Abnormal Uterine Bleeding

PDCI
Shon Rowan, M.D.
Dept of Ob-Gyn
 Objectives
1) Understand the physiology of the normal
menstrual cycle
2) Definitions new and old
3) Discuss causes of abnormal uterine bleeding
4) Briefly discuss treatment of abnormal uterine
bleeding
 Case #1
14 y.o.
Thelarche at age 10 3/12
Menarche at age 12 9/12
Menses occur at 3 week to 3 month intervals
Presents with heavy bleeding for the past 7 days
 Case # 2
22 y.o.
Has been on low dose oral contraceptive pills
for 18 months
PMH of regular menses prior to using the pill
Now with almost daily spotting for the past 2
months
 Case #3
29 y.o.
Menarche age 13 with regular menses
Used oral contraceptives from age 18 until
age 26.
Onset of heavy bleeding today
LMP 6 weeks ago
 Case #4
35 y.o. African American
Menarche age 11
Menses always regular but becoming
progressively more heavy and painful over
past 2 years.
Also complains of pelvic pressure
 Case #5
53 y.o. G0
Menarche age 14
Menses always irregular
Stopped having menses at age 50
Now with 3 weeks of spotting
Relevant Anatomy and Histology
 Which hormone is predominant during
follicular phase?
Which hormone is predominant during luteal
phase?
What part of the brain releases GnRH?
http://www.soc.ucsb.edu/sexin
fo/article/the-menstrual-cycle
 Terms and Definitions
Dysfunctional uterine bleeding (DUB)
Term no longer recommended
Intermenstrual bleeding:
Bleeding of variable amounts occurring between regular
menstrual periods
 Menorrhagia:
Prolonged (more than 7 days) or excessive (greater than
80 ml) uterine bleeding occurring at regular intervals
9-14% of women experience menorrhagia

This definition is used for research purposes and in

practice excess bleeding is based on patients perception
 Difficult to determine amount of blood loss by
subjective means
40% of women with >80ml blood loss
considered bleeding amount small or moderate
14% with <20ml blood loss considered
bleeding amount as heavy
Average loss of iron is 13 mg/cycle
70% of loss in first 2 days, 92% by 3 days
 Terms and Definitions
Metrorrhagia:
Uterine bleeding occurring at irregular but
frequent intervals, the amount being variable

Menometrorrhagia:
Prolonged bleeding at irregular intervals
 Terms and Definitions
Polymenorrhea:
Regular uterine bleeding at < 21 day intervals
Oligomenorrhea:
Intervals between bleeding vary from 35 days to 6
months
Amenorrhea:
No menses for at least 6 months

Primary Never had menses

Secondary previously had menses
 Just the Facts
1/3 of all outpatient gyn visits for bleeding
Mean Interval is 28 days; < 21 or >35 days
abnormal
Mean duration is 4 days; more than 7 days is
abnormally prolonged
 There is more variability in cycle for first 5-7
years after menarche and last 10 years before
menopause
 Pictorial Bleeding Assessment Chart
Score > 185 is associated with > 80 ml blood loss
Pts Date
Pad 1 2 3 4 5 6 7 8
1

20
Tampon 1 2 3 4 5 6 7 8
1

20

Daily Score
Abnormal Uterine Bleeding (AUB)
Acute or chronic
Defined: bleeding from uterine corpus that is
abnormal in:
Regularity
Volume
Frequency
Duration
Occurs in absence of pregnancy
 Acute AUB
Heavy bleeding of sufficient quantity to
require immediate intervention
Evaluation:
Assess to determine acuity
Determine etiology
Choose treatment
 Assessment
Prompt evaluation for signs of
hypovolemia
If unstable
Large bore IVs
Prepare for blood transfusion
Evaluate for causes
 Etiologies
Related to uterine structural abnormalities
P
A
L
M
Unrelated to uterine structural abnormalities
C
O
E
I
N
 Uterine abnormalities
P - Polyps
A - Adenomyosis
L - Leiomyoma
M - Malignancy and hyperplasia
 Anatomic Uterine Abnormalities
Endometrial Polyps
 Uterine abnormalities
P - Polyps
A - Adenomyosis
L - Leiomyoma
M - Malignancy and hyperplasia
 Anatomic Uterine Abnormalities
Adenomyosis
 Uterine abnormalities
P - Polyps
A - Adenomyosis
L - Leiomyoma
M - Malignancy and hyperplasia
 Anatomic Uterine Abnormalities
Uterine Fibroids (Leiomyomata uteri)
 Uterine abnormalities
P - Polyps
A - Adenomyosis
L - Leiomyoma
M - Malignancy and hyperplasia
 Malignancies
Endometrial carcinoma
 Malignancies
Leiomyosarcoma
 Non-uterine abnormalities
C -Coagulopathy
O - Ovulatory dysfunction
E - Endometrial
I - Iatrogenic
N - Not yet classified
Clinical Screening for an Underlying Disorder of Hemostasis in the Patient
With Excessive Menstrual Bleeding
Initial screening for an underlying disorder of hemostasis in patients with
excessive menstrual bleeding should be structured by the medical history. A
positive screening result* comprises the following circumstances:

