Abnormal Uterine Bleeding

Female Reproductive System & Breast


Clinicals - History

Fact Explanation

Introduction


Abnormal uterine bleeding (AUB) is any type of bleeding from the uterus that is out of the range of normal menstruation. It is a common complaint that is often multifactorial, and that can significantly interfere with the woman's quality of life.


The mnemonic "PALM-COEIN" can be used to recall the etiologies causing AUB. Here, "PALM" refers to structural causes, i.e., polyps, adenomyosis, leiomyoma, and malignancy; COEIN refers to non-structural causes, i.e., coagulopathies, ovulatory disorders, endometrial disorders, iatrogenic procedures, and "not otherwise classified" conditions.

AUB: heavy menstrual bleeding


AUB can present as heavy menstrual bleeding (HMB), i.e., a blood loss of >80 mL per cycle, with or without additional symptoms. This was previously termed "hypermenorrhea".


In the absence of additional findings, this form of AUB is associated with ovulatory cycles.

AUB: prolonged menstrual bleeding


AUB can manifest as prolonged menstrual bleeding, i.e., menstruating for >8 days. This was previous called "menometrorrhagia". This finding is suggestive of anovulation.

AUB: irregular menstrual bleeding


AUB can also manifest as irregular menstrual bleeding, i.e., occurring at intervals with a 20 day variation or more; earlier this was termed "menometrorrhagia". Similar to prolonged menstrual bleeding, this too is suggestive of anovulation.

AUB: intermenstrual bleeding


AUB can present as bleeding that occurs outside the normal menstrual period. Earlier, this was termed "metrorrhagia". This is triggered by poor corpus luteal development and inadequate progesterone secretion.

Bladder and bowel dysfunction


The presence of associated obstructive or irritative bowel and bladder symptoms is strongly suggestive of uterine fibroids.

Pelvic pain


The presence of chronic pelvic pain favors adenomyosis, especially if this is markedly exacerbated during menstruation. Acute severe pelvic pain may occur in fibroid degeneration.

Subfertility


Subfertility is a common accompaniment. When associated with intermenstrual bleeding, this is more likely to be due to hormonal imbalances. Alternately, this may be due to structural causes (e.g., uterine polyps and fibroids) distorting the uterine cavity and interfering with implantation.

Symptoms of anemia


Symptoms of anemia include fatigue, weakness, pallor, and dizziness. These are typically a consequence of HMB.

Introduction


Abnormal uterine bleeding (AUB) is any type of bleeding from the uterus that is out of the range of normal menstruation. It is a common complaint that is often multifactorial, and that can significantly interfere with the woman's quality of life.


The mnemonic "PALM-COEIN" can be used to recall the etiologies causing AUB. Here, "PALM" refers to structural causes, i.e., polyps, adenomyosis, leiomyoma, and malignancy; COEIN refers to non-structural causes, i.e., coagulopathies, ovulatory disorders, endometrial disorders, iatrogenic procedures, and "not otherwise classified" conditions.

AUB: heavy menstrual bleeding


AUB can present as heavy menstrual bleeding (HMB), i.e., a blood loss of >80 mL per cycle, with or without additional symptoms. This was previously termed "hypermenorrhea".


In the absence of additional findings, this form of AUB is associated with ovulatory cycles.

AUB: prolonged menstrual bleeding


AUB can manifest as prolonged menstrual bleeding, i.e., menstruating for >8 days. This was previous called "menometrorrhagia". This finding is suggestive of anovulation.

AUB: irregular menstrual bleeding


AUB can also manifest as irregular menstrual bleeding, i.e., occurring at intervals with a 20 day variation or more; earlier this was termed "menometrorrhagia". Similar to prolonged menstrual bleeding, this too is suggestive of anovulation.

AUB: intermenstrual bleeding


AUB can present as bleeding that occurs outside the normal menstrual period. Earlier, this was termed "metrorrhagia". This is triggered by poor corpus luteal development and inadequate progesterone secretion.

Bladder and bowel dysfunction


The presence of associated obstructive or irritative bowel and bladder symptoms is strongly suggestive of uterine fibroids.

Pelvic pain


The presence of chronic pelvic pain favors adenomyosis, especially if this is markedly exacerbated during menstruation. Acute severe pelvic pain may occur in fibroid degeneration.

Subfertility


Subfertility is a common accompaniment. When associated with intermenstrual bleeding, this is more likely to be due to hormonal imbalances. Alternately, this may be due to structural causes (e.g., uterine polyps and fibroids) distorting the uterine cavity and interfering with implantation.

Symptoms of anemia


Symptoms of anemia include fatigue, weakness, pallor, and dizziness. These are typically a consequence of HMB.

Clinicals - Examination

Fact Explanation

General examination: Obesity


Obesity is a risk factor for heavy menstrual bleeding (HMB).


Estrogen levels are elevated due to conversion of androstenedione into estrone by the adipose tissue; this stimulates endometrial growth, thus predisposing to increased menstrual bleeding.

