Abnormal Uterine Bleeding: Etiology and Management

Abnormal Uterine Bleeding (AUB)

• AUB is a common health concern in women, characterized by excessive or prolonged bleeding.
• Mean amount of menstrual blood loss in one cycle is approximately 35 mL, but may be as much as 60 mL.
• Heavy menstrual bleeding occurs in 9% to 14% of healthy women.

Diagnostic Tests

• Measurement of hemoglobin, serum iron, serum ferritin, beta human chorionic gonadotropin, thyroid-stimulating hormone, and prolactin levels.
• Endometrial biopsy and hysteroscopy.
• Sonohysterography and hysterosalpingography.
• Magnetic Resonance Imaging (MRI) may be helpful in diagnosing adenomyosis or surgical planning for leiomyoma.

Causes of AUB

• PALM-COEIN classification system:
  • P: Polyps
  • A: Adenomyosis
  • L: Leiomyoma
  • M: Malignancy and hyperplasia
  • C: Coagulopathy
  • O: Ovulatory dysfunction
  • E: Endometrial
  • I: Iatrogenic
  • N: Not yet classified

Endometrial Polyps

• Localized overgrowths of endometrial tissue, containing glands, stroma, and blood vessels, covered with epithelium.
• Most commonly found in reproductive-age women.
• Estrogen stimulation plays a key role in their development.

Adenomyosis

• Defined by the presence of endometrial glands and stroma in the uterine myometrium.
• Can occur as focal (adenomyoma) or diffuse.
• Peak incidence in the fifth decade of life.
• Multiparity is considered the most significant risk factor.

Leiomyoma

• Benign tumors of the uterine myometrium.
• Can cause abnormal bleeding due to size, location, and number.
• Subclassification of leiomyomas:
  • Type 0: Intracavitary fibroids.
  • Type 1: Submucosal fibroids, more than 50% intracavitary.
  • Type 2: Submucosal fibroids, less than 50% intracavitary.

Coagulopathy

• Systemic diseases, particularly disorders of blood coagulation, may initially present as AUB.
• Von Willebrand disease and prothrombin deficiency are examples.
• Routine screening for coagulation defects is mainly indicated for adolescents with prolonged heavy menses.

Management of AUB

• High doses of oral or intravenous estrogen usually stop acute bleeding episodes.

• Tranexamic acid (TXA) stops bleeding in most cases.

• Alternative regimen is high-dose oral progestogen for a week, with tapering of the dosage thereafter.

• Oral contraceptives, nonsteroidal anti-inflammatory drugs, TXA, or a prolonged course of progestogens, or levonorgestrel released locally from an intrauterine system (LNG-IUS) may be used.### Abnormal Uterine Bleeding (AUB)

• AUB can be caused by various factors, including hormonal imbalances, coagulopathies, and anatomical abnormalities.

Treatment Options

• Hormonal or surgical ablation of the endometrium
• Uterine artery embolization
• Radiofrequency ablation
• Myomectomy through various surgical approaches

Classification of Leiomyomas

• Leiomyomas can be classified using the PALM-COEIN system
• A subscript 0 indicates the absence of leiomyomas, while a number 1 indicates their presence
• The letters SM can be inserted to indicate a fibroid's location as submucosal

Coagulopathies

• Hemophilias A and B are X-linked recessive deficiencies of factor VIII and factor IX, respectively
• Women who are carriers for these disorders can have reduced levels of factors VIII and IX, leading to mild hemophilia
• Rare inherited coagulopathies of other clotting factors (V, VII, X, XI, XIII) can also cause menorrhagia
• Disorders that produce platelet deficiency, such as leukemia, severe sepsis, idiopathic thrombocytopenic purpura, and hypersplenism, can cause excessive bleeding
• Chronic anticoagulation as a result of medications like heparin, low-molecular-weight heparin, direct thrombin inhibitors, and direct factor Xa inhibitors can also lead to bleeding

Malignancies

• Malignancies associated with the female reproductive tract include vulvar, vaginal, cervical, endometrial, uterine, and adnexal (ovarian or fallopian tube) cancers

Other Causes of AUB

• Ovulatory dysfunction
• Endometrial polyp
• Adenomyosis
• Iatrogenic causes
• Not yet classified causes