Abnormal uterine bleeding

Question 1

AUB - background

Answer 1

AUB = changes in volume, frequency, intervals and duration of menstrual cycle.

In childbearing years, may present as (7):

1. Amenorrhoea (no menses for >90d)
2. Menorrhagia (excessive/prolonged but regular bleeding)
3. Polymenorrhoea (bleeding intervals 35d)
4. Metrorrhagia (irregular intervals between bleeding)
5. Menometrorrhagia (prolonged and excessive bleeding and irregular intervals)
6. Intermenstrual bleeding

Question 2

AUB - ddx

Answer 2

P + PALE CV + COI

1. Pregnancy (5)
   - Live
   - Miscarriage
   - Ectopic
   - Trophoblastic disease
   - Retained products
2. Structural (PALE CV)
   - Polyps
   - Adenomyosis
   - Leiomyoma (myoma/fibroid)
   - Endometrial hyperplasia, endometrial cancer (2)
   - Cervical polyps, cervical cancer (2)
   - Vaginal lesions, vaginal tumours, vaginitis, valvovaginitis (4)
   Note - even though AUB is associated with adenomyosis, it does not occur frequently in endometriosis
3. Systemic, iatrogenic and other (COIS)
   - Coagulation disorders, hepatic failure (failure of synthesis of clotting factors)
   - Ovulatory dysfunction (peri-menarchal, peri-menopausal, excess androgens [e.g. PCOS, CAH, androgen-producing tumours], thyroid disorders, excess prolactin and hypothalamic disorders) - ?
   - Iatrogenic
   - STIs (may present with intermenstrual bleeding or PCB)

Question 3

AUB - hx

Answer 3

In addition to usual O&G hx + phx + fhx, etc., include:

1. Sx of anaemia - e.g. SOB, palpitations, fatigue, dizziness (may be caused by heavy menstrual bleeding with hx of clots and flooding and necessity to change sanitary protection >2hourly)
2. Sx of thyroid dysfunction - e.g. weight gain, skin and hair changes, intolerance to cold
3. Sx of bleeding disorders - e.g. easy bruising, mucosal bleeding, prolonged bleeding from wounds, fhx
4. Sx of malignancy - e.g. unexplained weight loss
5. Medication hx - e.g. anticoagulants, tamoxifen use, hormone therapy, herbal preparations (e.g. soya)

Question 4

AUB - ex

Answer 4

1. Vitals, BMI
2. Breast examination (why?)
3. Chest examination (why?)
4. Abdominal examination (why?)
5. Gynaecological examination
   + other examination as necessary (?)

Question 5

AUB - ix

Answer 5

1. b-hCG to exclude pregnancy, ectopic and trophoblastic disease
2. FBE for anaemia, platelet disorders
3. Coagulation profile for bleeding diatheses
4. TSH and thyroid hormone levels if suspecting thyroid dysfunction
5. Others - e.g. testosterone, fasting prolactin, LFTs, UEC (why?), Pap smear, transvaginal pelvic ultrasound, hysteroscopy/dilatation + curettage (if ultrasound shows thickened endometrial lining)