Armando Hasudungan
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Abnormal Uterine Bleeding

Overview Abnormal uterine bleeding (AUB) is a common gynecologic complaint, accounting for one-third of outpatient visits to gynecologists. AUB can be caused by a wide variety of local and systemic diseases or related to medications. The most common etiologies in nonpregnant women are structural uterine pathology, anovulation, disorders of hemostasis, or neoplasia. This section will mainly focus […]

Overview Abnormal uterine bleeding (AUB) is a common gynecologic complaint, accounting for one-third of outpatient visits to gynecologists. AUB can be caused by a wide variety of local and systemic diseases or related to medications. The most common etiologies in nonpregnant women are structural uterine pathology, anovulation, disorders of hemostasis, or neoplasia. This section will mainly focus on adults who are not pregnant. AUB includes amenorrhoea, menorrhagia, polymenorrhoea, oligomenorhea, intermenstrual bleeding, etc.

Definition
AUB: refers to menstrual bleeding of abnormal quantity, duration, or schedule
Menorrhagia: Abnormal heavy bleeding at menstruation
Dysmenorrhea: Painful menstruation
Amenorrhea: refers to absence of bleeding for at least three usual cycle lengths.

Normal Anatomy and Physiology of the menstrual Cycle

The characteristics of normal menstrual bleeding are

  • Frequency every 21 to 35 days
  • Occurs at fairly regular intervals
  • Volume of blood ≤80 mL
  • Duration is 5 days

 

Female Reproductive Cycle

Differential Diagnosis – PALM-COIEN

Structural Causes – PALM

  • Pregnancy
  • Polyps
  • Adenomyosis
  • Leiomyoma (Myoma or fibroid)
  • Malignancuy

Systemic and Iatrogenic – COIEN

  • Coagulation
  • Ovulatory dysfunction
  • Iatrogenic
  • Endometrium
  • Not yet classified
Think The most common cause of AUB in pubertal adolescents is anovulation due to an immature hypothalamic pituitary axis. Other common causes include pregnancy, infection, the use of hormonal contraceptives, stress (psychogenic or exercise induced), bleeding disorders, and endocrine disorders (eg, hypothyroidism, polycystic ovary syndrome)
Remember Dysfunctional uterine bleeding is defined as AUB without an identifiable pathologic condition

History and Examination

  • General History
  • Is the uterus the source of the bleeding? 
  • Is the patient premenarchal or postmenopausal? — The differential diagnosis of AUB for reproductive-age women differs from that of premenarchal or postmenopausal patients. Thus, it is important to establish the reproductive status of the patient.
    More info on Per Vaginal bleeding (Postmenopausal) 
  • Is the patient pregnant? — All patients with AUB should have pregnancy testing.
  • What is the bleeding pattern? Abnormal menstrual cycle?
 Remember Consider local gynaecological and non-gynaecological causes of bleeding

Investigations

  • Full Blood Count
  • EUC
  • Serum B-HCG
  • Urine B-HCG
  • Coagulation test
  • Endocrine investigations
    • Thyroid Function Test
    • Prolactin levels
    • Androgen levels
    • Oestrogen leves
    • FSH and LH levels
  • Pevlic Ultraound → if not effective transvaginal ultrasound
  • Saline infusion sonography
  • Hysterectomy
Side note Saline infusion sonography (also called sonohysterography) is a technique in which sterile saline is instilled into the endometrial cavity and a transvaginal ultrasound examination is performed. This procedure allows for an architectural evaluation of the uterine cavity to detect lesions (eg, polyps or small submucous fibroids) that may be missed or poorly defined by transvaginal sonography alone

After pregnancy has been excluded, endometrial sampling should be performed in women with AUB at an increased risk of endometrial hyperplasia or cancer.

Increased risk of endometrial cancer
Post-menopausal women
Age >45 to menopause
Endometrial hyperplasia
Tamoxifen use
Unopposed endogenous/exogenous oestrogen
Family history of endometrial cancer
Family history of ovarian and breast cancer
Lynch syndrome
Radiotherapy

 

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