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Abnormal Uterine Bleeding (AUB)

Common reason women seek health care.
20% gyn visits.
25% gyn surgeries.
Any uterine bleeding that is irregular in amount, duration, or timing.
May or may not be related to menstrual cycle.


AUB can be

Normal physiologic event → irregular bleeding resulting from anovulation that often accompanies menarche.
Symptomatic of perimenopause.
Pathologic, life-threatening conditions → ectopic pregnancy; endometrial cancer.


Understanding AUB:

Know physiologic basis of normal menstrual physiology.
Functional structure of reproductive tract.


Normal Menstruation

Requires coordination of the hypothalamic-pituitary-ovarian axis. (HPOA)
Wide variation in menstrual cycles – know what is “normal” for each patient.


Normal Menstrual Patterns:

Cycle length: 21-40 days; average 29.5 days.
Duration: 3-8 days.
Blood loss – 40-80cc.
Ovulatory bleeding: spotting around ovulation → 14 days before next menses.


Age-related menstrual changes:

May be anovulatory for more than half of 1st postmenarcheal year.
Gradual ↓ in length and quantity during the 5 years preceding menopause.
Can have anovulatory cycles.


AUB present when:

Interval between the start of successive menses is ≤ 21 days.
Duration of menstrual flow > 7 days.
Menstrual blood loss > 80 cc.
Deviations from a previously established menstrual pattern:
Sudden ↑ of 2 or more sanitary pads per day.
Menses lasting ≥ 3 days longer than usual.
Intermenstrual bleeding.
Interval between menses ≥ 4 days less than usual.


AUB Terminology:

Intermenstrual bleeding: Uterine bleeding between regular menses.
Menorrhagia or hypermenorrhea: Prolonged (more than 7 days) or excessive (greater than 80cc) uterine bleeding occurring at regular intervals.
Metrorrhagia: Bleeding occurring at irregular, frequent intervals, the amount being variable.
Oligomenorrhea: Infrequent, irregular uterine bleeding occurring at intervals greater than 45 days.
Polymenorrhea: Frequent, regular episodes of uterine bleeding occurring at intervals of less than 18 days.


Causes of AUB:



Causes of AUB:

Disruptions of endocrine function at any level of HPOA → disrupt normal menstrual physiology → cause a disturbance of menstrual cycle’s regularity, frequency, duration, or volume


Women of childbearing age presenting with AUB

do a pregnancy test first.


AUB Etiology

Chronic anovulation.
Ovulatory problems.
Systemic disease.
Gynecologic problems.
Coagulation problems


AUB Endocrine problems/systemic:

Adrenal hyperplasia.
Cushings syndrome.
Polycystic ovary syndrome.
Thyroid disease.


AUB Medications/substances/herbs:

Herbs (ginkgo, ginseng, soy)
Hormone therapy.
SSRI antidepressants.
Hormonal contraceptives.


AUB - Problems with HIPOA

Systemic illness (e.g., PCOS, pituitary, thyroid)
Premature ovarian failure.
Eating disorders.
Severe dieting and/or weight loss.
Excessive exercise.


AUB Reproductive tract disease/dysfunction:

Endometrial hyperplasia.
Leiomyomas (leiomyomatas, myomas, fibroids)
Cause 1/3 of presenting cases.
Outflow tract obstruction.
Ovarian tumors.


AUB - Systemic disease

Thyroid dysfunction.
Liver disease.
Coagulation defects.
Von Willebrand’s
Idiopathic thrombocytopenia


CNM/NP Role in Management of AUB

Complete history & initial physical examination.
Initial lab evaluation.
Referral to appropriate specialist for further evaluation & treatment.
Patient counseling, education, & reassurance.


Assessment of AUB

A well-taken history will lead the clinician almost to the end of the diagnostic path, even before the patient has been examined & without a single laboratory test or diagnostic procedure has been performed.



Patient’s age
Incidence of various causes of bleeding problems change depending on woman’s stage of life:
Reproductively mature.


Chief Complaint:

Description of vaginal bleeding – timing, amount, color, character, onset, duration of problem.
Does bleeding occur at regular or irregular intervals?
Associated symptoms, what relieves or worsens condition.
May ask patient to complete a bleeding assessment diary → may give better idea of amount of bleeding



General medical/surgical history to include:
Detailed menstrual history.
Contraceptive history.
Sexual history.
Gyn history
Pap test history.
Gyn surgeries.
Sti’s or other infections of genital tract/organs.