General examination: Pallor


Pallor on physical examination may indicate anemia secondary to HMB.

General examination: tissue hemorrhages


The presence of petechiae, purpura, ecchymoses, or gum bleeding suggests at an underlying bleeding disorder.

General examination: signs of systemic disease


The presence of stigmata suggestive of thyroid disease, Cushing syndrome, or hyperandrogenism may indicate an endocrinopathy causing the AUB.

Pelvic examination: visualization of the cervix


Visualization of the cervix may reveal an ectropion, cervical polyp, intrauterine fibroid extruding through the cervical canal, or features of malignancy.

Pelvic examination: enlarged uterus


Uterine enlargement suggests at fibroids.

Pelvic examination: tender and bulky uterus


A tender and bulky uterus on bimanual examination may indicate adenomyosis.

Pelvic examination: pelvic mass


The presence of a pelvic mass may suggest fibroids, adenomyosis, or a possible malignancy.

General examination: Obesity


Obesity is a risk factor for heavy menstrual bleeding (HMB).


Estrogen levels are elevated due to conversion of androstenedione into estrone by the adipose tissue; this stimulates endometrial growth, thus predisposing to increased menstrual bleeding.

General examination: Pallor


Pallor on physical examination may indicate anemia secondary to HMB.

General examination: tissue hemorrhages


The presence of petechiae, purpura, ecchymoses, or gum bleeding suggests at an underlying bleeding disorder.

General examination: signs of systemic disease


The presence of stigmata suggestive of thyroid disease, Cushing syndrome, or hyperandrogenism may indicate an endocrinopathy causing the AUB.

Pelvic examination: visualization of the cervix


Visualization of the cervix may reveal an ectropion, cervical polyp, intrauterine fibroid extruding through the cervical canal, or features of malignancy.

Pelvic examination: enlarged uterus


Uterine enlargement suggests at fibroids.

Pelvic examination: tender and bulky uterus


A tender and bulky uterus on bimanual examination may indicate adenomyosis.

Pelvic examination: pelvic mass


The presence of a pelvic mass may suggest fibroids, adenomyosis, or a possible malignancy.

Differential Diagnoses

Fact Explanation

Cause of AUB: polyp


Endometrial polyps are an abnormal outgrowth of hypertrophied endometrial tissue. They are a widely accepted cause for AUB.


However, most polyps are asymptomatic; therefore, alternative explanations for AUB should still be considered and excluded before concluding that the polyp is the source of bleeding.

Cause of AUB: adenomyosis


Adenomyosis refers to the invasion of the myometrium by endometrial glands and stroma. This affects myometrial contractility, giving rise to AUB.


Unfortunately, adenomyosis often co-exists with other uterine pathologies such as fibroids, polyps and endometrial hyperplasia; it is uncertain how much it alone contributes to AUB.

Cause of AUB: fibroids


Fibroids are often encountered in women with AUB. However, it is important to note that most fibroids are asymptomatic; alternate causes for the bleeding should be considered before concluding that the fibroids are the culprit.

Cause of AUB: gynecological malignancies


Cervical cancer should be considered in women with recurrent intermenstrual bleeding. Endometrial carcinoma can give rise to irregular and prolonged menstrual bleeding, but is rare in premenopausal women. Ovarian cancer is a rare cause of AUB.

Cause of AUB: coagulopathy


AUB may be the result of previously unrecognized innate or acquired coagulopathies. This possibility should be particularly considered in the following situations:


- If the woman has had heavy bleeding since menarche;

- If there is a history of postpartum haemorrhage;

- If she has experienced surgical and/or dental related-bleeding;

- If she has recurrent and unexplained bruising, epistaxis, or frequent gum bleeding;

- If she has a positive family history of bleeding disorders;

- If she has symptoms and signs suggesting chronic hepatic, renal, or metabolic dysfunction.

Cause of AUB: ovulatory disorders


If pattern of bleeding suggests anovulation, possibilities to consider include: hypothalamic-pituitary-ovarian (HPO) axis disorders; endocrinopathies such as polycystic ovarian syndrome, hypothyroidism, or hyperprolactinemia; mental and physical stress; obesity; anorexia; and extreme exercise.


Furthermore, AUB experienced at the extremes of reproductive age suggests at ovulatory dysfunction.

Cause of AUB: other endometrial pathologies


HMB occurring in patients with regular menstrual cycles, a structurally normal uterus, and no evidence of coagulopathy or other systemic disease is likely to be due to an underlying endometrial cause.


Due to the lack of specific tests, this is currently a diagnosis of exclusion.

Cause of AUB: iatrogenic interventions


Iatrogenic AUB is usually a result of hormonal disturbances due to estrogen or progestins; gonadotropin-releasing hormone (GnRH) agonists; aromatase inhibitors; or certain anticonvulsant, antibiotic, antipsychotic, or anticoagulant medications.


Furthermore, intrauterine devices can give rise to a low-grade endometritis causing or contributing to AUB.

