CASE 05: ABNORMAL UTERINE BLEEDING

ABNORMAL UTERINE BLEEDING 3. MENOMETRORRHAGIA

 Any form of uterine bleeding that deviates from the  MENO: profuse + METRO: irregular + RRHAGIA: interval
normal menstrual cycle.  Irregular intervals
 Normal: woman is expected to bleed only during menses  Problem: Amount of the flow
4. METRORRHAGIA
Normal Menses  Irregular interval
 Cyclic Bleeding  No pattern
 Duration: 4 - 7 days
 Interval: 28 - 35 days 5. POLYMENORRHEA
 Amount: No more than 80 cc  What if the cycles come too often every 14 to 15 days?
 Cycle: < 21 days
The amount is difficult to quantify, it is determined by getting
the hemoglobin & hematocrit before & after menstruation. 6. OLIGOMENORRHEA
 What if the cycles come once every two months?
Book:  Cycle: > 45 days
Assessment of menstrual blood loss (MBL):  Book: Interval 35 days to 6 months
 MBL measurement: Hgb, serum Fe & serum Ferritin
 More accurate: Alkaline hematic method: Hematin CLASSIFICATION:
To classify AUB, you will have to find out by history, to find the
 Average MBL: 35 – 60 mL (Iron: 13 mg) possible cause
 TV MBL: 2x due to Endometrial Tissue Exudate
1. DYSFUNCTIONAL: Ovulatory or Anovulatory
At age 12, 13 & 14, menstruation may not yet be in the normal 2. ORGANIC: Systemic or Reproductive Tract Disorder
cycle, because there is a certain time the menses may still not
be in normal at the extremes of life during the pubertal age & In the evaluation of a patient with AUB, you have to take note
pre-menopausal period. of the AGE because there are certain causes that are true only
for certain age of the patient
Book: Menstruation is variable in 2 years following menarche,
preceding menopause, times of life during which anovulatory DYSFUNCTIONAL (HORMONAL)
cycles are most frequent.  Diagnosis by EXCLUSION
 Endocrinologic Problem
FORMS:
How would it manifest? Anovulatory Dysfunctional Bleeding
1. INTERMENSTRUAL BLEEDING  Take note of the age of the patient & type of bleeding
 Definition: Bleeding in between menses  Age: Post menarchial & Pre-menopausal
 When would inter-menstrual bleeding be normal?  Type of Bleeding: usually MENOMETRORRHAGIA

 Pattern: Unpredictable, non-periodic, irregular cycles

Jun 16 Jun 28 – 30 July 15  Pelvic Exam: Normal except you will be able to
Day 1 intermenstrual Bleeding Day 1 demonstrate bleeding from the cervix os

A woman may have mid-cycle bleeding that will last for only a
few hours and will only stain the underwear. This will come
every month & will be notice on day 14-15 of the cycle.
This is mid-cycle bleeding or termed: OVULATORY BLEEDING
What is the cause? Why does a woman bleed at the time she is
ovulating?
 In ovulation, there is mechanical extrusion of the egg that
will cause bleeding inside the peritoneal cavity and will
NOT cause bleeding thru the vagina. That bleeding inside
the peritoneum is termed as OVULATORY PAIN or
MITTELSCHMERZ
 Some patient would think they are recently ovulating
because of a pain on one side of the pelvis.
 During this time Estrogen will rise, but just before
ovulation there will be a fall in Estrogen. And it is the fall
of this Estrogen that will trigger the LH surge to cause
ovulation. This will be responsible for the little stains in
underwear known as the KLEINE-REGAL SIGN
2. MENORRHAGIA (HYPERMENORRHEA)
 AKA Heavy Menstrual Bleeding (HMB) (> 7 days)
 Regular intervals
 Problem: Amount of the flow (> 80 mL)
When do you expect this to be normal?