Physical Examination

General physical examination should be done with special attention to:
Body weight:
Underweight – can cause irregular bleeding.
Obesity – can cause anovulation.
Signs of endocrine disorders:
Delayed or precocious sexual development.
Signs of androgen excess:
Changes in hair growth or distribution.


Physical Examination (cont)

22% of women with AUB have thyroid disease.
Lymph nodes
Help to rule out gynecologic cancers & pelvic infections.
Symptoms of coagulation disorders:


Pelvic exam

Note origin of bleeding – rectal, vaginal, labial, or uterine.
Note location of any lesions.
Observe the introitus for bruising and laceration.
Observe for signs of estrogen deficiency – urogenital atrophy or atrophic vaginitis can cause AUB.


Speculum exam

Evaluate source, amount, color, character, & odor of any observed bleeding.
Note any lesions, lacerations.
Note abnormal vaginal discharge.
Bleeding can be related to vaginitis, cervicitis.


Bimanual exam:

Note size, shape, consistency of any masses.
Note tenderness with palpation. Evaluate cervical motion tenderness.
R/O pregnancy, uterine & ovarian pathology, PID.


Rectovaginal examination:

Can help to confirm diagnosis of PID or endometriosis.
Assess rectal lesions & masses.


Laboratory & Diagnostic Tests

Choice of lab tests guided by H&P.
Most lab work used to rule out pathology.
Urine pregnancy test as indicated.
Vaginal labs:
Pap smear.
STI testing, vaginal/cervical culture.
Wet mount – evaluate for vaginitis.


Diagnostic Testing

Transvaginal ultrasound
Identify pelvic masses.
R/O pregnancy, threatened abortion,
ectopic pregnancy.
Measure endometrial thickness – if endometrial hyperplasia or cancer is suspected.
Endometrial thickness > 5mm suspicious of endometrial hyperplasia.
More predictive in postmenopausal women than younger women


Diagnostic Testing

Colposcopy with cervical biopsy as needed.

Endometrial Biopsy (EMB)
Simple procedure, usually well tolerated.
Flexible suction curette sampling device used to obtain endometrial sample.
R/O endometrial cancer.
NSAID 30-45 minutes prior to procedure → decrease cramping & uterine spasm.


Who needs EMB?

Any woman older than 40 with new onset AUB.
Any woman with a history of prolonged exposure to unopposed estrogen, regardless of age.
20-25% endometrial cancer → premenopausal women.


Treatment of AUB

AUB treated by treating underlying cause – organic, systemic, iatrogenic.

Surgically – D&C, removal of fibroids/polyps, hysterectomy, endometrial ablation, uterine artery embolization.

Medically – hormonally (COC, Depo), LNG-IUS, cyclic progesterone.

If all causes of AUB have been ruled out – diagnosis of dysfunctional uterine bleeding (DUB) can be made.


Dysfunctional Uterine Bleeding (DUB)

Diagnosis of exclusion – excessive bleeding with no demonstrable organic cause.
Associated with abnormalities in the hormonal secretory activities of the endometrium.
Usually of endocrine origin.
Occurs more frequently during puberty & in perimenopausal years.
Two types:
Anovulatory (90%)
Ovulatory (10%)


Ovulatory DUB

Occurs in peak reproductive years.
Bleeding predictable but excessive & prolonged.
Etiology not clearly understood – Possible causes:
Constant low level of estrogen with a prolonged progesterone secretion → causes irregular shedding of endometrium.
Imbalance in prostaglandins → endometrium fails to produce adequate amounts of the vasoconstrictive prostaglandin PGF2.
Treatment: oral contraceptives x 3 cycles; most ovulatory women will revert back to normal menstrual cycle.


Anovulatory DUB

Anovulation – most common hormonal disorder leading to DUB.

Most common in peri-menarcheal & peri-menopausal years.

Can occur at any time – can be caused by increased stress.


Failure of HPOA feedback mechanism → no normal folliculogenesis → corpus luteum does not form.

Causes failure of normal cyclical progesterone secretion.
Leads to a state of continuous estrogen production & continued proliferation of endometrium – “hyperplasia”.
Overgrown endometrium sheds erratically & unpredictably as areas outgrow their blood supply.


