FINAL YR MBBS,
ABNORMAL UTERINE BLEEDING
Arise from a number of
Prior to menopause 20%
of gynecology visits & ¼
th of gynecological
procedures are done.
INCIDENCE OF AUB
Affects 10 – 30% of
reproductive aged women
& upto 50% of
NORMAL MENSTRUAL CYCLE
Periodic physiologic discharge of blood,mucus
& other cellular debris from the uterine mucosa,occurs at
more or less regular intervals from time of puberty to
Cycle length - 28 +/- 7 days
Duration - 2 to 6 days
Blood loss - 50 to 80 ml.
PHASES OF MENSTRUAL CYCLE
Menstruation is an
external indicator of
NEUROHORMONAL CONTROL OF
ROLE OF EICOSANOIDS IN
• PROLIFERATIVE PHASE:
Endometrium sythesises equal amounts of
PGF2a & PGE2. [PGF2a:PGE2 = 1:1]
• SECRETORY PHASE:
PGF2a increases under the influence of
progesterone [PGF2a:PGE2 = 2:1] causing
contraction as predominant action.
• Relative proportion of various PGs in
endometrium is responsible for blood flow.
HOW DOES MENSTRUAL FLOW CEASE?
Primary - fibrin and platelet-onion skinned plug
Around 24hrs- most of superficial layer shed
After 24hrs- Intense vasoconstriction of spiral arterioles
and endothelial swelling
OCCLUSION OF ARTERIOLES
By 48-72hrs - regeneration of basal glands whose rate
proportional to growth of follicle.
Disturbance of endometrial degeneration and
sloughing in a regular cyclic fashion results in
aberrant uterine bleeding.
Bleeding in any of the following situations is
• Bleeding between periods
• Spotting anytime in the menstrual cycle
• Bleeding heavier or for more days than normal.
DIFFERENTIAL DIAGNOSIS OF AUB
-Anatomic uterine lesions.
-Anatomic non uterine lesion.
Exogenous hormone administration
- sex steroids,corticostroids.
Chronic renal failure
Endocrinopathies – thyroid disorder,adrenal
PREGNANCY ASSOCIATED CAUSES
Gestational trophoblastic disease
Postabortal or postpartum infection
ANATOMIC UTERINE LESIONS
• Neoplasm - leiomyoma,polyp,endometrial
• Infections - STD,tuberculosis.
• Mechanical - intra uterine device,perforation.
• Arteriovenous malformation.
ANATOMIC NON UTERINE LESIONS
Ovarian lesions - hormonally functional
Fallopian tube - salpingitis,cancer.
Cervical and vaginal
lesions - cancer,polyp,infection,
USUAL CAUSES OF AUB BY AGE
BIRTH 10 20 30 40 50 60
TRAUMA, HORMONAL CONTRACEPTION, VAGINAL/ENDOMETRIAL
INFECTION, PREGNANCY COMPLICATION, ATROPHY,
OVARIAN TUMOR. INFECTION, HORMONE THERAPHY,
ENDOCRINE DISORDER, ENDOMETRIAL CA.
DIAGNOSTIC EVALUATION OF
• Menstrual History:
- Onset of abnormal menses
- Intermenstrual interval.
• Marital History:
H/O - Post coital bleeding
- Any oral contraceptives
- IUCD insertion.
• Obstetric History:
H/O - Abortion
- Ectopic pregnancy
• Past History:
- Underlying systemic illness
- Any bleeding disorder
• Family History:
- Tuberculosis contact
- Any bleeding diathesis.
• Clinical Evaluation:
The site of uterine bleeding must be
The details of history and physical findings
narrow the number of possibilities to establish the
Objective methods for measuring menstrual
1.Photometric alkaline hematin test
2.Pictorial bleeding assessment chart
PICTORIAL BLEEDING ASSESSMENT
LABORATORY EVALUATION OF
Complete blood count:
-to exclude anemia & thrombocytopenia.
Nucelic acid based test for chlamydia &
Wet prep to exclude trichomonas.
- offers anatomic
information regarding the
- offers greater patient
comfort and comparable detection
of endometrial hyperplasia and
-used to accurately evaluate the
myometrium, endometrium, and
-permits detection of intracavitary
masses as well as differentiation of
lesions as being endometrial,
submucosal, or intramural.
Transvaginal Color Doppler
-This technique has been
evaluated in identifying and
differentiating endometrial pathology in
the context of uterine bleeding
• Cytologic Examination:
Both cervical and endometrial cancers can
cause abnormal bleeding and evidence for these
tumors can often be found with Pap smear
-to detect intracavitary lesions such as
leiomyomas and polyps that might be missed using
transvaginal sonography or endometrial sampling.
Thyroid Function Test:
Liver Function Test:
Renal Function Test:
Urine Pregnancy Test:
-exclude the possibility that relates to a
complication of pregnancy.
-to document ovulation or anovulation.
- to exclude cancer
- to identify the underlying pathology to
allow optimal treatment.
In approximately one half of cases, no organic
pathology is identified.
is diagnosed, that is,
“A DIAGNOSIS OF EXCLUSION”.