1. Abnormal Vaginal Bleeding In Adults
Dr. Zahra Shahshahan
October 2016

2. INTRODUCTION
Chronic abnormal uterine bleeding (AUB), a term that refers to menstrual bleeding of abnormal quantity, duration, or schedule, is a common gynecologic problem, occurring in approximately 10 to 35 percent of women.

3. Normal Menstruation Parameters
Clinical dimensions of menstruation and menstrual cycle
Descriptive terms
Normal limits (5th to 95th centiles)
Frequency of menses (days)
Absent
Infrequent
>38
Normal
24 to 38
Frequent
<24
Regularity of menses (variation defined as shortest to longest cycle length, in days)
Regular
Variation ≤7 to 9 days*
Irregular
Variation >7 to 9 days*
Duration of flow (days)
≤8 days
Prolonged
>8 days
Volume of monthly blood loss (objective) 
Heavy
>80
5 to 80
Light
<5
Volume of monthly blood loss (subjective)
Clinical definition of heavy menstrual bleeding (HMB): based on the patient's perception of volume (refer to UpToDate topic on abnormal uterine bleeding in reproductive-age women)
*Normal variation depends on age; these data are calculated excluding short and long outliers.

4. PALM-COEIN Classification System For Abnormal Uterine Bleeding In Nongravid Reproductive-age Women

5. FIBROID LOCATIONS IN THE UTERUS

6. Causes Of Abnormal Uterine Bleeding In Nonpregnant Adolescents According To Bleeding Pattern
Associated clinical features
Suggested evaluation
Amenorrhea
Primary amenorrhea
Absence of menarche by age 15 years
Secondary amenorrhea
Absence of menses for:
≥90 days in adolescents who had regular menstrual cycles, or
≥6 months in adolescents who had irregular menstrual cycles

7. Associated clinical features Suggested evaluation
Bleeding pattern
Associated clinical features
Suggested evaluation
Irregular bleeding (unpredictable in timing and volume)
Common causes
Anovulatory uterine bleeding due to immature HPO axis
First year or two after menarche
Absence of premenstrual symptoms (eg, breast tenderness, weight gain, mood swings, cramping)
Absence of clinical features associated with other causes
Evaluation to exclude other possible causes of anovulatory uterine bleeding as indicated clinically
PCOS
Hyperandrogenism (hirsutism, acne, clitoromegaly)
Obesity
Less common causes
Hypothyroidism or hyperthyroidism
Recent weight gain or loss
Heat or cold intolerance
Family history of thyroid dysfunction
Thyroid-stimulating hormone
Hyperprolactinemia
Galactorrhea, headache, visual changes
Prolactin
Hypothalamic dysfunction
Poor nutrition
Intense exercise
Psychosocial stress
Follicle-stimulating hormone
Luteinizing hormone
Intermittent nonuterine bleeding mimicking irregular menses
Clinical features of sexually transmitted infection (eg, vaginal discharge, vulvovaginal lesions, post-coital bleeding)
Examination of external genitalia
Testing for sexually transmitted infection as indicated

8. Associated clinical features Suggested evaluation
Bleeding pattern
Associated clinical features
Suggested evaluation
Regular menses with excessive flow
Common causes
Bleeding disorder
Heavy bleeding with first period
Symptoms of bleeding disorder (eg, bruising, epistaxis, gum bleeding)
Family history of bleeding disorder
Complete blood count with platelets
Evaluation of peripheral blood smear
aPTT and PT
von Willebrand panel
Less common causes
Medications that affect hemostasis
Anticoagulant therapy
Hypothyroidism or hyperthyroidism
Recent weight gain or loss
Heat or cold intolerance
Family history of thyroid dysfunction
Thyroid-stimulating hormone
Structural lesions (eg, endometrial polyp, uterine leiomyoma [fibroid], congenital uterine anomaly)
Often asymptomatic
May be associated with pelvic pressure and pain
Pelvic ultrasonography

9. Associated clinical features Suggested evaluation
Bleeding pattern
Associated clinical features
Suggested evaluation
Regular menses with intermenstrual bleeding
Common causes
Hormonal contraception or intrauterine device
Recent initiation or poor adherence
Sexually transmitted infection
High-risk behaviors (eg, unprotected sexual activity, multiple partners)
Vaginal discharge
Vulvar lesions
Post-coital bleeding
Testing for sexually transmitted infection as indicated
Extrauterine causes of intermittent bleeding that may mimic intermenstrual uterine bleeding
Ectropion (eversion of the endocervix)
Speculum examination
Perineal trauma
History of perineal trauma or forced sexual activity
Examination of external genitalia
Cervical polyps
Chronic inflammation of the cervical canal
Medications
Anticoagulant therapy

10. Evaluation Of Abnormal Uterine Bleeding In Nonpregnant Reproductive-age Women

11. TREATMENT
AUB is a common gynecologic problem and may cause anemia and impair quality of life. Prolonged bleeding that is not cyclical is often caused by ovulatory dysfunction (AUB-O). In contrast, heavy menstrual bleeding (HMB) is cyclical and often associated with structural uterine disorders.
AUB treatment choices should take the following factors into consideration: etiology; severity of bleeding (eg, anemia, interference with daily activities); associated symptoms and issues (eg, dysmenorrhea/pelvic pain, infertility); contraceptive needs and plans for future pregnancy; medical comorbidities; risk of venous or arterial thrombosis; and patient preferences regarding, as well as access to, medical versus surgical and short-term versus long-term therapy.

12. TREATMENT
The goal of initial therapy is to control the bleeding, treat anemia (if present), and restore quality of life. Initial therapy is typically pharmacologic. Once the initial treatment goals have been accomplished, some women are satisfied with continuing chronic medical therapy, while others desire a treatment that requires less maintenance or is definitive.
For most women with HMB, we suggest estrogen-progestin contraceptives rather than other medications as first-line therapy. Oral or injectable progestin-only medications are also reasonable as first-line management. The levonorgestrel-releasing (20 mcg/day) intrauterine device (LNg20 IUD; Mirena) is the most effective medical treatment of HMB. However, due to logistical/financial issues, it is often appropriate to begin therapy with estrogen-progestin regimens or oral/injectable progestin therapy.

13. TREATMENT
Tranexamic acid or nonsteroidal antiinflammatory drugs are useful for patients with HMB who have contraindications to or would prefer to avoid hormonal agents. Expectant management is reasonable for women who are not anemic and do not desire treatment.
For women with AUB-O, estrogen-progestin formulations, oral progestin therapy, or the LNg20 are first-line treatment options, as these approaches reduce bleeding and decrease the risk of endometrial hyperplasia or cancer.

14. TREATMENT
We suggest the LNg20 rather than endometrial ablation. Endometrial ablation is a reasonable choice in women who do not desire future pregnancy and wish to avoid using or changing an intrauterine device. Hysterectomy is a reasonable option in women who do not desire future pregnancy, who desire definitive therapy, and who are aware of the risk of perioperative complications.
Estrogen-progestins contraceptives are contraindicated in women with risk factors for venous or arterial thrombosis (eg, history of venous thromboembolism, known thrombogenic mutations, ≥35 years-old and smoking ≥15 cigarettes/day). Progestins may be appropriate for some women with such risk factors, but medical consultation may be required. For women at an increased risk of venous or arterial thrombosis treated for AUB with progestins, we suggest the LNg20 rather than depot medroxyprogesterone acetate (DMPA) or high-dose oral progestins.

15. Thank You For Your Attention!!