Anovulatory DUB

Usually self-limited & normally cycling woman will revert back to her underlying menstrual cycle without treatment.

Intervention needed when abnormal bleeding episode is unusually heavy or recurrent.


Objectives in Treating DUB

Control bleeding.
Prevent recurrence.
Preserve fertility.
Correct associated disorders.
Induce ovulation in women who desire to conceive.


Factors influencing choice of therapy for treatment of DUB:

Woman’s age.
Severity of bleeding.
Number of children.
Desire for future fertility.
Presence of associated pelvic pathology.
Medical treatment preferred if more children are desired & there are no associated pelvic lesions


DUB Acute Bleeding Episode:

Medical D&C”:


DUB No orthostatic hypotension, HgB ≥ 10g/dl, bleeding not profuse:

2.5mg Premarin po q 4-6 hours.
Antiemetics may be needed secondary to high estrogen dosing.
Acute bleeding should lighten up after 3-4 doses.


DUB After acute bleeding:

LoOvral – 1 active pill qid X 4 days, TID X 3 days, BID X 2 days, 1 pill daily X 3 weeks.
Then one pill-free week → will have withdrawal bleed.


Continue to cycle for 3 months

If contraception needed → continue OCP.
OCP contraindicated → cycle Provera 10 mg. po for 14 days, off 14 days, on 14 days – for 3 months.


DUB Active bleeding episode - + orthostatic hypotension, Hgb < 10 g/dl, + profuse bleeding

Intravenous estrogen – 25mg every 4 hours. Maximum of 3 doses. (may need antiemetic)
Simultaneously → start with oral LoOvral therapy.
Cycle for 3 months – either OCPs or Provera.


Why use high dose estrogen to control acute bleeding?

High dose estrogen will allow sufficient endometrium buildup for estrogen/progesterone therapy to be effective.


Medical Treatment of Non-Emergent DUB
Hormonal Treatment:

Goal of hormonal treatment is to promote:
Universal, synchronous endometrial bleeding.
Structural stability.
Vasomotor rhythmicity.

Oral contraceptive or progestin therapy.

Age & need for contraception help determine medication choice.


Recurrent DUB → long-term menstrual cycle control:

Combined oral contraceptive pills.
Progestin therapy.
GNRH Analogues


Progestin Therapy:
for DUB

With anovulation – course of progestin will transform endometrium to secretory pattern & lead to synchronous withdrawal bleed.

Withdrawal bleed can be very heavy – especially if condition present for long


Progestin options: For DUB

Provera 10mg X 10 days.
Norethindrone 5mg X 10 days.
Progesterone-in-oil 100-150mg IM X 1 dose.
Progestin IUD


Progestin IUD
for DUB

Delivers progestational agent directly to endometrium.
Reduces menstrual flow → may induce amenorrhea.
Can control:
Anovulatory cycles.
Ovulatory cycles with heavy menstrual bleeding.


Nonsteroid Anti-inflammatory Agents for DUB

Prostaglandin synthetase inhibitors – decrease prostaglandin production within the endometrium & reduce menstrual blood loss.

20-50% decline in menstrual bleeding after treatment with NSAID.

Given to cycling women with heavy periods for first 3 days of flow.

Can be combined with OCs or progestins to enhance efficacy.


NSAID Therapy for DUB

Mefanamic acid (Ponstel) 500 mg TID
Ibuprofen 600 mg TID
Naproxen sodium 550 mg loading dose then 275 mg every 6 hours


GnRH Analogues (Synarel, Zoladex, Lupron Depot, Supprelin) For DUB

Suppresses HPOA & creates ‘medical menopause’.

Use with extreme caution in women who are at risk for osteoporosis.

GnRH analogues effective for menstrual suppression → side effects of estrogen deficiency problematic.


GnRH Analogues (Synarel, Zoladex, Lupron Depot, Supprelin for DUB side effects

Common side effects: hot flashes, emotional swings, reduced sexual drive, headache, nausea & vomiting, memory loss, changes in the skin & hair, rapid heartbeat, vaginitis, & weight changes.

For long term therapy, OCs or long-acting progestins are preferable.


Surgical Treatment of DUB

Surgical treatment should be used:
If anatomic abnormality identified early in diagnostic process.
Failed medical therapy.