Heavy menstrual bleeding since menarche

One of the following conditions:
Postpartum hemorrhage
Surgery-related bleeding
Bleeding associated with dental work
Two or more of the following conditions:
Bruising, one to two times per month
Epistaxis, one to two times per month
Frequent gum bleeding
Family history of bleeding symptoms
*Patients with a positive screening result should be considered for further
evaluation, including consultation with a hematolo- gist and testing for von
Willebrand factor and ristocetin cofac- tor.
Modified from Kouides PA, Conard J, Peyvandi F, Lukes A, Kadir R. Hemostasis and menstruation:
appropriate investigation for under- lying disorders of hemostasis in women with excessive menstrual
bleeding. Fertil Steril 2005;84:134551.
 D/O blood coagulation
Von Willebrands
Most common inherited bleeding disorder
Affects up to 1% of the population
Only 5% are symptomatic
Prothrombin deficiency
Platelet deficiency or dysfunction
 D/O blood coagulation
Von Willebrands
Among women with menorrhagia the prevalence
ranges from 5% to 15%.
More prevalent among Caucasians with
menorrhagia - 15.9%
Compared with 1.3% of African Americans
 Von Willebrand disease is an autosomally
inherited congenital bleeding disorder
involving a qualitative or quantitative
deficiency of von Willebrand factor (vWF).
Von Willebrand factor is a protein that is
critical for proper platelet adhesion and
protects against coagulant factor degradation.
 Non-uterine abnormalities
C -Coagulopathy
O - Ovulatory dysfunction
E - Endometrial
I - Iatrogenic
N - Not yet classified
 Ovulatory dysfunction
Abnormalities at any level of the
HPO axis can interrupt normal
ovulatory cycle
 Ovulatory dysfunction
Physiologic causes of Anovulation
Adolescence
Perimenopause
Lactation
Pregnancy
 Ovulatory dysfunction
Pathologic causes of Anovulation
Hyerandrogenic anovulation
PCOS
CAH
androgen-producing tumors
Hypothalamic dysfunction (anorexia nervosa)
Thyroid disease
Primary pituitary disease
Premature ovarian failure
Iatrogenic
Medications
 Diagnosis of PCOS
NCIHD, 1990: Consensus panel and
Androgen Excess Society Task Force, 2009
Ovulatory Dysfunction
Androgenic hyperfunction
Rotterdam criteria, 2003: (ASRM/ESHRE)
Ovulatory Dysfunction
Androgenic hyperfunction
Polycystic appearing ovaries
 Diagnosis of PCOS
In the absence of other conditions mimicking
PCOS
Thyroid
Prolactin
CAH
Cushings
Tumor
Can create PCAO by giving exogenous
androgens
 Thyroid disease
Both hypo- and hyperthyroidism can cause
menstrual irregularities from DUB to
amenorrhea
Occurs secondary to alterations in androgen
and estrogen metabolism
 Hyperprolactinemia
Accounts for 10-20% of non-pregnancy
cases of amenorrhea
Appears to be due to LH and possibly FSH
inhibition via GnRH inhibition
Treatment dopamine agonists
Bromocriptine
Carbergoline
 Organic
Disorders of blood coagulation
Von Willebrands
Prothrombin deficiency
Platelet deficiency or dysfunction
Thyroid disease
Hyperprolactinemia
Cirrhosis
Reproductive Tract Disease
 Cirrhosis
Associated with heavy bleeding because the
liver has decreased ability to metabolize
estrogens.
 Non-uterine abnormalities
C -Coagulopathy
O - Ovulatory dysfunction
E - Endometrial
I - Iatrogenic
N - Not yet classified
 Iatrogenic
Hormonal therapy
Contraceptives
 Non-uterine abnormalities
C -Coagulopathy
O - Ovulatory dysfunction
