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Normal and Abnormal Uterine Bleeding. UNC School of Medicine Obstetrics and Gynecology Clerkship Case Based Seminar Series. Objectives for Normal and Abnormal Bleeding. Define the normal menstrual cycle and describe its endocrinology and physiology Define abnormal uterine bleeding

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normal and abnormal uterine bleeding

Normal and AbnormalUterine Bleeding

UNC School of Medicine

Obstetrics and Gynecology Clerkship

Case Based Seminar Series

objectives for normal and abnormal bleeding
Objectives for Normal and Abnormal Bleeding
  • Define the normal menstrual cycle and describe its endocrinology and physiology
  • Define abnormal uterine bleeding
  • Describe the pathophysiology and identify etiologies of abnormal uterine bleeding
  • Discuss the steps in evaluation of abnormal uterine bleeding
  • Explain medical and surgical management options for patients with abnormal uterine bleeding
  • Counsel patients about management options for abnormal uterine bleeding
normal menstrual cycle1
Normal Menstrual Cycle

Basic functional components

  • Hypothalamic-pituitary unit
  • Ovaries
  • Uterus-endometrium
normal menstrual cycle2
Normal Menstrual Cycle

Proliferative (Follicular) Phase: Days 1-13

  • Rise in FSH stimulates maturation of ovarian follicle
  • Follicles secrete estrogen as they mature
  • Estrogen stimulates proliferation of the endometrial lining
  • Endometrium reaches maximum thickness in late follicular phase
  • Level of estrogen peaks on day 12-13, stimulating LH surge on day 14
  • LH surge stimulates ovulation
normal menstrual cycle3
Normal Menstrual Cycle

Secretory (Luteal) Phase: Days 14-28

  • After ovulation, FSH and LH cause follicle to transform into corpus luteum
  • Corpus luteum produces progesterone which maintains endometrial lining
  • Microvasculature becomes well-differentiated (spiral arterioles)
  • In absence of fertilization the corpus luteum involutes
  • Fall in progesterone triggers menstruation (endometrial sloughing)
normal menstrual cycle4
Normal Menstrual Cycle
  • Normal parameters:
    • Cycle interval: 24 – 35 days
    • Menses: 4 – 7 days
    • Blood loss: 30 – 45 mL
  • Ovulatory bleeding is cyclic and predictable
abnormal uterine bleeding definition
Abnormal Uterine Bleeding: Definition
  • Bleeding that is outside the normal parameters of the menstrual cycle (volume, duration, or interval)
  • Abnormal Uterine Bleeding (AUB):
    • Polymenorrhea: regular cycle interval < 24 days
    • Oligomenorrhea: regular cycle interval > 40 days
    • Menorrhagia: regular blood loss > 80 mL or menses > 7 days
    • Metrorrhagia: irregular bleeding
    • Menometrorrhagia: heavy and irregular bleeding
aub etiology
AUB: Etiology
  • Iatrogenic
    • Exogenous estrogen
    • Intrauterine device (IUD)
    • Heparin, Coumadin
  • Systemic
    • Hepatic disease
    • Thyroid disease
    • Hyperprolactinemia
    • Renal failure
    • Other
      • Anovulation (DUB)
  • Trauma
    • Cervical laceration
    • Foreign body
  • Organic
      • Pregnancy complication
      • Uterine leiomyoma
      • Adenomyosis
      • Endometrial polyp
      • Endometrial hyperplasia
      • Malignancy (cervix, uterus)
  • Dyscrasias
      • Von Willebrand’s Disease
      • Thrombocytopenia
aub evaluation
AUB: Evaluation
  • History
    • Detailed menstrual history (volume, duration, intervals)
    • Symptoms associated with ovulation
      • e.g. breast tenderness, bloating, mood changes
    • Associated symptoms
      • e.g. dysmenorrhea, post-coital bleeding, galactorrhea, hirsutism
    • Weight changes
    • Medical history and medications
  • Pelvic Exam
    • Cervical and vaginal lesions
    • Size, shape of uterus
aub evaluation1
AUB: Evaluation
  • Laboratory
    • Urine pregnancy test
    • CBC with platelets
    • Coagulation studies
    • Thyroid studies (TSH, T4)
    • Prolactin
  • Diagnostic Procedures
    • Pap smear
    • Endometrial biopsy (EMB)
    • Transvaginal ultrasound
    • Hysteroscopy
    • Saline-infusion sonography (SIS)
aub management medical
AUB: Management (Medical)
  • Directed at treating the underlying pathology with relief of volume and duration of menses
  • Medical management
    • NSAID’s
    • Combination hormonal contraceptives (e.g. OCP’s, vaginal ring, patch)
    • Levonorgestrel IUD (Mirena)
    • GnRH agonists (e.g. Lupron)
    • Correct medical condition
aub management surgical
AUB: Management (Surgical)
  • Surgical management
    • Endometrial ablation
    • D&C - IF clinically indicated
    • Myomectomy– IF leiomyomata and fertility desired
    • Hysteroscopic resection – IF polyp, submucousmyoma
    • Hysterectomy (TAH, TVH, or TLH)
dysfunctional uterine bleeding definition
Dysfunctional Uterine Bleeding: Definition
  • Abnormal uterine bleeding with no attributable underlying illness or pathology
    • Diagnosis of exclusion!
    • Must exclude all other causes of AUB
dub etiology
DUB: Etiology
  • Anovulation
    • Polycystic ovary syndrome (PCOS)
    • Obesity
    • Adrenal hyperplasia
    • Luteal phase defect (rare)
dub pcos
  • Polycystic ovary syndrome (PCOS)
    • Increased circulating androgens aromatize to estrone (E1)
    • Constant, noncyclic, unopposed level of estrogen stimulates growth and development of the endometrium
    • Estrogen provides feedback to pituitary, resulting in low FSH and high LH
    • Static levels of LH trigger chronic anovulation
    • Without ovulation, progesterone-induced changes do not occur
    • Endometrium outgrows blood supply and sloughs at irregular times in unpredictable amounts (usually frequent and heavy)
dub etiology1




