Has been replaced with EMB as a diagnostic tool in assessing the endometrium.
Reserved for acute heavy bleeding unresponsive to emergent medical care.
Has only a temporary effect – 65% of patients will have a recurrence of bleeding by 3 months.



Endometrial cavity evaluated by direct visualization → treatment focused on area of abnormality.Complements D&C & used in conjunction with one another whenever anatomic abnormality is suspected.


Hysteroscopic Resection

Hysteroscopy → access to endometrial cavity for therapeutic intervention.

Surgical tools can be passed through the operating channel of hysteroscope & submucosal fibroids & endometrial polyps resected.



Traditionally, treatment of choice for chronic dysfunctional bleeding – especially when preservation of fertility was not an issue.

Newer surgical treatments & medical treatment options → rate of hysterectomy for DUB has declined.

Still important therapeutic option in properly selected patients.


Endometrial Ablation

Surgical procedure  endometrial cavity destroyed by either electrocauterization or laser vaporization.
Not for women who desire to keep fertility.
Destroys uterine lining – benefit women who have heavy menstrual bleeding but do not have other underlying uterine problems, such as polyps, hyperplasia of the endometrium, or cancer.
Uses hysteroscope to view uterine cavity → uses electric or laser device to heat & destroy the endometrium.


Balloon ablation (Thermachoice)

Balloon at the tip of a catheter tube filled with fluid & inflated until it conforms to the walls of the uterus.
Probe in the balloon heats fluid to destroy endometrial lining.


Amenorrhea –

lack of menstruation.
2 categories:


Primary Amenorrhea:

No period by age 14 in the absence of growth or development of secondary sexual characteristics.

No period by age 16 regardless of the presence of normal growth & development with the appearance of secondary sexual characteristics.


Primary Amenorrhea:
3 most common diagnoses (75% of all cases):

Gonadal failure.
Congenital absence of the uterus & vagina.
Constitutional delay.


Amenorrhea Gonadal failure:

Congenital defects of gonadotropin production.
Congenital central nervous system (CNS) defects.
Dysfunctional hypothalamic-pituitary-ovarian axis.


Amenorrhea Congenital anatomic malformation of the reproductive system:

Absence of vagina & uterus.
Uterine hypoplasia – an abnormally small uterus.
Usually have normal ovarian function → have skeletal growth & development of secondary sex characteristics but no menarche.


Secondary Amenorrhea:

Absence of periods for:
At least 3 of the previous cycle intervals.
Or 6 months of amenorrhea.


Amenorrhea In women of childbearing age, rule out

Patient history.
Pregnancy test.

Accompanying symptoms.


Most common causes of secondary amenorrhea: (@75% of all cases):

Chronic anovulation.
Weight loss/anorexia.


Secondary Amenorrhea – Other Causes

Functional hypothalamic amenorrhea:
Disturbances in the hypothalamus, pituitary, & thyroid system.
Can be influenced by nutrition, emotions, environmental stressors!
Polycystic Ovary Syndrome – PCOS
Elevated prolactin levels – galactorrhea
Can be caused by pituitary tumor.
Some drugs will  prolactin levels – oc’s, antipsychotic drugs.


Premature ovarian failure – absence of menstruation & early depletion of follicles before 40. Causes include:

Adrenal, pituitary, or thyroid deficiencies.
Low levels of certain growth factors, called inhibins, that are produced by the ovaries.
Hypergonadotropic hypogonadism – no development of functional ovaries; i.e., Turner’s Syndrome.
Radiation therapy & anti-cancer agents.
Autoimmune diseases.


Medical problems may be a possible cause of amenorrhea:

Thyroid disorders.
Cushing’s disease.
Crohn’s disease.
Sickle-cell disease.
Kidney disease.


Athletic amenorrhea: (runners, dancers

Several possible causes:
Low percentages of body fat.
Weight loss.
Excessive training.
Poor nutritional habits.


Chronic Amenorrhea – Health Problems


Osteoporosis – secondary to  estrogen levels
Amenorrhea is common in young female athletes & those with eating disorders.
Bone growth at its peak in adolescence & young adulthood → long-term consequences with losing bone density at this time.


Menstruation Requires:

An intact outflow tract:
Requires patency & continuity of vaginal orifice, vaginal canal, & endocervix with uterine cavity.

