NORMAL &

ABNORMAL
UTERINE
BLEEDING
Suzanne Bush, MD, FACOG
Clinical Associate Professor
FSU College of Medicine
Objectives
• Recognize the characteristics of Normal Menstrual
Bleeding (The LMP as the fourth vital sign!)
• Describe the etiologies of Abnormal Uterine Bleeding
(AUB.)
• Understand etiologies of AUB with respect to the life
stages of women.
• Understand the diagnostic tools to identify the etiology of
the AUB.
• State the medical & surgical options available in primary
care and gynecology settings.
Case One
• 16 year old G0P0 presents because she is concerned
about her periods being irregular. She describes her
cycles as coming the 18th of one month & the 16th the next
month. She never knows when it is coming.

• How would you counsel this patient?

How would you counsel this patient?

A. Oral combined contraception pills will regulate her

cycles

B. She needs to do 3 months of a menstrual diary using

an App on her smartphone

C. She probably has a luteal phase defect and needs

progesterone days 15-25.

D. She has normal cycles and needs reassurance.

Normal Menstruation

• The Menstrual Cycle

In the normal menstrual cycle, orderly cyclic hormone
production and parallel proliferation of the uterine lining
prepare for implantation of the embryo.

Berek & Novak’s Gynecology, 2012, p.145

Normal Menstruation

• “The menstrual cycle starts with the first day of

bleeding of one period and ends with the first day of
the next. In most women, the cycle lasts about 28
days. Cycles that are shorter or longer by 7 days are
normal.”
ACOG Website: FAQ095
The Normal Menstrual Period

• Blood loss < 80 ml (average 30-35 ml)

• Duration of flow 2-7 days (average 4 days)
• Cycle length 21 - 35 days (average 29 days)
{28 days +/- 7 days}
Phases of the Menstrual Cycle
Reproductive Cycle
• Follicular (variable)
• Begins with Menses & ends with luteinizing (LH) hormone
surge

• Ovulation (30-36 hours)

• Begins with LH surge and ends with ovulation

• Luteal (14 days)

• Begins with the end of the LH surge and ends with onset of
menses
Phases of the Menstrual Cycle
Endometrium
• Proliferative
• Begins with menses and ends at ovulation

• Secretory
• Begins at ovulation and ends with menses
Case Two
• A 25 year old G0P0 just moved to the area and desires a
pregnancy. She has irregular menses. She was told by
her previous doctor that she has polycystic ovarian
syndrome (PCOS) and does not ovulate. She has results
of a day 21 endometrial biopsy that shows “Secretory
Endometrium.” What can you tell this patient?
What can you tell this patient?
• The biopsy confirms anovulation

• The biopsy was done on the wrong day

• The biopsy confirms ovulation.

• This patient does not have PCOS

Compare
Phases of the Phases of the
Reproductive Cycle Endometrium

• Follicular • Proliferative

• Ovulatory
• Secretory
• Luteal
The Normal Menstrual Cycle
Another Way of Looking at It

M. Manting; DUB LECTURE 2008

Regulation:
Hypothalamic Pituitary Axis

• Hypothalamus is the
pulse generator
mediated through
GnRH

• GnRH cannot be
directly measured

• Negative Feedback
Loop
Regulation of The Ovary
2 Cell Theory
• Theca Cell

• Granulosa Cell
Abnormal Uterine Bleeding (AUB)

• Definition:
• Any change in
• Prevalence:
menstrual period
• 20 million office
• Flow
visits/year
• Duration
• 25% of visits to
• Frequency gynecologists
• Bleeding between
cycles
Old Terminology

• Menorrhagia • Dysmenorrhea
• Metrorrhagia • Amenorrhea
• Menometrorrhagia • Oligomenorrhea
• Polymenorrhea • Hypomenorrhea
New Terminology

• Heavy Menstrual Bleeding

• Acute
• Chronic

• Intermenstrual Bleeding
Munro MG, FIGO Classification of AUB 2011
Clinical dimensions of menstruation and the
Descriptive terms Normal limits (5th to 95th percentiles)
menstrual cycle