DUB: Etiology

Ovulatory Cycle

dub evaluation
DUB: Evaluation
  • Pelvic Exam
    • Cervical and vaginal lesions
    • Size, shape of uterus
  • Laboratory evaluation
    • Urine pregnancy test
    • CBC with platelets
    • Coagulation studies
    • Thyroid studies (TSH, T4)
    • DHEAS and testosterone, if symptoms of hirsutism
    • Prolactin
  • Procedures
    • Endometrial biopsy (R/O neoplasia)
    • Transvaginal ultrasound (R/O anatomic lesions)
dub management medical
DUB: Management (Medical)
  • Massive Intractable Bleeding
    • Conjugated Estrogens 25 mg IV
  • Continued Management after Massive Bleeding
    • Conjugated Estrogens 2.5 mg po daily x 25 days
    • Medroxyprogesterone acetate 10 mg for the last 10 days
    • Allow 5-7 days for withdrawal bleed
    • Administer Mirena IUD
dub management medical1
DUB: Management (Medical)
  • Management of Moderate Menometrorrhagia
    • Estrogen-Progestin Combination
      • Conjugated Estrogen 1.25 mg po daily x 25 days + Medroxyprogesterone acetate 10 mg po for last 10 days
      • OCP x 21 days, with 7 day withdrawal
    • Cyclic Progestin
      • Medroxyprogesterone acetate 10 mg po daily x 10-15 days ea. month
      • Norethindrone acetate 5 mg po daily x 10-15 days ea. month
      • 5 – 7 days menstrual withdrawal should follow cessation ea. month
    • Mirena IUD
dub management surgical
DUB: Management (Surgical)
  • Patients who do not respond to medical therapy
  • Patients who do not desire future pregnancies
  • Management:
    • Endometrial ablation
    • Hysterectomy
bottom line concepts
Bottom Line Concepts
  • Abnormal menstruation is one of the most common problems dealt with in the gynecologic clinic.
  • Understanding of the physiology and endocrinology of the menstrual cycle is imperative in a thorough evaluation and management of AUB.
  • It is important to rule out unsuspected pregnancies and endometrial cancer in the evaluation of AUB.
  • Irregular bleeding that is unrelated to anatomic lesions of the uterus is referred to as dysfunctional uterine bleeding (DUB/anovulatory).
  • Before DUB can be diagnosed, anatomic causes including neoplasia should be excluded.
  • The primary goal of treatment of DUB is to ensure regular shedding of the endometrium and consequent regulation of menses.
  • In AUB from other causes it is important to correct underlying pathology and decrease volume and duration of menses.
references and resources
References and Resources
  • APGO Medical Student Educational Objectives, 9th edition, (2009), Educational Topic 45 (p96-97).
  • Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010), Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William NP Herbert, Douglas W Laube, Roger P Smith. Chapter 35 (p315-319).
  • Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone, Calvin J Hobel. Chapter 33 (p368-370).