Abnormal uterine bleeding

Question 1

Abnormal uterine bleeding (previously dysfunctional uterine bleeding) is a common problem affecting 20-25% of women of reproductive age, incoorporating

Answer 1

amenorrhoea (>90days)
menorrhagia
polymenorrhoea (cycle 35 days)
metrorrhagia - irregular cycles
intermenstrual bleeding

Question 2

What are the major causes of abnormal uterine bleeding?

Answer 2

Polyps
Adenomyosis
Leiomyoma (fibroid)
Malignancy - endometrial hyperplasia and Ca plus localised causes - cervical or vulval Ca, infection
Coagulopathy - Factor V Leiden
Ovulatory dysfunction - e.g. PCOS
Iatrogenic - e.g. anticoagulation
Endometrium "DUB" - dx of exclusion

Question 3

How do I assess a woman presenting with AUB?

Answer 3

1) History is key -
menstrual hx
screening - Pap smear and gardasil vax
STI hx
Obs hx

Sx of: anemia, hypothyroid, malignancy
medications,
Med Hx and family hx

Examination
pallor
thyroid
abdo - tender? mass?
VE - vulva, vagina, speculum - cervix appearance?
Bimanual - masses?

Question 4

How will I investigate AUB?

Answer 4

Serum hCG - exclude pregnancy
FBC - anemia, platelet disorders
Coags for bleeding diatheses
TSH and T4 if suspecting thyroid dysfunction
FSH/LH
Progesterone day 21 for anovulation

Pap smear if appropriate
TV USS
Contrast sonohystography to define polyps/fibroids
Hysteroscopy and endometrial sampling

Question 5

What medical treatments are available for AUB?

Answer 5

Medical mx is:
Hormonal -
- Mirena - IUD secreting locally acting progestogen - may decrease AUB by 90%, takes 6 months though
- Implanon - implanted version of this
- COCP - may decrease AUB by 45%
Non-hormonal (take during menstruation only to reduce blood loss)
- NSAIDs e.g. mefanamic acid
- Tranexamic acid

Question 6

What surgical treatments are available for AUB?

Answer 6

Local excision - e.g. polypectomy, myomectomy via hysteroscopy, or laparoscopic removal of intramural fibroid depending on surgeon. Allows preservation of fertility.
Endometrial ablation - for women who are certain that they have completed their family
Hysterectomy - the definitive treatment for AUB. Usually leaving the ovaries in premenopausal women with no ovarian pathology. Women require admission to hospital, surgical assessment and anaesthetic assessment. Risks of hysterectomy are - infection, haemorrhage, damage to other organs, urinary dysfunction, plus VTE and anaesthetic complications.