Ayman Al-Talib, MD,SSCOG,GOC
Assist. Professor
Gynecologic Oncologist & MIS
Faculty of Medicine, IAU
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Normal Ovulatory Cycle
 Follicular development  ovulation (Day 14)  corpus
luteal function  luteolysis
 Endometrium is exposed to:
 ovarian production of estrogen 
(proliferation)
 Combination of estrogen and progesterone 
(secretory phase)
 Estrogen and progesterone withdrawal
(desquamation and repair)
 21 - 35 days, lasting 2 to 7 days, flow <80 mL/cycle
 Predictable cyclic menses reflect regular ovulation
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Menstrual Cycle Chart
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Anovulatory Bleeding
 Corpus luteum is not formed
 Ovary fails to secrete progesterone, although estrogen
production continues…………
 Result is continuous, unopposed Es stimulation of
endometrium:
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endometrial proliferation without Progesterone-induced
differentiation / stabilization
 Endometrium becomes excessively vascular without
stromal support  fragility and irregular endometrial
bleeding
 Common in pre-menarche and peri-menopause
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Endometrial dysfunction:
- PG’s imbalance:- (decrease PGF2a : increase PGE2
ratio).
- Increased fibrinolytic activity.
- Ineffective contraction of myometrial muscles
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AUB
 The bleeding is unpredictable in many ways.
 It might be excessively heavy or light, prolonged,
frequent, or random.
 AUB occurs without recognizable pelvic pathology,
general medical disease, or pregnancy.
 It is considered a diagnosis of exclusion.
 AUB should be suspected in patients with
unpredictable or episodic heavy or light bleeding
despite a normal pelvic examination.
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Abnormal Uterine Bleeding (AUB/DUB)
 1/3 of out-patient visits
 Most after menarche or peri-menopausal (anovulatory)
 Multiple causes, but mostly:
 -Pregnancy related (always R/O)
 -Structural uterine pathology (fibroids, polyps,
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adenomyosis)
-Anovulation (PCO)
-Disorder of haemostasis
-Trauma
-Infection
-Neoplasia
-Non gynecological source (urethra, rectum)
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Anovulatory AUB
 In some adolescent girls and perimenopausal
women, Ovarian follicles develop(FSH Stimulation)
and produce estrogen in variable amount leading to
proliferation of endometrium .
 Dominant follicle may not develop due to
insufficient LH surge – no ovulation—no
development of carpus Luteum ---no progesterone -- no secretary changes in endometrium ; estrogen
still secreted by follicles (grannulosa cells) .
 Unopposed estrogenic Stimulation and some time
hyper ( super threshold ) level of estrogen results in
over growth of endometrium(hyperplasia) ---resulting in prolonged cycle and increased blood
loss during period.
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Ovulatory AUB
 More common in women of reproductive age group
(21-40 years ) .
 Accounts for 20% cases of AUB.
 Patient usually present excessive cyclic bleeding /
premenstrual spotting.
 Periods are associated with Pain.
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Differential Diagnosis
 Structural
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Uterine or cervical polyp (P)
Adenomyosis (A)
Uterine leiomyoma(L)
Cervical stenosis/Asherman’s (hypomenorrhea)
Trauma (I)
 Malignancy
 Uterine or Cervical cancer (M)
 Endometrial hyperplasia (potentially pre-malignant) (E)
 Ovarian tumor (GCT)
 Hormonal
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Anovulatory bleeding…..the commonest (O)
Hypogonadotropic hypogonadism
Pregnancy
Contraception (i.e. OCPs, IUD)
 Bleeding disorders
 von Willebrand’s Disease, Hemophilia/Factor deficiencies, platelet
disorders (C)
 Systemic disorders
 Hyperthyroidism
 Hypothyroidism
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Terminology and PALM-COEIN etiology
classification
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Uterine or cervical polyp (AUB-P)
Adenomyosis (AUB-A)
Uterine leiomyoma (AUB-L)
Malignancy (AUB-M)
Coagulopathy (AUB-C)
Ovulatory dysfunction (AUB-O)
Endometrial causes (AUB-E)
Iatrogenic causes (AUB-I)
Not otherwise classified (AUB-N)
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AUB
 Menorrhagia: excessive (>80 mL/cycle) or prolonged
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menstrual bleeding , REGULAR(>7 days)
 Polymenorrhea: frequent menstrual bleeding. Strictly,
menses occur q < 21 d or less
Oligomenorrhea: bleeding with interval > 35 days
Metrorrhagia: light bleeding at irregular intervals
Menometrorrhagia: heavy bleeding at irregular
intervals
Intermenstrual bleeding: bleeding between menses
Post coital spotting: vaginal bleeding within 24h of
intercourse
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HISTORY
Because AUB is considered a diagnosis of exclusion, the presence or absence of
signs and symptoms of other causes of anovulatory bleeding must be
determined.