Development of the endometrium of the uterus:
Stimulated & regulated by the sex hormones – estrogen & progesterone.
Secretion of these hormones originates in ovary & dependent on the cyclic process of follicle development, ovulation, & corpus luteum function.


Menstruation Requires

Maturation of the follicular cycle that is provided by stimuli originating in the anterior pituitary.
Releases gonadotropins:
Follicle-stimulation hormone – FSH.
Luteinizing hormone – LH.

Regulation of the anterior pituitary of the basal hypothalamus.
Gonadotropin-releasing hormone – GnRH.


Evaluation of Amenorrhea:

Initial evaluation should be simple & logical to identify the source of the problem


Amenorrhea can be caused by:

Disorders of the outflow tract or uterine target organ.
Disorders of the ovary.
Disorders of the anterior pituitary.
Disorders of central nervous system (hypothalamic) factors.


Data Collection:
for amenorrhea

History & physical exam → evaluate for:
Evidence of psychological dysfunction or emotional stress.
Family history of apparent genetic anomalies.
Signs of a physical problem:
Nutritional status.
Abnormal growth & development.
Presence of a normal reproductive tract.
Evidence of CNS disease.


Laboratory/Diagnostic Testing: for Amenorrhea

Urine pregnancy test:
Regardless of history.
Easy test.
If positive, eliminates need for further evaluation of amenorrhea.


If pregnancy has been ruled out:
Amenorrhea work-up

Step 1
TSH (thyroid-stimulating hormone).
Rule out thyroid disease.
Prolactin level.
Rule out hyperprolactinemia.
Progesterone challenge test


Progesterone challenge test:

Level of endogenous estrogen.
Competence of the outflow tract.
Give a progestational agent with no estrogenic activity.
Within 2-7 days after the conclusion of progestational medication, the patient will either bleed or not bleed.


Test Results - Step 1 :
for Amenorrhea

Elevated TSH  hypothyroidism  needs appropriate treatment.
Elevated Prolactin → hyperprolactinemia → needs appropriate evaluation/treatment.


+ withdrawal bleed (progesterone challenge test) with normal TSH & normal prolactin level:

Confirms presence of a functional outflow tract & a uterus lined with reactive endometrium  sufficient endogenous estrogen.
Presence of estrogen  confirms minimal function of the ovary, pituitary, & CNS.
Can make a reliable diagnosis of anovulation  provide appropriate treatment.


No withdrawal bleed from progesterone challenge test with normal prolactin level & normal TSH

proceed to Step 2:


Step 2 for amenorrhea

Give estrogen & progestin cycle – 21 days of 1.25mg of conjugated estrogens + provera 10mg daily for the last 5 days.
Challenges capacity of uterus & outflow tract with exogenous estrogen.

With withdrawal bleed  endometrium & outflow tract have normal functional abilities if properly stimulated by estrogen.


If there is no withdrawal bleed  defect in the endometrium or outflow tract.
for step 2 for amenorrhea

Possible defects:
Congenital abnormality of uterus or outflow tract.
Asherman’s Syndrome – secondary amenorrhea from the destruction of the endometrium  intrauterine scarification & adhesion formation – overzealous curettage, uterine surgery (c-section, myomectomy, metroplasty)


With + stimulation of endometrium with exogenous estrogen  need to determine if lack of estrogen is due to a fault in the ovary or CNS-pituitary axis

proceed to Step 3.


Step 3
for amenorrhea

Evaluate FSH & LH levels:
Normal levels  needs evaluation of anterior pituitary gland (coned-down view of Sella Turcica)
If normal, diagnosis of hypothalamic amenorrhea can be made.
If abnormal  needs MRI for evaluation of pituitary tumor.


Step 3 results for amenorrhea

FSH & LH levels:
Low levels  same evaluation as for normal levels.

High levels  diagnosis of ovarian failure can be made.At step 3 there are numerous tests that can also be performed to confirm or rule out various disease &/or genetic problems.


Treatment for amenorrhea

Once cause of amenorrhea is identified → detailed pathology & treatment are handled by specialists.

Hormonal therapy with oral contraceptives may be initiated to provide estrogen source & provide cyclic shedding of the endometrium.


Only hypothalamic amenorrhea may not require extensive medical treatment:

Reversible causes of hypothalamic dysfunction → stress, weight loss for nonorganic reasons, & strenuous exercise programs.

Counseling & behavioral modification.