial biopsy
o Women older than 35 years
o Women with long history of excessive
bleeding
o Endometrial lining of >8mm has greater
sensitivity for picking up endometrial
pathology
o <4mm little benefit for biopsy
o Show secretory bleeding if taken at the
onset of bleeding (ovulatory function)
Transvaginal Ultrasound
o Rule out pathology
o Endometrial biopsy guiding
SHG level assay
o Rule out intercavity lesion before ascribing
the diagnosis to ovulatory DUB
Saline sonography/sonohysterography
o Saline or sterile water, 10-15mL is
introduced to the cervix with an
insemination catheter or HSG catheter that
has a balloon for inflation in the cervical
canal, allowing continuous infusion
Hysteroscopy
o Diagnostic and therapeutic (e.g. polyp
removal)
Dilation and Curettage (D&C)

TREATMENT
Goals:
1. Stop an acute heavy bleeding episode
2. Reduce the amount of MBL in subsequent
menstrual cycles

Anovulatory dysfunctional uterine bleeding

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In adolescents: main direction is to

temporize the problem will be corrected
with time and maturity of the HPO axis
o Cyclic progesterone
Medroxyprogesterone acetate 10mg
for 10 days each month for 6
months
o Oral contraceptives
May not be necessary because it
does not allow the HPO to mature
on its own
Option in chronic cases > 6 months

o In perimenopausal women:
Low dose 20g OC pill in a non-
smoking woman
Cyclic progesterones prevent
endometrial tissue from building
up, but cant control bleeding
because of hormonal situation
unpredictability

Ovulatory dysfunctional bleedingReduce the
amount of excessive bleeding
o Local Progesterone Exposure
Progesterone releasing IUD- not
available
Levonorgestrel-releasing
intrauterine system (LNG-IUS)-5
years
o Nonsteroidal Anti-Inflammatory Drugs
(NSAIDs)
Ideal: Block selectively the
synthesis of prostacyclin alone
without decreasing thromboxane
formation/ platelet aggregation
Current NSAIDs- block both
Reduce MBL in ovulating women
Mefanamic acid, Ibuprofen,
Meclofenamate sodium, naproxen
Given at first 3 days of menses or
throughout the bleeding episode
o Antifibrinolytic Drugs
-Aminocaproic Acid (EACA),
tetranexamic acid (AMCA), and
para-aminomethyl benzoic acid
(PAMBA) are potent inhibitors of
fibrinolysis
Side effects: nausea, dizziness,
diarrhea, headaches, abdominal
pain and allergic manifestations
o Androgenic Steroids (Danazol)
Side effects: weight gain and acne
o Gonadotropin-Releasing Hormone Agonists
Inhibit ovarian steroid production
with GnRH agonists
Limited to women with severe MBL
who fail to respond to other
methods of medical management
o

and with to retain their

childbearing capacity



MANAGEMENT OF ACUTE BLEEDING
Pharmacologic Agents
o Estrogens
Diagnosis independent
Temporary measure
Estrogen causes rapid growth of the
endometrium over the denuded and
raw epithelial surfaces
High doses of oral or IV estrogen
will stop acute bleeding episodes in
most cases of abnormal bleeding
o Progesterone
Stop endometrial growth and
support and organize the
endometrium so that an organized
slough occurs after their
withdrawal
Increase PGF2/PGE ratio
Oppose the effects of estrogen in
anovulatory women

SURGICAL THERAPY
Dilation and Curettage
o Diagnostic and therapeutic
o Treatment of choice for women suffering
from hypovolemia
o Preferred approach for older women and
with those with medical risk factors for
whom high dose hormonal therapy might
pose a great risk (endometrial neoplasia)
o Only treats the acute episodes of excess
uterine bleeding, not subsequent episodes

Endometrial Ablation (EA)
o If medical therapy is not effective
o Exceptions are women who have very large
uteri caused by fibroids, endometrial
hyperplasia or cancer
o Resectoscopic EA is carried out with a loop
electrode, roller ball or grooved or spiked
electrode to vaporize the endometrium

Hysterectomy
o Removal of the uterus
o Reserved for a woman with other
indications for hysterectomy such as
leiomyoma or uterine prolapse.
o Should only be used to treat persistent
ovulatory DUB after all medical therapy has
failed and the amount of MBL has been
documented to be excessive by direct
measurement of abnormally low serum
ferritin levels

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