Age of patient will direct you for the question!
 When did the bleeding start (LMP)? Pregnancy related.
Delayed period? (pregnancy test)
 What is the nature of the bleeding (frequency, duration,
volume, relationship to activities such as coitus)
 Quantity : number of pads, soakness
 Are there symptoms of ovulation? (molimina)
 Were there precipitating factors, such as trauma?
 Any associated symptoms? S & S of anemia!
 Keep in your mind: Ask relevant questions according to the
case.
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 Menstrual history:
 Regular cyclic periods – ovulatory
 Menorrhagia since menarche - Bleeding diathesis
 Intermenstrual bleeding (think of structural lesion
e.g. endometrial polyp, fibroid, cervical neoplasia)
 IUCD or OCP - intermenstrual bleeding
 Is she having coital relations? Post coital? Cervical
polyp, cancer??
 Perimenarcheal and perimenopausal –
Anovulation
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 Medical History:
 Does she have a systemic disorder? chronic liver or renal
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disease, thrombocytopenia –menorrhagia
bleeding associated with surgery, dental extraction,
childbirth, or bruising (>5 cm)/epistaxis/bleeding gums
once or twice a month
Cold or Heat intolerance, Constipation or diarrhea -thyroid
disease
Family History:
Is there a personal or family history of a bleeding disorder?
Drug History: Any medications? Anticoagulants –
menorrhagia
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Review of systems
 Lower abdominal pain, fever, vaginal discharge -infection
(endometritis, vaginitis)
 Changes in bladder or bowel function - mass effect from a
local neoplasm or non-uterine bleeding
 Headaches, breast discharge, visual disturbances prolactinoma or other cranial tumor
 Hirsutism or hair loss, acne – PCOS
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PHYSICAL EXAMINATION
 General examination (pallor)
 Signs of systemic illness, such as fever, chronic
liver dis.(?)
 Ecchymoses
 Enlarged thyroid gland
 Hyperandrogenism (hirsutism, acne,
clitoromegaly, or male pattern balding)
 Acanthosis nigricans - insulin resistance and
anovulation….PCOD
 Galactorrhea - hyperprolactinemia
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 Speculum and pelvic examinations
 Bleeding site: vulva, vagina, cervix, urethra, or anus
 Any suspicious findings (mass, laceration, ulceration,
vaginal discharge, foreign body)
 Assess the size, contour, and tenderness of the uterus
(fibroids, adenomyosis, pregnancy, or
infection)
 Examine the adnexa for an ovarian tumor
 Evaluate for tenderness - infection
 Cervical cytology and any visible cervical lesion
should be biopsied
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Signs…
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LABORATORY EVALUATION
 Pregnancy test in all reproductive age women
 Hemoglobin/hematocrit- anemia
 Platelet count – thrombocytopenia
 Coagulation testing - PTT, PT, BT, factor VIII, and
von Willebrand factor antigen and activity
 STD: Gonorrhea, Chlamydia, trichomonads
 Prolactin level
 Androgen levels: Testosterone, DHEAS
 TSH
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 Endometrial biopsy - endometrial cancer hyperplasia( All
women > 35 years)
 18 and 35 years if with risk factors for endometrial cancer
(family or personal history of ovarian, breast,colon, or
endometrial cancer; tamoxifen use; chronic anovulation;
obesity; estrogen therapy; prior endometrial hyperplasia;
diabetes)
 Result of biopsy interpretation:
  Secretory endometrium – ovulation
  Proliferative endometrium – anovulation
  Inflammation of the endometrium - endometritis
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ADDITIONAL LAB. EVALUATION
 Ultrasound(Intrauterine pregnancy, Ectopic, Gestational
trophoblastic disease,Fibroids, adenomyosis, endometrial
lining, ovaries)
 Saline infusion sonography (sonohysterography) Fibroids,
polyps
 Hysteroscopy
 Rarely, MRI
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Polyps
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Management
 Is bleeding ovulatory or anovulatory?
