Abnormal Uterine Bleeding

Dr. Majda Komaikh; FRCOG, Reproductive Medicine

Associate Professor, Obstetrics & Gynaecology
Faculty of Medicine
Abnormal Uterine Bleeding

 Common gynaeological symptom, accounting for 25% of

gynaecological surgeries.

 Before menarche

 Childbearing age

 Postmenopausal women
Before Menarche:

 Trauma

 Sexual abuse

 Malignancy
 Childbearing Age:

 Pregnancy-related conditions:
Ectopic pregnancy, miscarriage, trophoblastic disease

 Iatrogenic:
Medications, herbal, HRT, OCP, IUCD

 Systemic disorders:
CAH, Cushing, coagulopathy, thrombocytopenia
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 Pituitary-ovarian axis:
Hyperprolactinemia, PCOS

 Genital tract pathology:

Infection, neoplasm, trauma

 Dysfunctional uterine bleeding (DUB)

Postmenopausal Age:

 HRT

 Atrophic Vaginitis

 Malignancy
 Terms Used to Describe Abnormal Uterine Bleeding

Oligomenorrhea:
Bleeding occurs at intervals of > 35 days and usually is caused by a prolonged follicular
phase.

Menorrhagia:
Bleeding occurs at normal intervals (21 to 35 days) but with heavy flow
( ≥ 80 mL) or duration ( ≥ 7 days

Menometrorrhagia:
Bleeding occurs at irregular, noncyclic intervals and with heavy flow
( ≥ 80 mL) or duration ( ≥ 7 days).

Polymenorrhea:
Bleeding occurs at intervals of < 21 days and may be caused by a luteal-phase

Defect
Amenorrhea:
Bleeding is absent for 6 months or more in a nonmenopausal woman

Postmenopausal bleeding :
Bleeding recurs in a menopausal woman at least 1 year after cessation of cycles
Dysfunctional uterine bleeding:

This ovulatory or anovulatory bleeding is diagnosed after the exclusion of pregnancy

or pregnancy-related disorders, medications, iatrogenic causes, obvious genital tract
pathology, and systemic conditions.
Differential Diagnosis of Abnormal
Uterine Bleeding
Pregnancy and pregnancy-related conditions
Medications and iatrogenic causes
Anticoagulants Ectopic pregnancy
Antipsychotics Miscarriage
Hormone replacement Trophoblastic disease
Intrauterine devices
Oral contraceptive pills,
including progestin-only pills
Tamoxifen

Genital tract pathology Systemic conditions

•Infections: cervicitis, endometritis, Adrenal hyperplasia and Cushing’s dx
myometritis, salpingitis Blood dyscrasias : leukemia/ thrombocytopenia
Coagulopathies
•Benign anatomic abnormalities: Hepatic disease
adenomyosis, leiomyomata,
polyps of the cervix or endometrium Hypothalamic suppression
(from stress, weight loss,
•Premalignant lesions: cervical excessive exercise)
dysplasia, endometrial Pituitary adenoma or
Hyperplasia Hyperprolactinemia

•Malignant lesions: cervical Polycystic ovary syndrome

squamous cell carcinoma, Renal disease
endometrial adenocarcinoma, Thyroid disease
estrogen-producing ovarian
tumors, testosterone-producing
ovarian tumors, leiomyosarcoma
Dysfunctional uterine bleeding
•Trauma: foreign body, abrasions, (diagnosis of exclusion)
lacerations, sexual abuse or assault
 Ovarian Cause

PCOS

•Obesity, acne, oligomenorrhea/secondary amenorrhea

•Unopposed E stimulation, elevated androgen, insulin resistance

•Anovulation

•Treatment: ovulation induction,

progestogens
 Pituitary Cause

Hyperprolactinemia
Symptoms: galactorrhea, olig- ,amenorrhea

Treatment: Bromocriptine, Cabergoline

 Hypothalamic

Hypothalamic disorders:

• Eating disorders

• Stress

• Exercise-induced
 Genital Tract

•Uterine causes:
Fibroid uterus
Endometrial polyp

•Cervical causes:
Endometrial polyp
Cervical cancer
Evaluation of Abnormal Uterine Bleeding:

Diagnostic step Pertinent signs, Conditions

symptoms, and tests
Pelvic pain Abortion, ectopic
History Nausea, vomiting, Pregnancy

Wt gain, cold intolerance Hypothyroidism

Easy bruising, tendency to bleed Coagulopathy

Jaundice, hepatitis Liver dx

Hirsutism, acne,obesity PCOS

Postcoital bleeding Cervical causes

Galactorrhea,headache, visual disturbances Hyperprolactinemia

Thyroid enlargment Hypothyroidism

Physical examination Hepatomegaalt, Bruises Liverdiseases
Enlarged uterus Fibroiduterus
Adnexal mass PCOS

Laboratory Tests
BhCG Pregnancy

CBC Anemia

LFT Liver Dx
TSH,prolctin, Hypothyroidism, hyperprolactnemia

Pap smear Cervical dysplasia

Endometrialbiopsy Endometrial causes

Ultrasoundscan Fibroids, polyps

Hysteroscopy
 Genital Tract

Genital Tract Pathology

Fibroid Menorrhagia

Treatment : Myomectomy
Endometrial polyp

Gross App.

Hysteroscopic Hysteroscopic
Resection Appearance.
Cervical Polyp

Postcoital bleeding, Intermenstrual bleeding

Cervical Cancer

Postcoital bleeding, Intermenstrual bleeding

Dysfunctional Uterine Bleeding (DUB):

• Diagnosis of exclusion
Management

•Medical Treatment
•Minimal invasive surgery
•Surgical treatment
Medical treatment

•OCP
•Progestogens: anovulatory cycles
•Mefenamic acid , Tranxamic acid: Menorrhagia
•Mirena IUCD
Menorrhagia

Mirena releases a low amount of progestin levonorgestrel continuously over a 5-year

period
Endometrial Ablation or Endometrial resection

•Indications

•Procedure

•Complications
Hysterectomy

•Completed her family

•Age

•Seek definite treatment

•Other pathology