Abnormal menstruations;

AUB and Dysmenorrhea

ABEBE C (MD)

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Objectives
At the end of this session students will able
to;
 define AUB and DUB
 Describe terminologies of AUB
 Mention structural and functional causes
of AUB
 List management principles of AUB

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AUB
 Definition: any bleeding from the uterus
that differs from the usual menstrual cycle
in frequency, amount, duration of flow

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Physiologic uterine bleeding
It is estrogen progesterone withdrawal
bleeding
 The duration of normal menstrual flow is
generally 5 days(1-8days)
 The normal menstrual cycle typically lasts
between 21 days and 35 days
 Less than 80cc
 It results from the choreographed
relationship between the endometrium and
its regulating factors
 Changes in either of these frequently result
in abnormal bleeding
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AUB incidence
 It affects 10 to 30 percent of
reproductive-aged women and up to 50
percent of perimenopausal women
 Age and reproductive status are great
influences common in adolescents,
perimenopausal women &reproductive
age
 etiologies of bleeding within these
demographics aids in diagnosis and
treatment
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AUB
 It is a common gynecologic complaint
that affect females of all ages
 Menorrhagia defined as prolonged or
heavy cyclic menstruation(≥7 days
or≥8o ml)
 Metrorrhagia describes intermenstrual
bleeding
 menometrorrhagia

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AUB…
 In some women, there is diminished
or shortening of menses, hypomenorrhea
 Normal menstruation typically occurs every 28
days ± 7 days Cycles with intervals longer than
35 days describe a state of oligomenorrhea
 The term withdrawal bleeding refers to the
predictable bleeding that results from an abrupt
decline in progesterone levels
 Postciotal bleeding considered as cervical ca until
proven otherwise
 Polymenorrhea menses that comes in every <21
days

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Postmenopausal bleeding
 bleeding that occurs after 12 months of
amenorrhea in a middle aged woman
 more likely to be caused by pathological
disease
 must always be investigated
 at least ¼ of PMB woman have neoplsia

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AUB…
Difficult to assess objectively
 Extraction of Hgb from sanitary napkins
 Hgb value ≤12g/dl
 The no. of pads used(clots more than one
inch and changing pads within every 3hrs )
 pictorial blood assessment chart (PBAC)
NB; none of them are acurate are accurate

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AUB…etiology
 PALM-COEIN Introduced in 2011 by the
International Federation of Gynecology and
Obstetrics (FIGO)
◦ PALM
polyp,
adenomyosis,
leiomyoma,
malignancy and hyperplasia,
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AUB…
◦ COEIN
coagulopathy,
ovulatory dysfunction,
endometrial,
iatrogenic
not yet classified
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Etiologies based on age group
 Childhood; vaginal than uterine are the
most common causes of bleeding
Vulvovaginitis is the most frequent cause,
but dermatologic conditions,
neoplastic growths, or
trauma by accident,
abuse, or foreign body
Precocious puberty

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Etio…
 Adolescents ;
anovulation
coagulation defects
pregnancy
STD or sexual abuse
Reproductive age;
sexualy transmitted disease
pregnancy related
Myoma ,adenomyosis and endometrial polyps
bleeding increase with age within this age
group
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Etio…
 Perimenopause
anovulatory HPO axis dysfunction
premalignant and malignant conditions
Menopause
endometrial or vaginal atrophy-commenest
benign polyps
endometrial ca
Estrogen producing ovarian tumor
Vulvar ,vaginal and cervical ca

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Dysfunctional uterine bleedg
 DUB is AUB without identified organic cause
 half of women with abnormal bleeding will have
DUB
 The term is further categorized as
anovulatory DUB (80-90%) or
ovulatory DUB
 With this form, bleeding episodes are irregular
and amenorrhea, metrorrhagia and menorrhagia
are common.
Eg. many women with anovulation may be
amenorrheic for weeks to months followed by
irregular, prolonged, and heavy bleeding

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Anovulatory 80-90%
• unopposed est  leads to excessive glandular
proliferation with lack of stromal support
unstable, fragile, hetrogenous endometrium
prone to superficial breakdown and bleeding.