E - Endometrial
I - Iatrogenic
N - Not yet classified
 Endometrial
Endometrial atrophy
 Treatment
Disorders of coagulation
Combined hormonal contraceptives will increase
Factor VIII and in addition will suppress
ovulation and decrease endometrial thickness so
less blood loss
Hypothyroidism and Cirrhosis
Medical therapy
 Accidents of Pregnancy
Most common cause of reproductive age
abnormal uterine bleeding
Miscarriage: Threatened, Incomplete or
Complete Abortion
Ectopic pregnancy
 Accidents of Pregnancy
Gestational Trophoblastic Disease
 Cervical Lesions
Polyp Cancer
 Reproductive tract disease
Vaginal lesions
Foreign bodies
 Case #1
15 y.o.
Thelarche at age 10 3/12
Menarche at age 12 9/12
Menses occur at 3 week to 3 month intervals
Presently with heavy bleeding for the past 7 days
 Most Likely Causes
Anovulatory cycles (Estrogen break-through
bleeding)
Coagulation defect
Thyroid disease
Congenital anomalies
Pregnancy
 Case # 2
22 y.o.
Has been on low dose OCs for 18 months
PMH of regular menses prior to using the pill
Now with almost daily spotting for the past 2
months
 Most Likely Cause
Endometrial atrophy due to low dose OCs
OCPs are mixture of estrogen and progestin or
progestin only
Low dose estrogen may be inadequate to
proliferate the endometrium
Give supplemental estrogen or higher dose
OC
 Case #3
29 y.o.
Menarche age 13 with regular menses
Used oral contraceptives from age 18 until
age 26.
Onset of heavy bleeding today
LMP 6 weeks ago
 Most Likely Causes
Accident of pregnancy
Anovulatory bleeding
Other reproductive tract disease
 Case #4
35 y.o. African American
Menarche age 11
Menses always regular but becoming
progressively more heavy and painful over
past 2 years.
Also complains of pelvic pressure
 Most Likely Causes
Other reproductive tract disease
Fibroids
Accident of pregnancy
Anovulatory bleeding
 Case #5
53 y.o. G0
Menarche age 14
Menses always irregular
Stopped having menses at age 50
Now with 3 weeks of spotting
 Most Likely Causes
Think malignancy
 Treatment
Reproductive Tract disease
Accidents of pregnancy: Surgical or medical
therapy
Malignancy: Surgical, chemotherapy, radiation
Anatomic: Usually treated surgically
Use of Endometrial ablation for specific cases
Foreign Bodies: Vaginoscopy, Exam under
anesthesia
 Dysfunctional Causes
Anovulatory bleeding
Ovulatory bleeding
? Prolonged C.L. (Halbans syndrome)
? Irregular shedding

Iatrogenic (hormonal therapy, ?drugs)

 Treatment
Dysfunctional bleeding (anovulation or other
disorders of ovulation)
Cyclic Progestins, Combined Hormonal
Contraceptives
NSAIDs
PGE2 and PGF2a increase in endometrium during the
menstrual cycle
NSAIDs inhibit PG synthesis and decrease blood loss
 Insulin Sensitizing agents
Progestin containing IUDs
High dose progestins, oral or I.M.
GnRH analogs
? Surgical
Acute Treatment of Heavy Menses
High dose Estrogen
Premarin 25 mg IV every 4 hours for up to 24 hrs
followed by administration of a progestin
High Dose oral contraceptives
Every 6 hours for 2 days, then every 8 hrs for 2 days then
every 12 hours for 2 days then daily for 16 days
High dose Progestins
Provera 20-40 mg/day, Norethindrone 5-10 mg/day
 Summary
Abnormal uterine bleeding can be due to
uterine or structural or non-structural causes
Depending on the stage of the womans
reproductive life span, some diagnoses are
more likely than others.