Frequency of menses (days) Frequent <24

Normal 24–38

Infrequent >38

Regularity of menses (cycle to cycle variation over

Absent No
12 months)

Regular 2–20 days

Irregular >20 days

Duration of flow (days) Prolonged >8.0 days

Normal 4.5–8.0 days

Shortened <4.5 days

Volume of monthly blood loss (mL) Heavy >80

Normal 5–80

Light <5
History for AUB

• HPI
Ask lots of
questions!
• Onset

• Quantity :
• Spotting or heavy
• daily or intermittent

• Duration
History for AUB
• Gender Specific
• Menstrual
• Associated Symptoms
• Contraception
• Pain
• Gynecologic
• Nausea
• Fatigue • Obstetric
• Headache • Sexual
• Mastalgia • Genital Infections
Other Important Details

• Family History
• Anyone else? • PMH
• Von Willebrand's • Chronic conditions
• PCOS • Liver disease
• Kidney disease

• PSH • Anemia
• Drugs /medications
• Nutrition and exercise
• Psychiatric
• Weight changes
medications
• Exercise habits
• Thyroid Disorders
• Diet
• Blood thinners
Case Three
• 48 year old G2P2, S/P Bilateral Tubal Ligation 14 years
ago, referred from her primary care office with RLQ pain
of 3 months duration. LMP 5 weeks ago has had many
years of irregular menses thought to be menopause
transition.
• Ultrasound shows an 8 cm adnexal cyst with CA 125
normal.
The next step is:
• Get her on the schedule for surgery

• MRI

• Order Follicle Stimulating hormone(FSH)

• Urine Pregnancy Test

• Estradiol
Pregnancy

Age is not an Never forget

issue! pregnancy

Assumption
can lead to
death Prove it!
Differential Diagnosis Of AUB
• Structural: PALM-COEIN
(Non Gravid Women)

• Life Cycles: Pre-menarche

Menarche
Reproductive
Post-Menopause

• Anatomic: “Bottoms Up”

PALM-COEIN
• FIGO Classification System (PALM-COEIN) for causes of
AUB in non gravid women of reproductive age

• Structural vs. Non-Structural

• Developed to create a universally accepted nomenclature

PALM
Structural Causes

P- Polyp (AUB-P)

A- Adenomyosis(AUB-A)

L- Leiomyoma (AUB-L)
Submucosal myoma (AUB-LSM)

M- Malignancy & hyperplasia (AUB-M)

 COEIN
Non-Structural Causes

C- Coagulopathy (AUB-C)

O-Ovulatory dysfunction (AUB-O)

E- Endometrial (AUB-E)

I- Iatrogenic (AUB-I)

N- Not yet classified (AUB-N)

Case Four
• 42 year old G3P3 who is in your civic group
presents with heavy, cyclic uterine bleeding. You
note spider angioma across her chest & down her
arms. She has a slightly protuberant abdomen.
Her husband had a vasectomy 7 years ago, and
her pregnancy test is negative.
The best next step in evaluating her
heavy uterine bleeding:
• Fasting Blood Glucose

• Thyroid Stimulating Hormone

• Liver Function Test

• Follicle Stimulating Hormone

• Estradiol
What FIGO nomenclature would you use
to label her AUB?
• AUB-C

• AUB-O

• AUB-E

• AUB-I

• AUB-N
Liver Disease
• Patients known to have liver disease manifest
additional symptomatology because of abnormal
hepatic function.

• Evaluate patients for spider angioma, palmar

erythema, splenomegaly, ascites, jaundice, and
asterixis.
 Differential Etiology
of AUB
Diagnosis
Life Cycles
of AUB Approach

Menarche Reproductive Post-

Pre-menarche
Menopausal

•Coagulation
•E2 withdrawal •Pregnancy
Defects •Carcinoma
@birth •Anovulation
•Hypothalamic •Vaginal Atrophy
•Foreign Body •Endogenous
Immaturity •E2 Replacement
•Sarcoma •Exogenous
•Psychogenic •Anatomic
•Ovarian Tumor •Anatomic
•Trauma
Differential Diagnosis of AUB:
Anatomical

• “Bottoms Up” • Contiguous Anatomy

• Vulva • GU
• Vagina • GI
• Cervix
• Ovary • Non-Pelvic Etiology
• Brain • Endogenous
• Iatrogenic
EVALUATION OF AUB

Pregnant?

