Dr. Aya M. Serry Abnormal Uterine Bleeding (AUB) 2016 Pathophysiology Dr. Aya M. Serry Abnormal Uterine Bleeding (AUB) 2016

Definitions Interval: 28 +/- 7 days (21-35 days) Normal menstrual cycle Interval: 28 +/- 7 days (21-35 days) Can change from cycle to cycle Length </= 7 days Flow: Average blood loss: 35ml (20-60ml) Menorrhagia Prolonged – more than 7 days or Heavy – greater than 80ml/day Can be called “hypermenorrhea”

Definitions Polymenorrhea Bleeding occuring at intervals <21 days Oligomenorrhea Intervals between bleeding episodes vary from 35 days to 6 months Amenorrhea No menses for 6 months or more

Etiology of AUB Pregnancy Hormonal Imbalance (hypothalamus /pituitary /ovary) Hemostatic Disorders (systemic and local) Reproductive Tract Pathology

Pregnancy Spontaneous/Incomplete Abortion Gestational Trophoblastic Disease (a term used for a group of pregnancy-related tumors. These tumors are rare, and they appear when cells in the womb start to grow out of control) “Normal Pregnancy”

Hormonal Hormonal Causes of AUB can be devided into : A)ANOVULATORY AUB B)OVULATORY AUB

Hormonal A) Anovulatory AUB (No Luteal Phase): - The corpus luteum does not form in an anovulatory cycle, resulting in a failure of the cyclical secretion of progesterone - Without progesterone, there is continuous unopposed production of estradiol, which stimulates overgrowth of the endometrium. (endometrial hyperplasia) - The endometrium grows thick until it outgrows its blood supply, resulting in necrosis and irregular bleeding

Anovulation or Oligo-Ovulation Pathophysiology In a reproductive age patient who is not having regular menses, must determine if 1. Progesterone Deficient 2. Estrogen and Progesterone Deficient

Anovulation or Oligo-Ovulation Patholophysiology LACK OF PROGESTERONE Estrogen production with lack of progesterone leads to unopposed estrogen stimulation of the endometrium Can result in irregular shedding of the endometrium resulting in unscheduled/heavy bleeding Potential for development of endometrial hyperplasia or cancer.

Anovulation or Oligo-Ovulation Pathophysiology: lack of ESTROGEN and PROGESTERONE Lack of estrogen AND progesterone in reproductive age women can lead to osteoprorosis, increased risk for heart disease, and reduced quality of life Examples: anorexia nervosa, athletic amenorrhea,

Hormonal B) Ovulatory AUB: - Presents as menorrhagia (Abnormally heavy bleeding at menstruation) - A less common cause of AUB; believed to be caused by a defect in local endometrial hemostasis - The mechanism is unknown, but theories include hormonal imbalance and alterations in fibrinolysis.

Systemic Hemostatic Disorders Inherited disorders Example: Hemophilias (medical condition in which the ability of the blood to clot is severely reduced, causing the sufferer to bleed severely from even a slight injury) Acquired disorders Example: Liver Disease Iatrogenic (drug induced ) Anticoagulants NSAIDS

Reproductive Tract Disorders Ovarian and Uterine Lesions Poly Cystic Ovaries (PCOs) Endometrial polyps Endometritis Hyperplasia or cancer

Diagnosis of AUB Your doctor will ask you about your personal and family health history as well as your Menstrual Cycle It may be helpful if you keep track of your menstrual cycle before your doctor visit (dates, length and type of bleeding) You also may have blood tests (hormonal levels check). And a pregnancy test to check if you are pregnant

Diagnosis of AUB Some other tests may be needed to diagnose AUB Including: Sonohysterography: Fluid is placed into the uterus via a thin tube while ultrasound images of the uterus are taken Hysteroscopy: Thin device is inserted through the vagina, allowing your doctor to see inside your uterus Endometrial Biopsy

Treatment of AUB Medications: Birth control Pills Antibiotics Hormonal medications Birth control Pills Antibiotics Anti-inflammatory drugs

Treatment of AUB Surgeries: D&C Surgery to remove abnormal uterine growths (Polyps) Endometrial ablation Hysterectomy (removal of the uterus)