- Ovulatory …. treat the underlying cause (e.g.Fibroid/ hyprrplasia/
GCT…….)
- Anovulatory
 Acute management
 Estrogen:(promotes rapid endometrial growth to cover denuded
endometrial surfaces) conjugated equine estrogens PO up to 10 mg/d
in 4 divided doses or IV 25 mg q 4 hrs for 24 hrs
 D&C (temporary measure – not therapeutic)
 Ongoing management
 Replace Progesterone: Progesterone pills (continuous or cyclical),
injections, OCP, Other measures
 Hormonal…… IUCD(Mirena)
 Remove the endometrium: Ablation …many methods
 Remove the organ: Hysterectomy
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Management
 Iron supplements
 Non-steroidal anti-indflammatory drugs(NSAIDs)
 Tranexamic acid
 Oral contraceptives
 Oral progestogen
 Hormonal IUD (Mirena)
 Danazol
 GnRH
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NSAIDs
Mefenamic acid (Ponstan®):
- Is the most common drug used by adolescent
female; for dysmenorrhea as well.
- 3 capsules daily, from day 1 to day
5 of the cycle.
- It decreases menstrual blood loss by 25%.
- Side effects: gastritis, gastric ulcer.
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Antifibrinolytic
Tranexamic acid (500mg tab):
It works by preventing blood clots from breaking down too quickly. This
helps to reduce excessive bleeding.
- 3 capsule daily, from day 1 to day 5 of the
cycle.
- It decreases menstrual blood loss by 50%.
- Main side effects; nausea and vomiting, ~ 25%
of patients stop it because of these side effects.
- Rarely, it may cause cerebral thrombosis, so it
is contraindicated in patient with risk factors for
thromboembolism.
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Hormonal
1-Progestogens:
- Norethisterone and Medoxyprogesterone
acetate (MPA).
- It is the most common drug used for AUB.
- 5 mg twice daily, from day 5 to day 25 of
the cycle./ or 14 days per cycle
- It decreases menstrual blood loss by 25%.
- No serious side effects.
- So its safe to use.
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2- Combined oral contraceptive pill:
-1tab daily for 21 days, from day 5.
- It decreases menstrual blood loss by 50%.
- Minor side effects: Nausea , vomiting ,
headache , irritability , increase in weight...
- Major side effects: HT, thromboembolism,
cardiovascular…
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Later Reproductive Age
Surgical therapy
 hysterectomy and endometrial ablation
 only indicated when medical Rx has failed
and childbearing complete
 Some studies suggest hysterectomy may
have higher long-term satisfaction than
ablation
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Hysterectomy
Hysterectomy involves the removal of the uterus.
Hysterectomy can be 'total', in which the uterine cervix is also
removed, or 'subtotal', in which the cervix is retained.
Hysterectomy is often accompanied by bilateral
oophorectomy (removal of both ovaries).
The precise choice of operation should be determined after
detailed discussion between the doctor and patient.
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 Dysmenorrhea: is a chronic, cyclic pelvic pain
associated with menstruation.
1- Primary: painful menstruation without associated
pelvic disease
2- Secondary: painful menstruation caused by pelvic
pathology
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Primary dysmenorrhea
 is the most common gynecologic complaint and one of the leading
causes of absenteeism in young women
 Increased levels of Prostaglandins stimulates uterine smooth muscle
contraction → vasoconstriction of the uterine arteries → uterine
hypoxia → pain of dysmenorrhea
 Onset: within 6-12 months after menarche, relived after first delivery
 Usually begins few hrs before or with the onset of menstruation
 The pain is crampy/ colicky in the lower abdomen and suprapubic
area associated with nausea, vomitting, diarrhea, headache and fatigue.
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Treatment of 1ry dysmenorrhea
1- NSAIDs are 1st line treatment
*Propionic acid derivatives (Ibuprofen, naproxen)
*Ponstan (mefenamic acid)
2- Oral contraceptives
* If NSAID are not effective or contraindicated
* 90% effective within 3-4 months of use
3- Some Pt may require combining both drugs
4- Consider 2ry dysmenorrhea if no improvement with therapy
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Causes of 2ry dysmenorrhea
 Endometriosis
 Adenomyosis
 Endometrial polyp
 Fibroid
 Cx stenosis
 Pelvic inflammatory disease
 Presence of an IUD
 Adhesions
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Thank you
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