• endometrium slough off in isolated location, the

remaining raw surface is restimulated by est and
heals as another part of endometrium is slough
off

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Anovulatory
 Any factor that interferes with the normal
pulsatile secretion of GnRH leads to an
ovulation
Causes –
.Hyperprolactinemia – P. adenoma,
psychotropic drugs,hypothyroidism
 stress and anxiety
 rapid weight loss
 anorexia nervosa

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Ovulatory DUB
 DUB 2ry to hormonal causes may occur
during ovulatory cycles
 ovulatory pts with AUB are more likely to
have an underlying organic pathology & are
not true DUB ptsThis form of DUB is thought
to stem predominately from vascular dilatation
alone
 vessels supplying the endometrium have
decreased vascular tone and therefore
increased rates of blood loss due to
vasodilatation

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 Patient evaluation
Hx
 Age of menarche and menopause
 Menstrual bleeding patterns
 Severity of bleeding (clots or flooding)
 Pain (severity and treatment)
 Medical conditions medical Hx – sms of endocrine &
other organic diseases
 bleeding tendency & family Hx of bleeding disorder
 sms of stress & sms of PID
 Surgical history
 Use of medications
 Symptoms and signs of possible hemostatic disorder
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Physical examination
 General Physical Exam
 Pelvic Exam
◦ External Speculum Exam
◦ Cervical Cancer Screening
◦ Bimanual Exam

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Laboratory Tests
 Pregnancy test (blood or urine)
 Complete blood count
 Targeted screening for bleeding disorders
(when indicated)†
 Thyroid-stimulating hormone level
 Chlamydia trachomatis

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Imaging
 Saline infusion sonohysterography and
Transvaginal ultrasonography
intra Ux polyps, submucous myoma,
ovarian masses
Ux contour, endometrial thickness
 Magnetic resonance imaging
 Hysteroscopy(Gold standard for Dx of AUB
)
If a structural lesion is suspected based
upon H&P
not required in every woman with AUB

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Hysteroscopy

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Endometrial biopsy
Indication
 those at risk for endometrial hyperplasia
or ca
 those older than 40 yrs of age
 those younger than 40 yrs of age who
have chronic unopposed est breakthrough
bleeding

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 Management
 Depending on the etiology of etiology
1. Hormonal treatment
 progestins(treatment of choice for ano.DUB)
- oral medroxy progesterone acetate 10 mg/day for the 1st
12 days each month or day 16 through 25 of each cycle
 Oral contraceptives
• Convert a fragile, overgrown endometrium into a
pseudo decidualized structurally stable lining
• Controls bleeding with in 24 hrs
 High dose estrogen
• Low dose combined OCP  2 to 3x a day for 5 to 7 days,
then once a day for 3 months.

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2.Medical therapy
 NSAID
inhibit synthesis of PGs
- alter the balance b/n thromboxane &
prostacycline
- effective in ovulatory DUB
 GnRH agonists
down regulate pituitary synthesis of FSH & LH and
induce “medical menopause

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Manag…..
3. Rx coagulation disorder
4. Surgical therapy
 D&C with or without hysteroscopy
 Hysterectomy
5.Endometria ablation
destruction of endometrium

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Dysmenorrhea
 Cyclic pain with menstruation is common
and accompanies most menses
 Classically described as;
lower backache
nausea and vomiting
diarrhea or headache
Primary without an identifiable pathology
Secondary cyclic pain with identified
pathology

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 secondary dysmenorrhea frequently
complicates endometriosis,
leiomyomas,
PID,
adenomyosis,
endometrial polyps, and
menstrual outlet obstruction
IUD
ovarian cysts

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Dysmenorrhea ….
 Compared with secondary
dysmenorrhea, primary dysmenorrhea
more commonly begins shortly after
menarche
 Pain characteristics, however, typically
fail to differentiate between the two
types,
 increased pain duration or severity is
positively associated with earlier age at
menarche, long menstrual periods,
smoking, and increased body mass
index (BMI)
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Pthophysiology
 During endometrial sloughing,
endometrial cells release prostaglandins
as menstruation begins……
 Prostaglandins stimulate myometrial
contractions and incite ischemia
 more severe dysmenorrhea have higher
levels of prostaglandins
 in menstrual fluid, and these levels are
highest during the first2 days of
menstruation.

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Treatment
1. NSAIDs often prefered
acts as COX enzyme inhibitors ---1-3 days before
menses for few days
2. Steroid hormones ;they result in endometrial atrophy
&in turn lower PGS
COC(prefered),implants or DMPA
3. GnRH agonists and androgens >estrogen lowering
effect
5. others (exercise, topical heat,acupancture)
6. Surgery for refractory cases hysterectomy if fertility
needed presacral neurectomy can be done
 etiologic treatment for secondary dysmenorrhea in
adition to the above

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Thank u

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