NORMAL & ABNORMAL UTERINE BLEEDINGSuzanne Bush, MD, FACOGClinical Associate Professor FSU College of Medicine

Objectives• Recognize the characteristics of Normal Menstrual

Bleeding (The LMP as the fourth vital sign!)• Describe the etiologies of Abnormal Uterine Bleeding

(AUB.)• Understand etiologies of AUB with respect to the life

stages of women.• Understand the diagnostic tools to identify the etiology of

the AUB.• State the medical & surgical options available in primary

care and gynecology settings.

Case One• 16 year old G0P0 presents because she is concerned

about her periods being irregular. She describes her cycles as coming the 18th of one month & the 16th the next month. She never knows when it is coming.

• How would you counsel this patient?

How would you counsel this patient?

A. Oral combined contraception pills will regulate her cycles

B. She needs to do 3 months of a menstrual diary using an App on her smartphone

C. She probably has a luteal phase defect and needs progesterone days 15-25.

D. She has normal cycles and needs reassurance.

Normal Menstruation

• The Menstrual Cycle

In the normal menstrual cycle, orderly cyclic hormone production and parallel proliferation of the uterine lining prepare for implantation of the embryo.

Berek & Novak’s Gynecology, 2012, p.145

Normal Menstruation

• “The menstrual cycle starts with the first day of bleeding of one period and ends with the first day of the next. In most women, the cycle lasts about 28 days. Cycles that are shorter or longer by 7 days are normal.”

ACOG Website: FAQ095

The Normal Menstrual Period

•Blood loss < 80 ml (average 30-35 ml)•Duration of flow 2-7 days (average 4 days)•Cycle length 21 - 35 days (average 29 days)

{28 days +/- 7 days}

Phases of the Menstrual CycleReproductive Cycle

• Follicular (variable)• Begins with Menses & ends with luteinizing (LH) hormone

surge

• Ovulation (30-36 hours)• Begins with LH surge and ends with ovulation

• Luteal (14 days)• Begins with the end of the LH surge and ends with onset of

menses

Phases of the Menstrual CycleEndometrium• Proliferative

• Begins with menses and ends at ovulation

• Secretory• Begins at ovulation and ends with menses

Case Two• A 25 year old G0P0 just moved to the area and desires a

pregnancy. She has irregular menses. She was told by her previous doctor that she has polycystic ovarian syndrome (PCOS) and does not ovulate. She has results of a day 21 endometrial biopsy that shows “Secretory Endometrium.” What can you tell this patient?

What can you tell this patient?• The biopsy confirms anovulation

• The biopsy was done on the wrong day

• The biopsy confirms ovulation.

• This patient does not have PCOS

Compare

Phases of the Reproductive Cycle

• Follicular

• Ovulatory

• Luteal

Phases of the Endometrium

• Proliferative

• Secretory

The Normal Menstrual CycleAnother Way of Looking at It

M. Manting; DUB LECTURE 2008

Regulation:Hypothalamic Pituitary Axis

• Hypothalamus is the pulse generator mediated through GnRH

• GnRH cannot be directly measured

• Negative Feedback Loop

Regulation of The Ovary2 Cell Theory

• Theca Cell

• Granulosa Cell

Abnormal Uterine Bleeding (AUB)

• Definition:• Any change in

menstrual period• Flow• Duration• Frequency • Bleeding between cycles

• Prevalence:• 20 million office visits/year

• 25% of visits to gynecologists

Old Terminology

• Menorrhagia • Metrorrhagia • Menometrorrhagia • Polymenorrhea

• Dysmenorrhea• Amenorrhea• Oligomenorrhea• Hypomenorrhea

New Terminology

• Heavy Menstrual Bleeding• Acute• Chronic

• Intermenstrual Bleeding Munro MG, FIGO Classification of AUB 2011

Clinical dimensions of menstruation and the menstrual cycle

Descriptive terms Normal limits (5th to 95th percentiles)

Frequency of menses (days) Frequent <24

  Normal 24–38

  Infrequent >38

Regularity of menses (cycle to cycle variation over 12 months)

Absent No

  Regular 2–20 days

  Irregular >20 days

Duration of flow (days) Prolonged >8.0 days

  Normal 4.5–8.0 days

  Shortened <4.5 days

Volume of monthly blood loss (mL) Heavy >80

  Normal 5–80

  Light <5

History for AUB

• HPI

• Onset

• Quantity : • Spotting or heavy• daily or intermittent

• Duration

Ask lots of questions!