Cause of AUB: causes not otherwise classified


Arteriovenous malformations, endometrial pseudoaneurysms, myometrial hypertrophy, and chronic endometritis example rare causes of AUB that do not easily fit in to the "structural" vs "nonstructural" classification.

Differential diagnosis: non-uterine bleeding


Not all vaginal bleeding should be presumed to originate from the uterus.


Examples of common non-uterine causes of bleeding which can be mistaken for AUB include: cervical ectropion, vaginal atrophy, inflammatory lesions, vulvo-vaginal malignancies, bleeding from the urinary tract, sexual abuse, and trauma.

Differential diagnosis: gestational bleeding


In all patients with AUB, pregnancy must be ruled out. Abortion, ectopic pregnancy, and hydatidiform moles can all mimic AUB.

Differential diagnosis: postcoital bleeding


Postcoital bleeding is a form of vaginal bleeding that occurs after intercourse and is unrelated to menstrual periods. As an isolated complaint, it should prompt the consideration of cervical pathologies, including malignancy.

Differential diagnosis: contraceptive-induced bleeding


Irregular bleeding may occur in association with hormonal contraception; this is termed "breakthrough" bleeding. Furthermore, the scheduled bleeding of oral combined contraceptive pills is called "withdrawal" bleeding. Neither of these represent AUB.


Intrauterine contraceptive device can also give rise to irregular or unscheduled bleeding.

Differential diagnosis: bleeding due to a cesarean scar defect


Cesarean scar defects are associated with AUB, in the form of prolonged menstruation. This possibility should be considered in women with a past history of caesarean birth.

Cause of AUB: polyp


Endometrial polyps are an abnormal outgrowth of hypertrophied endometrial tissue. They are a widely accepted cause for AUB.


However, most polyps are asymptomatic; therefore, alternative explanations for AUB should still be considered and excluded before concluding that the polyp is the source of bleeding.

Cause of AUB: adenomyosis


Adenomyosis refers to the invasion of the myometrium by endometrial glands and stroma. This affects myometrial contractility, giving rise to AUB.


Unfortunately, adenomyosis often co-exists with other uterine pathologies such as fibroids, polyps and endometrial hyperplasia; it is uncertain how much it alone contributes to AUB.

Cause of AUB: fibroids


Fibroids are often encountered in women with AUB. However, it is important to note that most fibroids are asymptomatic; alternate causes for the bleeding should be considered before concluding that the fibroids are the culprit.

Cause of AUB: gynecological malignancies


Cervical cancer should be considered in women with recurrent intermenstrual bleeding. Endometrial carcinoma can give rise to irregular and prolonged menstrual bleeding, but is rare in premenopausal women. Ovarian cancer is a rare cause of AUB.

Cause of AUB: coagulopathy


AUB may be the result of previously unrecognized innate or acquired coagulopathies. This possibility should be particularly considered in the following situations:


- If the woman has had heavy bleeding since menarche;

- If there is a history of postpartum haemorrhage;

- If she has experienced surgical and/or dental related-bleeding;

- If she has recurrent and unexplained bruising, epistaxis, or frequent gum bleeding;

- If she has a positive family history of bleeding disorders;

- If she has symptoms and signs suggesting chronic hepatic, renal, or metabolic dysfunction.

Cause of AUB: ovulatory disorders


If pattern of bleeding suggests anovulation, possibilities to consider include: hypothalamic-pituitary-ovarian (HPO) axis disorders; endocrinopathies such as polycystic ovarian syndrome, hypothyroidism, or hyperprolactinemia; mental and physical stress; obesity; anorexia; and extreme exercise.


Furthermore, AUB experienced at the extremes of reproductive age suggests at ovulatory dysfunction.

Cause of AUB: other endometrial pathologies


HMB occurring in patients with regular menstrual cycles, a structurally normal uterus, and no evidence of coagulopathy or other systemic disease is likely to be due to an underlying endometrial cause.


Due to the lack of specific tests, this is currently a diagnosis of exclusion.

Cause of AUB: iatrogenic interventions


Iatrogenic AUB is usually a result of hormonal disturbances due to estrogen or progestins; gonadotropin-releasing hormone (GnRH) agonists; aromatase inhibitors; or certain anticonvulsant, antibiotic, antipsychotic, or anticoagulant medications.


Furthermore, intrauterine devices can give rise to a low-grade endometritis causing or contributing to AUB.

Cause of AUB: causes not otherwise classified


Arteriovenous malformations, endometrial pseudoaneurysms, myometrial hypertrophy, and chronic endometritis example rare causes of AUB that do not easily fit in to the "structural" vs "nonstructural" classification.

Differential diagnosis: non-uterine bleeding


Not all vaginal bleeding should be presumed to originate from the uterus.


Examples of common non-uterine causes of bleeding which can be mistaken for AUB include: cervical ectropion, vaginal atrophy, inflammatory lesions, vulvo-vaginal malignancies, bleeding from the urinary tract, sexual abuse, and trauma.