st
Post-menarcheal: 1 2 – 3 years after menarche
Cause: Immaturity of the HPO Axis
Book: Also failure of + feedback of Estradiol to cause LH surge
 Pre-menopausal: about age 45 – 46 may have irregular
menstruation indicating anovulation
Cause: Start of ovarian failure, the follicles in the ovaries
are already depleted
o Female: depletion of follicles
o Male: can manufacture the sperm every 72 days
What would be the main cause? What is absent in the patient?
 Absence of Progesterone & Corpus Luteum
 In TVS, you will be able to see only the thickened
endometrium because of the proliferation of the
O
endometrium 2 to the continuous effect of estrogen & on
Day 20 you will not be able to see the presence of the
corpus luteum
Book:
 Anovulatory: Continuous estradiol production without
corpus luteum formation & progesterone production
 Continuous proliferation  Outgrow BS  Necrosis
Other causes of anovulatory:
 PCOS
 Hypothalamic dysfunction
 Hypothyroidism
 Hyperprolactinemia (> 20 ng/mL)
 Cushing’s Syndrome
TX
To have menstruation:
1. Progesterone
 Supplement: 2nd half of the cycle
 If a woman ovulates on day 14 or 15 of the cycle, by day
15- 16 we expect her to produce her own progesterone so
supplement after supposedly the day I should expect her
to ovulate
 Give her cyclic progesterone (Between Day 16 - 25)
To have pregnancy:
2. Ovulatory Drugs
 Make her ovulate to produce her own progesterone
 If she ovulates from the dominant follicle there will be
ovulation, that follicle per ovulation that took place will
now be converted to corpus luteum which is destined to
produce her own progesterone.
 Drugs: Clomiphene Citrate
To make her menstruation regular:
3. OCP
 To supplement a deficient hormonal status of the patient
To simply stop the bleeding:
4. Danazol, GnRH agonist
 Danazol is a testosterone derivative; if patient stops
bleeding there is no DUB.
Ovulatory Dysfunctional Bleeding
 Normal, Regular, periodic, predictable cycles
 No demonstrable reproductive organ disorder
 Pattern: Menorrhagia (HMB)
Book Cause:
O
o Abnormalities of the platelet plug (1 line of defense)
o ↓ PGF2α (mediates uterine contractility)
o ↑ PGE (vasodilator)
o Excessive uterine production of prostacyclin (vasodilator
PG that opposes platelet adhesion & may interfere with
uterine contractility)
o Abnormal Endothelin & vascular endothelial GF (controls
BV formation)
 PGF2α/PGE is inversely proportional to MBL
TX:
 Anti-prostaglandin or Prostaglandin Synthetase Inhibitor
 NSAIDS
 Hemostatics like Tranexamic Acid
ORGANIC
 Type of Bleeding: usually MENORRHAGIA
 Pattern: Profuse menses, regular intervals
Systemic
Causes:
 Antithrombotics: ASA or Clopidogrel (exogenous)
 Diseases: any form of a blood dyscrasia or hematopoietic
disorder (Hemolytic Anemia, Leukemia, ITP)
 Disorders of Blood Coagulation (vWB disease)
 Cirrhosis (↓ capacity to metabolize Estrogens
That is why for a young girl (Age 14 – 15) presenting with AUB
while you would like to think this is anovulatory DUB because
she is post-menarcheal – ALWAYS R/O BLOOD DYSCRASIA
 Unless indicated by clinical signs: petechiae or ecchymosis
Reproductive Tract Disorders
1. Accidents of pregnancy
 Abortion
 Ectopic pregnancy
 Gestational Trophoblastic Disease (any woman who has
had a recent pregnancy)
 Eclampsia? NO - not unless it causes to an abruption
placenta
When a woman is in the reproductive age group with AUB -
ALWAYS R/O ACCIDENTS OF PREGNANCY
2. Infection of the Upper Genital Tract
What is Puerperium?
 The state of a woman during childbirth or immediately
thereafter, approximate 6-week period lasting from
childbirth to the return of normal uterine size
3. Endometritis
 ENDOMETRITIS following delivery patient may have
delayed post-partum hemorrhage after infection
 Prolonged Menstruation
 More commonly: Episodic inter-menstrual spotting, Pre-
mentrual spotting
4. Malignancies:
 Considered if in elderly age group except when thinking of
cervical cancer because these malignancies may range
from vagina (not common), can be cervical or uterine
Book:
 Endometrial & Cervical Ca > Vagina, vulva, fallopian tube
 Estrogen producing ovarian tumors,
 Granulosa Theca Cell Tumors – Excessive uterine bleeding
Cervical Ca
 Symptom: bleeding every now and then
 Profile/ Risk Factors: Early coitarche, several male partner,
multipara, infection with HPV
 DX: Speculum Exam
 How is bleeding related to contact? Post-coital Bleeding
5. Anatomic Uterine Abnormalities
 Submucus myoma, Endometrial polyp, Adenomyosis
 Prolonged excessive regular uterine bleeding
 Cause: Abnormal vasculature & blood flow, as well as ↑
inflammatory changes
Leiomyomas
 Tumors of myometrium
 Not all would cause AUB, it is only when you are dealing
with the SUBMUCOUS type
Endometrial Polyp
 Tongue like projections within the endometrial lining
 Symptom: INTERMENSTRUAL BLEEDING
 DX Procedure: SIS – observe floating of polyp
