1. Abnormal Uterine Bleeding
By YANG FENG
OBGYN Dept, Nanfang Hospital

2. Normal menstrual duration: 3-7d Normal menstrual cycle: 21-35d Normal blood loss<80ml

3. Abnormal uterine bleeding
Menorrhagia: heavy menstrual bleeding,>80ml Metrorrhagia: bleeding between periods Oligomenorrhea: >35-day cycle length Polymenorrhea: <21-day cycle length Amenorrhea: lack of periods for 3-6m Bleeding after sex Bleeding after menopause

4. Classification—PALM COEIN

5. AUB-O
AUB-O is the result of chronic unopposed estrogen on the endometrium.
Abnormalities at any level of the HPO axis
Rule-out diagnosis

6. HPO Axis and menstrual cycle

7. Evaluation

9. Evaluation General physical: Pelvic examination
Vital signs
signs of PCOS(excessive weight, hirsutism, acne)
signs of thyroid disease(thyroid nodule)
signs of insulin resistance (acathosis nigricans,BMI)
signs of bleeding disorder
(petechiae, ecchymoses, skin pallor, swollen joints)
signs of immune disease(rash, photosensitivity)
Pelvic examination
Speculum: lesions, pap smear if indicated
Bimanual examination

10. Laboratory testing Pregnency tests CBC LFT TSH TCT
Clamydia trachomatis
Targeted screening for bleeding disorders (when indicated)
Determine ovulatory status: cycle charting, BBT

11. Imaging tests when indicated
Transvaginal ultrasound
Sonohysterography
Hysteroscopy
MRI

12. Tissue sampling methods (when indicated)
Endometrial biopsy
>45ys
history of unopposed extrogen exposure
risk factors for endometrial hyperplasia
obesity, PCOS, chronic anovulation,
breast cancer, tamoxifen use,
family history of EMC,BC,CC
failed medical treatment or persistent AUB
Hysteroscopy directed endometrial sampling

13. Aged based differential diagnosis
Neonates
Premenarchal
Early postmenarche
Reproductive age
Perimenopausal
Postmenopausal

14. Aged based differential diagnosis
Neonates:
estrogen withdrawal
Premenarchal:
foreign body
trauma, abuse
cancer
precocious puberty

15. Aged based differential diagnosis
Early postmenarche
pregnancy
anovulation: HPO immaturity (90% of cases)
stress: mental disorder or exercise induced
infection
coagulopathy

16. Aged based differential diagnosis
Reproductive age
pregnancy
anovulation
polyps/fibroids/adenomyosis
medication related (oral contraceptives)
infection
cancer
coagulopathy, endocrine disorder

17. Aged based differential diagnosis
Perimenopausal
Anovulation
Hyperplasia and cancer
Polyp/fibroid/adenomyosis
Postmenopausal
cancer
atrophy
polyp
estrogen therapy
selective extrogen receptor modulators

18. Acute menorrhagia Initial assessment of vital signs
IV assess, blood transfusion if unstable
Stop the bleeding
estrogen, OCP or progestin, tranexamic acid
Foley balloon catheter(tamponade)
Surgical: D&C if persistent heavy bleeding
hysterectomy/embolization as last resort
Long-term maintenance therapy

20. Chronic menorrhagia Medical options Oral contraceptives
Levonorgestrel intrauterine device
GnRH-a
Failed medical therapy or known surgical indication
hysteroscopy
hysterectomy
endometrial ablation

21. Endometrial ablation

22. Case 1 Chief complaint: I’ve been bleeding from my vagina
(58 year-old)

23. History of present illness
58yr obese woman, 6 month history of vaginal bleeding
Menopause: 10 yrs ago
Gyn history: clomiphene for ovulation induction
Denies OCPs or history of STDs
Pap smears: last was normal, 4 mo ago

24. Physical examination VS: BP 155/90 General exam: unremarkable
Pelvic exam: unremarkable

25. Differential diagnosis
Endometrial carcinoma
Endometrial hyperplasia
Endometrial atrophy
Endometrial polyps

26. Initial diagnostic plan
Next step?
Result: Complex hyperplasia with atypia

27. Is it enough by just doing a D&C. NO
Is it enough by just doing a D&C? NO!!! Always reassure there is no cancer

29. Treatment plan Surgical staging exploratory laparotomy TAH+BSO
selective lymph node dissection

30. Case2 Chief complaint: I have heavy periods every few weeks or so
(32yo)

31. HPI 32yr G4P4, irregular, heavy menses q3-4wks Tubal ligation 3yrs ago
Denies bleeding disorders & easy bruising
No vulvar, vaginal or cervical lesions
Dark blood in the vagina with mucosa pink & moist but cervical mucus is thin & watery
Uterus: asymmetric, minimally enlarged but nontener & mobile. No adnexal masses.

32. Differential diagnosis
Pregnancy complications
Anatomic uterine lesion
Anovulation

33. Initial diagnostic plan
Pregnancy test!!!
negative
rules out pregnancy related problems

34. Further diagnostic plan
Transvaginal ultrasound
Hysterosonography

35. Treatment plan

36. Case 3
Chief complaint:
Spotting for a month
(56yo)

37. HPI
56yr, G11P9, still have regular periods. spotting for a month. No vulvar, vaginal or cervical lesions. Uterus: symmetric enlarged, soft and nontender No adnexal masses. Ultrasound: a 6*5cm mass in the uterine cavity.

38. Initial diagnostic plan
Diagnostic fractional curretage
Hydatidiform mole

39. Initial diagnostic plan
Pregnancy test!

40. Review Classification: PALM-COEIN Aged based differential diagnosis
Management of acute menorrhagia

41. References
ACOG Practice Bulletin
Diagnosis of Abnormal Uterine Bleeding in Reproductive-Aged Women
Management of Abnormal Uterine
Bleeding Associated With Ovulatory
Dysfunction
ACOG Committee Opinion
Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women

42. Thank You!
Q&A Time