Differential diagnosis: gestational bleeding


In all patients with AUB, pregnancy must be ruled out. Abortion, ectopic pregnancy, and hydatidiform moles can all mimic AUB.

Differential diagnosis: postcoital bleeding


Postcoital bleeding is a form of vaginal bleeding that occurs after intercourse and is unrelated to menstrual periods. As an isolated complaint, it should prompt the consideration of cervical pathologies, including malignancy.

Differential diagnosis: contraceptive-induced bleeding


Irregular bleeding may occur in association with hormonal contraception; this is termed "breakthrough" bleeding. Furthermore, the scheduled bleeding of oral combined contraceptive pills is called "withdrawal" bleeding. Neither of these represent AUB.


Intrauterine contraceptive device can also give rise to irregular or unscheduled bleeding.

Differential diagnosis: bleeding due to a cesarean scar defect


Cesarean scar defects are associated with AUB, in the form of prolonged menstruation. This possibility should be considered in women with a past history of caesarean birth.

Investigations - Diagnosis

Fact Explanation

Pictorial blood assessment chart


The patient's perception of the severity of bleeding does not always correlate with the objective degree of blood loss. At present, the most effective method of quantifying the severity of blood loss is via a pictogram questionnaire.

Pregnancy testing


Testing for pregnancy is mandatory, so as to rule out uterine bleeding due to ectopic pregnancy, abortion, or hCG secreting tumors.

Complete blood count


A complete blood count is mandatory in all women with HMB, especially if symptoms of anemia are present. Importantly though, a normal hemoglobin level does not exclude HMB.

Coagulation studies


Screening for a coagulopathy should not be routinely performed, unless the clinical picture is suggestive in this regard.

Transvaginal ultrasound


Transvaginal ultrasound (TV-USS) is key in the workup of these patients; and is mandatory if the uterus is palpable abdominally, the pelvic examination is inconclusive, or a pelvic mass is suspected. It can establish the presence or absence of fibroids, adenomyosis, polyps, and endometrial pathology.

Saline infusion ultrasonography


When the TV-USS is inconclusive, or intracavitary abnormalities are suspected, saline infusion sonography (SIS) can provide the needed enhanced views of the endometrium.

Endometrial sampling


Endometrial sampling is indicated in women with persistent intermenstrual bleeding, or in certain cases, after failed conservative treatment of AUB.

Pictorial blood assessment chart


The patient's perception of the severity of bleeding does not always correlate with the objective degree of blood loss. At present, the most effective method of quantifying the severity of blood loss is via a pictogram questionnaire.

Pregnancy testing


Testing for pregnancy is mandatory, so as to rule out uterine bleeding due to ectopic pregnancy, abortion, or hCG secreting tumors.

Complete blood count


A complete blood count is mandatory in all women with HMB, especially if symptoms of anemia are present. Importantly though, a normal hemoglobin level does not exclude HMB.

Coagulation studies


Screening for a coagulopathy should not be routinely performed, unless the clinical picture is suggestive in this regard.

Transvaginal ultrasound


Transvaginal ultrasound (TV-USS) is key in the workup of these patients; and is mandatory if the uterus is palpable abdominally, the pelvic examination is inconclusive, or a pelvic mass is suspected. It can establish the presence or absence of fibroids, adenomyosis, polyps, and endometrial pathology.

Saline infusion ultrasonography


When the TV-USS is inconclusive, or intracavitary abnormalities are suspected, saline infusion sonography (SIS) can provide the needed enhanced views of the endometrium.

Endometrial sampling


Endometrial sampling is indicated in women with persistent intermenstrual bleeding, or in certain cases, after failed conservative treatment of AUB.

Investigations - Management

Fact Explanation

Hysteroscopy


Hysteroscopy is recommended if transvaginal ultrasound shows no etiology suggestive of AUB, if the bleeding is unresponsive to medical therapy, or if the woman is 40 years of age or older.


Hysteroscopy is diagnostic and can be therapeutic; it allows direct inspection of the uterine cavity, targeted biopsy, and removal of focal lesions under direct visualisation.

Magnetic resonance imaging


Magnetic resonance imaging (MRI) is of limited value in the diagnosis of AUB, although it is an option in women who decline or are unsuitable for transvaginal ultrasound.


However, it is useful for the pre-operational assessment for myomectomy, fibroid embolization, and surgical treatment of endometrial malignancies.

Hysteroscopy


Hysteroscopy is recommended if transvaginal ultrasound shows no etiology suggestive of AUB, if the bleeding is unresponsive to medical therapy, or if the woman is 40 years of age or older.


Hysteroscopy is diagnostic and can be therapeutic; it allows direct inspection of the uterine cavity, targeted biopsy, and removal of focal lesions under direct visualisation.

Magnetic resonance imaging


Magnetic resonance imaging (MRI) is of limited value in the diagnosis of AUB, although it is an option in women who decline or are unsuitable for transvaginal ultrasound.