 Cannot be a simple UTZ. IF TVS–“thickened endometrium”
6. Cervical Lesions
 Erosion, polyps & cervicitis
 Irregular Bleeding  Post-coital spotting
 DX: Visualization of the cervix
7. Foreign Body
 The presence of foreign body in the form IUD would
present as HMB because that uterus contracts more
during menstruation in its effort to try to expel the IUD
Remember:
 In pathogenesis of Ovulatory DUB, this is all because of an
increase in prostaglandin. That’s why a woman bleeds
more, there is NO organic cause but it is simply because
of prostaglandin which is responsible for myometrial
contraction
8. Iatrogenic Causes:
 Oral & injectable steroids for contraception, HRT,
dysmenorrhea, hirsutism, acne, or endometriosis
 Tranquilizers & other psychotropic drugs may interfere
with the NT responsible for hypothalamic hormones
You will only be able to arrive at these organic causes of
bleeding after pelvic examination or even after doing an
ancillary procedure.
Principle: If you demonstrated an organic cause, the treatment
is towards that organic cause (If it is a polyp take out the polyp)
DX:
Order of Ruling out:
1. R/o systemic cause to dx reproductive tract disorder
2. R/o organic cause to diagnose DUB
 Β hCG – To rule out accidents of pregnancy
 Blood Count & Coagulation profile – To rule out systemic
TVS
 Best route to examine reproductive tract
 Possible Dx: Submucous Myoma, Polycystic Ovaries
 NOT PCOS, a syndrome is something a clinician will make a
diagnosis of. PCOS will be made up of Oligomenorrhea,
Hyperandrogenism & Polycystic Ovaries
 Can be able to see an abnormal lining of the uterus &
thickened endometrium which may mean endometrial
polyp, submucous myoma, endometrial hyperplasia, or
endometrial Ca
 If clinically you suspect it might be a polyp due to
presentation in the history of intermenstrual bleeding
instead a TVS, request for SIS.
HSG
 Primarily for the patency of the tubes
CASE 5
36 year old G1P1 (1011) consulted because of prolonged and profuse menses for the past 4 cycles. She claimed that her menstrual
cycles lasted for 10 days consuming 4 overnight pads per day. Her usual menses lasted for 4 days and she consumes about 3
regular pads per day. PPE: BP – 110/70 PR: 90/min; pale palpebral conjunctiva; Speculum: cervix is pink, smooth with minimal
bleeding per os: IE: cervix – firm, long, closed; uterus – normal in size, anteverted; adnexa – no masses & tenderness.
Type of Bleeding: Menorrhagia, HMB
WORK UP
To rule out ORGANIC cause of the problem: DO TVS
1. Rule out ORGANIC systemic causes:
 Is there presence of epistaxis, gum bleeding while
brushing your teeth, sustained wound bleed for long
 IF POSITIVE: do CBC, platelet, PT, APTT, TSH
Result: All are normal except for ↓ Hgb due to bleeding for 4
months.
2. Rule out ORGANIC reproductive tract disorder cause:
 Polyp? Remember the patient has HMB, not inter-
menstrual bleeding
 Foreign Body? Nothing in the history
 Pregnancy: do β hCG
 Malignancies:
 Cervix is clean: R/o cervical cancer
 No mass in adnexa: R/o possible ovarian malignancy
TVS Result:
 Proliferative endometrium, normal size uterus & ovaries
What is the next thing you need to do?
 See what day of the cycle is she in
 If she is on Day 7or 8 with proliferative endometrium then
it is normal
Hysteroscopy
 - Copy “Scope” meaning endoscopic examination under
minimally invasive surgery directly visualizing the
endometrial cavity
 Advantage: the moment a pathology can be seen, you can
convert from diagnostic to an operative & therapeutic
procedure
D&C
 Dilatation & Curettage
 Tagalog: “RASPA”
 Both diagnostic (GYN) & therapeutic (OB)

O
360 of uterine cavity is sampled
Endometrial Biopsy
 Take only representative samples
 Advantage: do not have to dilate the cervix which is
painful
 An office procedure which can be done in the clinic
Fractional D & C
 Practically not used anymore
 Divide the uterus into 2: Endometrial & Endocervix
 Objective: to find out especially if working diagnosis in
endometrial cancer is confine to the body or involve both
body & cervix.
Note: Gold standard is no longer Fractional D & C, you can just
do endometrial biopsy.
Book
 SHG: to rule out an intracavitary lesion before ascribing
the diagnosis to ovulatory DUB
 Endometrial Biopsy (> 8 mm), if obtained at the onset of
bleeding will show secretory changes (For age: >35, long
history of excessive bleeding)
Remember
 Dysfunctional Uterine Bleeding is diagnosed by exclusion.
 No demonstrable organic cause (RULED OUT)
 Patient experiences REGULAR profuse bleeding pointing
to an OVULATORY cycle.
There is nothing to treat her with hormones, perhaps the
problem is with the hemostatic mechanism. (Look at the
hemostasis of the menstrual cycle)
So this patient may simply need that use of Prostaglandin
Inhibitors, NSAIDS, or supplement it with hemostatics to
address the problem of HMB