History for AUB

• Associated Symptoms• Pain• Nausea• Fatigue• Headache• Mastalgia

• Gender Specific• Menstrual• Contraception • Gynecologic• Obstetric• Sexual• Genital Infections

Other Important Details

• Family History• Anyone else?• Von Willebrand's• PCOS

• PSH• Nutrition and exercise

• Weight changes• Exercise habits• Diet

• PMH • Chronic conditions

• Liver disease• Kidney disease

• Anemia• Drugs /medications• Psychiatric

medications• Thyroid Disorders• Blood thinners

Case Three• 48 year old G2P2, S/P Bilateral Tubal Ligation 14 years

ago, referred from her primary care office with RLQ pain of 3 months duration. LMP 5 weeks ago has had many years of irregular menses thought to be menopause transition.

• Ultrasound shows an 8 cm adnexal cyst with CA 125 normal.

The next step is:

• Get her on the schedule for surgery

• MRI

• Order Follicle Stimulating hormone(FSH)

• Urine Pregnancy Test

• Estradiol

Pregnancy

Age is not an issue!

Assumption can lead to

death

Never forget pregnancy

Prove it!

Differential Diagnosis Of AUB

• Structural: PALM-COEIN (Non Gravid Women)

• Life Cycles: Pre-menarche Menarche

Reproductive Post-Menopause

• Anatomic: “Bottoms Up”

PALM-COEIN• FIGO Classification System (PALM-COEIN) for causes of

AUB in non gravid women of reproductive age

• Structural vs. Non-Structural

• Developed to create a universally accepted nomenclature

PALMStructural Causes

P- Polyp (AUB-P)

A- Adenomyosis(AUB-A)

L- Leiomyoma (AUB-L)Submucosal myoma (AUB-LSM)

M- Malignancy & hyperplasia (AUB-M)

COEINNon-Structural Causes

C- Coagulopathy (AUB-C)

O-Ovulatory dysfunction (AUB-O)

E- Endometrial (AUB-E)

I- Iatrogenic (AUB-I)

N- Not yet classified (AUB-N)

Case Four

• 42 year old G3P3 who is in your civic group presents with heavy, cyclic uterine bleeding. You note spider angioma across her chest & down her arms. She has a slightly protuberant abdomen. Her husband had a vasectomy 7 years ago, and her pregnancy test is negative.

The best next step in evaluating her heavy uterine bleeding:

• Fasting Blood Glucose

• Thyroid Stimulating Hormone

• Liver Function Test

• Follicle Stimulating Hormone

• Estradiol

What FIGO nomenclature would you use to label her AUB?

• AUB-C

• AUB-O

• AUB-E

• AUB-I

• AUB-N

Liver Disease

• Patients known to have liver disease manifest additional symptomatology because of abnormal hepatic function.

• Evaluate patients for spider angioma, palmar erythema, splenomegaly, ascites, jaundice, and asterixis.