However, it is useful for the pre-operational assessment for myomectomy, fibroid embolization, and surgical treatment of endometrial malignancies.

Management - Supportive

Fact Explanation

Conservative management


In the absence of potential malignancies and structural or functional disease, conservative management (with oral iron replacement as indicated) is an acceptable first-line strategy, particularly for peri-menopausal women.

Non-hormonal methods


Non-hormonal options are limited to anti-fibrinolytics (e.g., tranexamic acid) or NSAIDs (e.g., mefenamic acid). These agents can reduce menstrual blood loss by up to 50% and are suitable first-line options for women who wish to conceive or avoid hormonal side effects.


NSAIDs and antifibrinolytic medications can be used together if beneficial; and also as an adjunct to hormonal preparations.

Combined oral contraceptive pill


Combined oral contraceptive pills (COCP) that contain at least ≥30 µg of ethinyl estradiol decrease menstrual blood loss by 40–50%. If taken consecutively (i.e., with no ‘pill free’ weeks) they reduce the number of menses experienced as well as the volume of blood loss.


COCP therapy is associated with an increased risk for venous thromboembolism and breast cancer; they also have a detrimental effect on breast milk production.

Progesterone only pill


In contrast to COCP, the progesterone only pill (POP) is associated with irregular bleeding and other undesirable progestogenic side effects; it is not usually recommended for the treatment of AUB.

Oral progestogens


Oral progestogens (e.g., norethisterone) are only suitable as a short-term measure to terminate a heavy bleed or regulate menstruation; they are not an option for long-term management.

Injectable progestogens


Intramuscular or subcutaneous high-dose progestogens (e.g., depot medroxyprogesterone acetate, DMPA) administered at 3-month intervals can induce amenorrhea in up to 50% of women; however, long-term use is associated with a transient reduction in bone mineral density.

Levonorgestrel-releasing intrauterine systems


Levonorgestrel-releasing intrauterine systems (LNG-IUS) are inserted and removed at 5-year intervals and can decrease menstrual blood loss by up to 96% after one year. However, these systems not recommended in the context of fibroids, as they may be expelled from the uterus; furthermore, a distorted uterine cavity preclude their use.

GnRH agonists


Gonadotropin releasing hormone (GnRH) agonists are useful for the short-term management of fibroids, drastically reducing their size. They are an option in peri-menopausal women with fibroids, or prior to myomectomy so as to reduce surgical blood loss. However, GnRH agonists also induce menopausal symptoms and are associated with a reduction in bone mineral density.

Selective progesterone receptor modulators (SPRM)


Selective progesterone receptor modulators (e.g., ulipristal acetate) are novel hormonal therapeutic agents that show promising results in the treatment of AUB by reducing dysmenorrhea, menstrual bleeding, and the size of any fibroids.


These agents have an endometrium-specific progesterone antagonist effect. They decrease menstrual blood loss without unwanted hypo-estrogenic side effects.

Treatment of causative


Where the AUB is due to an endocrinopathy, malignancy, or other underlying condition, this should be treated as appropriate.

Conservative management


In the absence of potential malignancies and structural or functional disease, conservative management (with oral iron replacement as indicated) is an acceptable first-line strategy, particularly for peri-menopausal women.

Non-hormonal methods


Non-hormonal options are limited to anti-fibrinolytics (e.g., tranexamic acid) or NSAIDs (e.g., mefenamic acid). These agents can reduce menstrual blood loss by up to 50% and are suitable first-line options for women who wish to conceive or avoid hormonal side effects.


NSAIDs and antifibrinolytic medications can be used together if beneficial; and also as an adjunct to hormonal preparations.

Combined oral contraceptive pill


Combined oral contraceptive pills (COCP) that contain at least ≥30 µg of ethinyl estradiol decrease menstrual blood loss by 40–50%. If taken consecutively (i.e., with no ‘pill free’ weeks) they reduce the number of menses experienced as well as the volume of blood loss.


COCP therapy is associated with an increased risk for venous thromboembolism and breast cancer; they also have a detrimental effect on breast milk production.

Progesterone only pill


In contrast to COCP, the progesterone only pill (POP) is associated with irregular bleeding and other undesirable progestogenic side effects; it is not usually recommended for the treatment of AUB.

Oral progestogens


Oral progestogens (e.g., norethisterone) are only suitable as a short-term measure to terminate a heavy bleed or regulate menstruation; they are not an option for long-term management.

Injectable progestogens


Intramuscular or subcutaneous high-dose progestogens (e.g., depot medroxyprogesterone acetate, DMPA) administered at 3-month intervals can induce amenorrhea in up to 50% of women; however, long-term use is associated with a transient reduction in bone mineral density.

Levonorgestrel-releasing intrauterine systems


Levonorgestrel-releasing intrauterine systems (LNG-IUS) are inserted and removed at 5-year intervals and can decrease menstrual blood loss by up to 96% after one year. However, these systems not recommended in the context of fibroids, as they may be expelled from the uterus; furthermore, a distorted uterine cavity preclude their use.

