Abnormal Uterine Bleeding A new classification system

Abnormal Uterine Bleeding Overarching term for the symptom of disturbed menstral bleeding Discarded terms DUB Menorrhagia AUB will be subdivided by causes such as polyps, ovulation disorders, etc

PALM-COEIN P A L Polyps either endometrial or endocervical AUB-P Adenomyosis AUB-A L Leiomyoma AUB-L

PALM-COEIN M C O Malignancy/hyperplasia AUB-M Coagulopathy either from clinical disorder or from anticoagulant medication AUB-C O Ovulatory disorders AUB-O

PALM-COEIN E I N Endometrial disorders AUB-E Iatrogenic AUB-I Non yet classified AUB-N

Patient with AUB Could they be anemic Are they on a drug that could cause AUB Are they ovulatory Are they at risk of hyperplasia/malignancy

Chronic AUB: =3 months of disturbed menstrual bleeding Could they be anemic? CBC No Yes Are they on a drug that could cause AUB? AUB-I AUB-C Are they ovulatory No Yes Are they at risk for malignancy/hyperplasia yes AUB-O Evaluate the uterus Endometrial sampling Ultrasound, sonohysterogram, hysteroscopy AUB-M negative AUB-A Positive AUB-P AUB-E AUB-L

AUB-I Hormonal contraception IUD Tricyclic antidepressants, phenothiazines

AUB-C Anticoagulant meds coagulopathies

Chronic AUB: =3 months of disturbed menstrual bleeding Could they be anemic? CBC No Yes Are they on a drug that could cause AUB? AUB-I AUB-C Are they ovulatory No Yes Are they at risk for malignancy/hyperplasia yes AUB-O Evaluate the uterus Endometrial sampling Ultrasound, sonohysterogram, hysteroscopy AUB-M negative AUB-A Positive AUB-P AUB-E AUB-L

AUB-O Most of the time no etiology PCOS Hypothyroid Hyperprolactinemia Mental stress Extreme changes in weight or exercise

Chronic AUB: =3 months of disturbed menstrual bleeding Could they be anemic? CBC No Yes Are they on a drug that could cause AUB? AUB-I AUB-C Are they ovulatory No Yes Are they at risk for malignancy/hyperplasia yes AUB-O Evaluate the uterus Endometrial sampling Ultrasound, sonohysterogram, hysteroscopy AUB-M negative AUB-A Positive AUB-P AUB-E AUB-L

Posterior Fibroid Slide courtesy of Linda Darlene Bradley, MD. This slide shows a TVS image of a posterior fibroid. Slide courtesy of Linda Darlene Bradley, MD. Slide courtesy of Linda Darlene Bradley, MD.

Saline Infusion Sonography

Posterior Class 3 Fibroid This slide shows a SIS image of a posterior Class 3 fibroid abutting the posterior endometrium. Slide courtesy of Linda Darlene Bradley, MD. Slide courtesy of Linda Darlene Bradley, MD.

Endometrial Polyps Slide courtesy of Linda Darlene Bradley, MD. This slide shows an SIS image of endometrial polyps. Slide courtesy of Linda Darlene Bradley, MD. Slide courtesy of Linda Darlene Bradley, MD.

Endometrial Polyps Slide courtesy of Linda Darlene Bradley, MD. This slide shows a hysteroscopic image of the endometrial polyps seen on the SIS in the previous slide. Slide courtesy of Linda Darlene Bradley, MD. Slide courtesy of Linda Darlene Bradley, MD.

Chronic AUB: =3 months of disturbed menstrual bleeding Could they be anemic? CBC No Yes Are they on a drug that could cause AUB? AUB-I AUB-C Are they ovulatory No Yes Are they at risk for malignancy/hyperplasia yes AUB-O Evaluate the uterus Endometrial sampling Ultrasound, sonohysterogram, hysteroscopy AUB-M negative AUB-A Positive AUB-P AUB-E AUB-L

Possible Endometrial Biopsy Findings Proliferative, secretory, benign, or atrophic endometrium Inactive endometrium Tissue insufficient for analysis No endometrial tissue seen Simple or complex hyperplasia without atypia Simple or complex hyperplasia with atypia Endometrial adenocarcinoma The results of most endometrial biopsies fall into one of several categories, shown on this slide. Atypia is the most important risk factor for endometrial cancer. Approximately 25% of patients with atypia have been reported to develop endometrial cancer, compared with only 2% of patients without atypia. A finding on biopsy of normal secretory endometrium indicates that the patient is having ovulatory cycles, and abnormal uterine bleeding is therefore most likely due to a cause other than anovulation.

Chronic AUB: =3 months of disturbed menstrual bleeding Could they be anemic? CBC No Yes Are they on a drug that could cause AUB? AUB-I AUB-C Are they ovulatory No Yes Are they at risk for malignancy/hyperplasia yes AUB-O Evaluate the uterus Endometrial sampling Ultrasound, sonohysterogram, hysteroscopy AUB-M negative AUB-A Positive AUB-P AUB-E AUB-L

AUB-A Adenomyosis usually found on hysterectomy specimen MRI

AUB-E Problem with prostiglandins Receptor problems Areas for research