Etiology of AUB

Life Cycles Approach

•E2 withdrawal @birth

•Foreign Body•Sarcoma

•Ovarian Tumor•Trauma

•Coagulation Defects

•Hypothalamic Immaturity

•Psychogenic

•Pregnancy•Anovulation•Endogenous•Exogenous

•Anatomic

•Carcinoma•Vaginal Atrophy•E2 Replacement

•Anatomic

Pre-menarche Menarche Reproductive Post-Menopausal

Differential Diagnosis of AUB

Differential Diagnosis of AUB: Anatomical

• “Bottoms Up”• Vulva• Vagina• Cervix• Ovary• Brain

• Contiguous Anatomy• GU• GI

• Non-Pelvic Etiology• Endogenous• Iatrogenic

EVALUATION OF AUB

YESNO

Acute * Sub-Acute * Chronic

AUB

Initial Assessment

• History & Physical• Vital Signs• Shock Signs

• Laboratory• Pregnancy Test• Complete Blood Count

EvaluationEvaluation of the Uterus & Endometrium

•Endometrial Biopsy•Transvaginal &/or abdominal Ultrasound (TVS/AUS)•Saline Sono-hysteroscopy (SIS)•Hysteroscopy

Endometrial Biopsy (EMB)

• Evaluation of the Endometrium• Pipelle

TVS & SIS

TVS

SIS

Evaluation

Hysteroscopy MRI• Precisely localizes sub-

mucosal fibroids

• MRI is not superior to TVS & SIS in overall diagnostic potential

Dueholm M, et al. Fertil Steril. 2001;76(2):350357

Treatment of AUB• Observation• Medical• Minimally invasive surgery• Major surgery

Medical Management

• Iron• Anti-fibrinolytics• Anti-prostiglandin• Progestins• Estrogen + progestins (OCP)

• Parenteral estrogens• Androgens • GnRH agonists• Anti-progestational agents

Surgical Approach

Minimally Invasive Surgery

• Intrauterine Device (IUD) with progesterone

• Dilation & Curettage

• Endometrial Ablation

Major Surgery

• Myomectomy• Total Abdominal

Hysterectomy (TAH)• Total Vaginal Hysterectomy

(TVH)• Laparoscopic Hysterectomy

• LSH (laparoscopic supra-cervical)

• TLH (total laparoscopic)• LAVH (laparoscopically

assisted vaginal hysterectomy)

• Robotic (TLH or LSH)

Final Case• 32 year old G2P2002 presents to the ER with 10 day

history of heavy uterine bleeding. She is pale and appears frightened. Pulse is 120, BP is 90/60. Hemoglobin is 6, Hematocrit is 18. Pregnancy test is negative.

How do you manage this patient?

The Best Next Step?• Oxygen & IV Fluids

• Type and Cross 2 units of blood

• Order a pelvic ultrasound

• Order TSH, CBC, Coagulation panel

• IV Conjugated Equine Estrogen

• Consent for surgery

Management

Acute AUB• Can be a life-threatening

emergency• Monitor vital signs, Start

oxygen• IV fluids (wide bore IV

catheter)• Type and Cross 2-4 units of

blood

• IV Estrogen• IM Progesterone• NSAIDS (Anti-prostaglandins

vs. Anti-fibrinolytics)• Emergency D&C

Chronic, Stable AUB

• Combined Oral Contraception

• AUB-O progestin therapy• Levonorgestrel IUD• Endometrial sampling is

indicated prior to starting hormones in older women

• Medical failures have the surgical options

Clinical Pearls

Age is Not an Issue!

Never Forget

Pregnancy!

Assumptions CanLead to Death!

PROVE IT!

References

• ACOG Practice Bulletin No. 136, July 2013• Beckmann, et al., Obstetrics & Gynecology, 7th ed.,

Chapters 37, 39• Clinical Management of Abnormal Uterine

Bleeding: APGO Educational Series, May 2002 • Dueholm M, et al. Fertil Steril. 2001;76(2):350357 • Fritz, MA, Speroff et al, Clinical and Gynecologic

Endocrinology and Infertility, 8th ed. 2011. • Manting M., AUB Lecture 2008• Munro, MG, et al, FIGO Classification System

(PALM-COEIN) for causes of AUB in non gravid women of reproductive age. Int J Gynaecol Obstet 2011; 113:3-13