GnRH agonists


Gonadotropin releasing hormone (GnRH) agonists are useful for the short-term management of fibroids, drastically reducing their size. They are an option in peri-menopausal women with fibroids, or prior to myomectomy so as to reduce surgical blood loss. However, GnRH agonists also induce menopausal symptoms and are associated with a reduction in bone mineral density.

Selective progesterone receptor modulators (SPRM)


Selective progesterone receptor modulators (e.g., ulipristal acetate) are novel hormonal therapeutic agents that show promising results in the treatment of AUB by reducing dysmenorrhea, menstrual bleeding, and the size of any fibroids.


These agents have an endometrium-specific progesterone antagonist effect. They decrease menstrual blood loss without unwanted hypo-estrogenic side effects.

Treatment of causative


Where the AUB is due to an endocrinopathy, malignancy, or other underlying condition, this should be treated as appropriate.

Management - Specific

Fact Explanation

Von Willebrand disease: desmopressin


Desmopressin is a specific therapy for type 1 von Willebrand disease (vWD), which constitutes the largest proportion of women with coagulopathy-associated AUB; it can also be used as a nonspecific hemostatic therapy for other types of coagulopathies.

Polyps: resection


Endometrial or cervical polyps associated with AUB should be treated via hysteroscopic polyp resection or polypectomy with visualisation, respectively. Recurrence and complications are uncommon.

Fibroids: myomectomy


Myomectomy can be performed via hysteroscopic, laparoscopic, or open techniques. However, fibroid recurrence may occur in a significant number of patients; conversely, in AUB in which the fibroid is an incidental finding, resolution of symptoms may not occur.

Dilation and curettage


Blind dilation of the cervix and curettage of the endometrium (D&C) should not be performed for the diagnosis or treatment of AUB, as this misses over 50% of intrauterine lesions when performed without hysteroscopy.


Furthermore, D&C may be temporarily effective in controlling acute HMB, but may in fact exacerbate the bleeding in the long run.

Endometrial ablation


Endometrial ablation involves destruction of the endometrium via an ablation device. Note that this has been found to be no more effective than the levonorgestrel intrauterine device, and less effective than hysterectomy in the treatment of AUB.


Fertility is significantly impaired after endometrial ablation, but conception is still possible.

Uterine artery embolization


Uterine artery embolization is a minimally invasive procedure that is effective in controlling AUB due to fibroids, adenomyosis, and vascular malformations; it is also helpful in reducing bleeding due to inoperable advanced-stage malignancies.

Hysterectomy


The definitive treatment for AUB is elective hysterectomy; however, this is associated with potential short- and long-term complications. Short-term complications include injury to the adjacent viscera, bleeding, venous thromboembolism and infection. Long-term complications include incontinence, bowel disorders and sexual dysfunction.


If performed along with oophorectomy, there is an added risk for cardiovascular disease and an increase in all-cause mortality.

Von Willebrand disease: desmopressin


Desmopressin is a specific therapy for type 1 von Willebrand disease (vWD), which constitutes the largest proportion of women with coagulopathy-associated AUB; it can also be used as a nonspecific hemostatic therapy for other types of coagulopathies.

Polyps: resection


Endometrial or cervical polyps associated with AUB should be treated via hysteroscopic polyp resection or polypectomy with visualisation, respectively. Recurrence and complications are uncommon.

Fibroids: myomectomy


Myomectomy can be performed via hysteroscopic, laparoscopic, or open techniques. However, fibroid recurrence may occur in a significant number of patients; conversely, in AUB in which the fibroid is an incidental finding, resolution of symptoms may not occur.

Dilation and curettage


Blind dilation of the cervix and curettage of the endometrium (D&C) should not be performed for the diagnosis or treatment of AUB, as this misses over 50% of intrauterine lesions when performed without hysteroscopy.


Furthermore, D&C may be temporarily effective in controlling acute HMB, but may in fact exacerbate the bleeding in the long run.

Endometrial ablation


Endometrial ablation involves destruction of the endometrium via an ablation device. Note that this has been found to be no more effective than the levonorgestrel intrauterine device, and less effective than hysterectomy in the treatment of AUB.


Fertility is significantly impaired after endometrial ablation, but conception is still possible.

Uterine artery embolization


Uterine artery embolization is a minimally invasive procedure that is effective in controlling AUB due to fibroids, adenomyosis, and vascular malformations; it is also helpful in reducing bleeding due to inoperable advanced-stage malignancies.

Hysterectomy


The definitive treatment for AUB is elective hysterectomy; however, this is associated with potential short- and long-term complications. Short-term complications include injury to the adjacent viscera, bleeding, venous thromboembolism and infection. Long-term complications include incontinence, bowel disorders and sexual dysfunction.


If performed along with oophorectomy, there is an added risk for cardiovascular disease and an increase in all-cause mortality.