NO
YES
Evaluate for Structural (PALM)
complications VS.

IUP, SAB, Ectopic Non-Structural (COEIN)

Acute * Sub-Acute * Chronic

AUB
Initial Assessment Evaluation
Evaluation of the Uterus &
Endometrium
• History & Physical • Endometrial Biopsy
• Vital Signs
• Transvaginal &/or
• Shock Signs abdominal Ultrasound
• Laboratory (TVS/AUS)
• Pregnancy Test • Saline Sono-hysteroscopy
(SIS)
• Complete Blood Count
• Hysteroscopy
Endometrial Biopsy (EMB)

• Evaluation of the
Endometrium
• Pipelle
TVS & SIS

TVS

SIS
Evaluation
Hysteroscopy MRI
• Precisely localizes sub-
mucosal fibroids

• MRI is not superior to

TVS & SIS in overall
diagnostic potential

Dueholm M, et al. Fertil Steril.

2001;76(2):350357
Treatment of AUB
• Observation
• Medical
• Minimally invasive surgery
• Major surgery
Medical Management

• Iron • Parenteral estrogens

• Anti-fibrinolytics • Androgens
• Anti-prostiglandin • GnRH agonists
• Progestins • Anti-progestational
• Estrogen + agents
progestins (OCP)
Surgical Approach
Minimally Invasive Surgery Major Surgery

• Intrauterine Device (IUD) • Myomectomy

• Total Abdominal
with progesterone Hysterectomy (TAH)
• Total Vaginal Hysterectomy
• Dilation & Curettage (TVH)
• Laparoscopic Hysterectomy
• LSH (laparoscopic supra-
cervical)
• Endometrial Ablation
• TLH (total laparoscopic)
• LAVH (laparoscopically
assisted vaginal
hysterectomy)
• Robotic (TLH or LSH)
Final Case
• 32 year old G2P2002 presents to the ER with 10 day
history of heavy uterine bleeding. She is pale and appears
frightened. Pulse is 120, BP is 90/60. Hemoglobin is 6,
Hematocrit is 18. Pregnancy test is negative.

How do you manage this patient?

The Best Next Step?
• Oxygen & IV Fluids

• Type and Cross 2 units of blood

• Order a pelvic ultrasound

• Order TSH, CBC, Coagulation panel

• IV Conjugated Equine Estrogen

• Consent for surgery

Management
Chronic,
Acute AUB Stable AUB
• Can be a life-threatening
emergency • Combined Oral
• Monitor vital signs, Start Contraception
oxygen
• IV fluids (wide bore IV • AUB-O progestin therapy
catheter)
• Type and Cross 2-4 units of • Levonorgestrel IUD
blood
• Endometrial sampling is
• IV Estrogen indicated prior to starting
• IM Progesterone hormones in older women
• NSAIDS (Anti-prostaglandins
vs. Anti-fibrinolytics) • Medical failures have the
• Emergency D&C surgical options
Clinical Pearls
Never
Forget
Pregnancy!

Age is
PROVE IT!
Not an Issue!

Assumptions Can
Lead to Death!
References

• ACOG Practice Bulletin No. 136, July 2013

• Beckmann, et al., Obstetrics & Gynecology, 7th
ed., Chapters 37, 39
• Clinical Management of Abnormal Uterine
Bleeding: APGO Educational Series, May 2002
• Dueholm M, et al. Fertil Steril. 2001;76(2):350357
• Fritz, MA, Speroff et al, Clinical and Gynecologic
Endocrinology and Infertility,
8th ed. 2011.
• Manting M., AUB Lecture 2008
• Munro, MG, et al, FIGO Classification System
(PALM-COEIN) for causes of AUB in non gravid
women of reproductive age. Int J Gynaecol Obstet
2011; 113:3-13