References

  1. WHITAKER L, CRITCHLEY HO. Abnormal uterine bleeding. Best Pract Res Clin Obstet Gynaecol [online] 2016 Jul:54-65 [viewed 27 April 2019] Available from: http://www.ncbi.nlm.nih.gov/pubmed/26803558
  2. CHEONG Y, CAMERON IT, CRITCHLEY HOD. Abnormal uterine bleeding. Br Med Bull [online] 2017 Sep 1, 123(1):103-114 [viewed 27 April 2019] Available from: http://www.ncbi.nlm.nih.gov/pubmed/28910998
  3. WHITAKER L, CRITCHLEY HO. Abnormal uterine bleeding Best Pract Res Clin Obstet Gynaecol [online] 2016 Jul:54-65 [viewed 27 April 2019] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4970656
  4. DASHARATHY SS, MUMFORD SL, POLLACK AZ, PERKINS NJ, MATTISON DR, WACTAWSKI-WENDE J, SCHISTERMAN EF. Menstrual Bleeding Patterns Among Regularly Menstruating Women Am J Epidemiol [online] 2012 Feb 20, 175(6):536-545 [viewed 27 April 2019] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3299419
  5. HAPANGAMA DK, BULMER JN. Pathophysiology of Heavy Menstrual Bleeding Womens Health (Lond) [online] 2016 Jan 1, 12(1):3-13 [viewed 27 April 2019] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5779569
  6. SRIPRASERT I, PAKRASHI T, KIMBLE T, ARCHER DF. Heavy menstrual bleeding diagnosis and medical management Contracept Reprod Med [online] 2017 Jul 24:20 [viewed 27 April 2019] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5683444
  7. SWEET MG, SCHMIDT-DALTON TA, WEISS PM, MADSEN KP. Evaluation and management of abnormal uterine bleeding in premenopausal women. Am Fam Physician [online] 2012 Jan 1, 85(1):35-43 [viewed 27 April 2019] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22230306
  8. SUN Y, WANG Y, MAO L, WEN J, BAI W. Prevalence of abnormal uterine bleeding according to new International Federation of Gynecology and Obstetrics classification in Chinese women of reproductive age: A cross-sectional study Medicine (Baltimore) [online] 2018 Aug 3, 97(31):e11457 [viewed 02 June 2019] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6081150
  9. WILLIAMS AR. Uterine fibroids – what’s new? F1000Res [online] 2017 Dec 7:2109 [viewed 27 April 2019] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5721931
  10. KHAN AT, SHEHMAR M, GUPTA JK. Uterine fibroids: current perspectives Int J Womens Health [online] 2014 Jan 29:95-114 [viewed 27 April 2019] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3914832
  11. HAN SC, KIM MD, JUNG DC, LEE M, LEE MS, PARK SI, WON JY, LEE DY, LEE KH. Degeneration of Leiomyoma in Patients Referred for Uterine Fibroid Embolization: Incidence, Imaging Features and Clinical Characteristics Yonsei Med J [online] 2012 Nov 28, 54(1):215-219 [viewed 27 April 2019] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3521269
  12. BERNARDI M, LAZZERI L, PERELLI F, REIS FM, PETRAGLIA F. Dysmenorrhea and related disorders F1000Res [online] 2017 Sep 5:1645 [viewed 27 April 2019] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5585876
  13. CRAWFORD NM, PRITCHARD DA, HERRING AH, STEINER AZ. A prospective evaluation of the impact of intermenstrual bleeding on natural fertility Fertil Steril [online] 2016 Jan 25, 105(5):1294-1300 [viewed 27 April 2019] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4853238
  14. HERMAN MC, MOL BW, BONGERS MY. Diagnosis of Heavy Menstrual Bleeding Womens Health (Lond) [online] 2016 Jan 1, 12(1):15-20 [viewed 27 April 2019] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5779565
  15. DONNEZ J, DOLMANS MM. Uterine fibroid management: from the present to the future Hum Reprod Update [online] 2016 Oct 20, 22(6):665-686 [viewed 27 April 2019] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5853598
  16. LI JJ, CHUNG JP, WANG S, LI TC, DUAN H. The Investigation and Management of Adenomyosis in Women Who Wish to Improve or Preserve Fertility Biomed Res Int [online] 2018 Mar 15:6832685 [viewed 27 April 2019] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5875064
  17. National Guideline Alliance (UK). Heavy menstrual bleeding (update) [online]. National Institute for Health and Care Excellence (UK), 2018 [viewed 02 July 2019]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537766/
  18. CHOPRA SHEETAL, LEV-TOAFF ANNA S., ORS FATIH, BERGIN DIANE. Adenomyosis:Common and Uncommon Manifestations on Sonography and Magnetic Resonance Imaging. [online] December, 25(5):617-627 [viewed 27 April 2019] Available from: doi:10.7863/jum.2006.25.5.617
  19. BAHAMONDES L, ALI M. Recent advances in managing and understanding menstrual disorders F1000Prime Rep [online] 2015 Mar 3:33 [viewed 27 April 2019] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4371378
  20. KHAN R, SHERWANI RK, RANA S, HAKIM S, S JAIRAJPURI Z. Clinco-Pathological Patterns in Women with Dysfunctional Uterine Bleeding Iran J Pathol [online] 2016 Winter, 11(1):20-26 [viewed 27 April 2019] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4749191
  21. TARNEY CM, HAN J. Postcoital bleeding: a review on etiology, diagnosis, and management. Obstet Gynecol Int [online] 2014:192087 [viewed 03 June 2019] Available from: http://www.ncbi.nlm.nih.gov/pubmed/25045355
  22. VARDHAN S, BHATTACHARYYA T, KOCHAR S, SODHI B. Bleeding in Early Pregnancy Med J Armed Forces India [online] 2007 Jan, 63(1):64-66 [viewed 03 June 2019] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4921709
  23. LUMSDEN MA, GEBBIE A, HOLLAND C. Managing unscheduled bleeding in non-pregnant premenopausal women. BMJ [online] 2013 Jun 4:f3251 [viewed 03 June 2019] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23737266
  24. FORAN T. The management of irregular bleeding in women using contraception. Aust Fam Physician [online] 2017 Oct, 46(10):717-720 [viewed 03 June 2019] Available from: http://www.ncbi.nlm.nih.gov/pubmed/29036769
  25. MASUDA H, UCHIDA H, MARUYAMA T, SATO K, SATO S, TANAKA M. Successful treatment of atypical cesarean scar defect using endoscopic surgery BMC Pregnancy Childbirth [online] 2015 Dec 22:342 [viewed 03 June 2019] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4687144
  26. NEUTZE D, ROQUE J. Clinical Evaluation of Bleeding and Bruising in Primary Care. Am Fam Physician [online] 2016 Feb 15, 93(4):279-86 [viewed 27 April 2019] Available from: http://www.ncbi.nlm.nih.gov/pubmed/26926815
  27. ROBERTS JC, FLOOD VH. Laboratory diagnosis of von Willebrand disease Int J Lab Hematol [online] 2015 May, 37(Suppl 1):11-17 [viewed 27 April 2019] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5600156
  28. KOLHE S. Management of abnormal uterine bleeding – focus on ambulatory hysteroscopy Int J Womens Health [online] 2018 Mar 22:127-136 [viewed 27 April 2019] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5868607
  29. MAYBIN JA, CRITCHLEY HO. Medical management of heavy menstrual bleeding Womens Health (Lond) [online] 2016 Jan, 12(1):27-34 [viewed 27 April 2019] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4728737
  30. JAMES AH. Heavy menstrual bleeding: work-up and management Hematology Am Soc Hematol Educ Program [online] 2016 Dec 2, 2016(1):236-242 [viewed 27 April 2019] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6142441
  31. KANTHI JM, REMADEVI C, SUMATHY S, SHARMA D, SREEDHAR S, JOSE A. Clinical Study of Endometrial Polyp and Role of Diagnostic Hysteroscopy and Blind Avulsion of Polyp J Clin Diagn Res [online] 2016 Jun 1, 10(6):QC01-QC04 [viewed 27 April 2019] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4963717
  32. DE LA CRUZ MS, BUCHANAN EM. Uterine Fibroids: Diagnosis and Treatment. Am Fam Physician [online] 2017 Jan 15, 95(2):100-107 [viewed 27 April 2019] Available from: http://www.ncbi.nlm.nih.gov/pubmed/28084714
  33. TANOS V, BERRY KE, FRIST M, CAMPO R, DEWILDE RL. Prevention and Management of Complications in Laparoscopic Myomectomy Biomed Res Int [online] 2018 Mar 5:8250952 [viewed 27 April 2019] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5859837
  34. BHARDWAJ R. Uterine artery embolisation Indian Heart J [online] 2012 May, 64(3):305-308 [viewed 27 April 2019] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3860712
  35. DAS CJ, RATHINAM D, MANCHANDA S, SRIVASTAVA DN. Endovascular uterine artery interventions. Indian J Radiol Imaging [online] 2017 Oct-Dec, 27(4):488-495 [viewed 27 April 2019] Available from: http://www.ncbi.nlm.nih.gov/pubmed/29379246
  36. CHEONG YING, CAMERON IAIN T, CRITCHLEY HILARY O D. Abnormal uterine bleeding. [online] 2019 March [viewed 27 April 2019] Available from: doi:10.1093/bmb/ldz008
  37. STEWART EA, SHUSTER LT, ROCCA WA. Reassessing Hysterectomy Minn Med [online] 2012 Mar, 95(3):36-39 [viewed 27 April 2019] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3804006
  38. PARKER WH, FESKANICH D, BRODER MS, CHANG E, SHOUPE D, FARQUHAR CM, BEREK JS, MANSON JE. Long-term Mortality Associated with Oophorectomy versus Ovarian Conservation in the Nurses’ Health Study Obstet Gynecol [online] 2013 Apr, 121(4):709-716 [viewed 27 April 2019] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4254662