Abnormal Uterine Bleeding😊

Abnormal Uterine Bleeding

Normal Characteristics of Menstrual Cycle

• Length of cycle: 24–38 days (Old: 21–35 days).

• No. of days bleeding: 4.5–8 days (Old: 2–8 days).

• Volume of blood loss: 20–80 ml.

• Cycle to cycle variation: 2–20 days.

Abnormal Uterine Bleeding

• Any deviation from normal characteristics of menstrual cycle.

• Causes: PALM COEIN.
• Polyp.
• Adenomyosis.
• Leiomyoma.
• Malignancy/hyperplasia.
• Coagulopathy.
• Ovulatory dysfunction.
• Endometrial cause.
• Iatrogenic → Copper T
• Not yet classified.

Investigation

• 1st:
• UPT except post-menopausal/virgin female.

• 2nd:
• TVS
• except puberty menorrhagia
• due to anovulation > coagulopathy

• 3rd:
• Endometrial biopsy
• IOC

Endometrial Biopsy/Endometrial Aspiration Cytology/Endometrial Sampling

Indications: C/O AUB.

• Reproductive Age
• If endometrial thickness ≥11 mm.
• Risk for endometrial cancer (using Tamoxifen).
• If bleeding despite medical Rx.

• Perimenopausal Age
• India: >> 40 years.
• International:  >>45 years.
• Always endometrial biopsy irrespective of USG findings.
• Eg: If 40 yr old comes with AUB and USG gives Fibroid → What is the next step
• Before managing fibroid → always do endometrial biopsy

• Postmenopausal Age
• If endometrial thickness ≥4 mm.

• Endometrial sampling instrument

Uses of endometrial biopsy

• Endometrial hyperplasia/cancer: IOC.

• Lynch syndrome: Screening.

• Genital TB diagnosis.

• Couples with anovulation:
• Ovulated: Glands coiled (Corkscrew/sawtooth appearance).
• Non ovulated: Simple tubular glands.

• Late menopause: Long oestrogen exposure

Procedure

• OP procedure

• Time:
• 2–3 days prior to menstruation.

• Instrument:
• Pipelle/vabra aspirator (Worldwide).
• Karman cannula (India).
• Also used in Terminations of pregnancy
• Menstrual regulation, aspiration, extraction

Endometrial Hyperplasia

With Atypia

• Chance of malignancy: 8–30%.

• Mx:
• Next step:
• FC + hysteroscopy.
• Best:
• Total abdominal hysterectomy/Simple hysterectomy/Type 1.

Without Atypia

• Chances of malignancy: 1–3%.

• Mx:
1. Progesterone
• Best: MIRENA (IUCD).
• Alternative: Oral progesterone.
• Continuous.
• Cyclical (12–14 days).
• Mechanism
• underregulation of estrogen receptor → anti proliferative
• For protective effect → Progesterone given for atleast 12 days
2. Persistent bleeding:
• FC + hysteroscopy.

Order of preference:

• Fractional curettage + hysteroscopy >
• Indications:
• EB report.
• Insufficient sample.
• Hyperplasia with atypia.
• Hyperplasia without atypia
• but patient continues to bleed despite Rx.
• Cervical stenosis.

• Dilatation curettage + hysteroscopy >

• Fractional curettage >

• Hysteroscopy.

Perimenopausal Bleeding

UPT → TVS → Endometrial biopsy.

1. Normal
• Mx of AUB:
• Tranexamic acid.
• OCP.
• Progesterone.
• If bleeding persists:
• Fractional curettage + hysteroscopy and ↓ GA in OT.

2. Swiss cheese pattern.
• Metropathia haemorrhagica (AKA Schroeder's disease).
• Mnemonic: Metroyil swiss cheese um kondu keri

3. Endometrial hyperplasia

Metropathia Hemorrhagica (AKA Schroeder's disease)

• Age: Perimenopausal female.

• C/O: 2–3 months of amenorrhea, followed by bleeding.

• Cause: Anovulatory cycles (decreased Progesterone).

• Risk of malignancy: 1%.

• Biopsy → Swiss cheese endometrium

• Rx: Cyclical Progesterone.

Postmenopausal Bleeding

Management

• Check endometrial thickness via TVS.
• <4 mm:
• Tranexamic acid.
• Persistent bleeding: FC + hysteroscopy.
• ≥4 mm:
• Endometrial biopsy.

AUB Causes → Fibroid, Polyp, Adenomyosis

Initial Assessment:

• Abnormal Uterine Bleeding (AUB) implies:
• UPT.
• TVS.

• If >= 40 years: Endometrial biopsy.
• If normal: Clinical diagnosis.

Fibroid

• Definition:
• Aka leiomyoma.
• Smooth muscle tumor from myometrium.
• Locations:
• Submucosal:
• Max bleeding risk (closest to cavity)
• Subserosal.
• Intramural.

Incidence

• Reproductive Age:
• Most common in reproductive age (25-35 years).

• Parity:
• Often nulliparous (hyperestrogenic condition).

Association

• Hormones:
• Estrogen and progesterone dependent tumor.

• Mutation: Caused by MED12 gene mutation.
• Mnemonic: MED12 gene mutation seen in 
• Fibroid
• Fibroadenoma
• Fibroadenoma (Phyllodes tumor) of breast.
• Mnemonic:
• Advice for Medicine after 12th (Med12) std → Fuck Fuck Fuck (FFF) → veruthe karangi karangi (whorled) cigar (cigar shape nuclei) valich nadakku

Symptoms

• Menstrual Bleeding:
• Heavy menstrual bleeding (HMB) or menorrhagia.
• Most common symptom.

• Other Symptoms:
• Dysmenorrhea.
• Infertility.
• Pressure symptoms.
• Pregnancy complications.

Microscopic Features

• Whirling pattern (tumor cells in round pattern).

• Cigar-shaped nuclei (elongated).

Gross Appearance

• Overall:
• Whorled appearance.
• Off-white color.

• Capsule:
• Pseudocapsule covering.
• Contains blood vessels.
• Center: Less vascular.
• Periphery: Most vascular

• Attachment:
• Arises from broad base.

Per Abdominal (P/A) Examination

• Abdominopelvic Lump:
• Unable to converge fingers below lump.
• Mobile, firm midline mass.

• Size:
• Up to 20 weeks pregnant uterus.

Per Vaginal (P/V) Examination

• Bimanual Palpation:
• Abdominopelvic mass: Firm, mobile, cannot be separated from uterus.
• Asymmetrically enlarged, non-tender uterus.
• Movement of mass: Transmitted to cervix.

Ultrasound Findings

• On Doppler:
• Increased vascularity around periphery.

• Lies outside endometrial cavity.

• Hypoechoic.

• Popcorn calcification seen in pelvis.

Popcorn calcification

Hysterosalpingography (HSG)

• Appearance:
• Filling defect with regular and smooth outlines.

On Hysteroscopy

Submucosal Fibroid:

• Pale coloured.

• Surface blood vessels.

Investigations (Ix)

• Initial Assessment:
• Abnormal Uterine Bleeding (AUB) implies:
• UPT.
• TVS.
• If >= 40 years: Endometrial biopsy.
• If normal: Clinical diagnosis.

• IOC (Investigation of Choice):
• Submucosal Fibroid:
• Saline Infusion Sonography (SIS) > TVS
• Also for Polyps

• Hysteroscopy: Diagnostic.

• Other:
• MRI: Not done routinely.

Management (Mx)

• Asymptomatic:
• Observation.

• Symptomatic:
• Large subserous fibroid or infertility.
• Depends on type of fibroid.

Management of Symptomatic Fibroid

Submucosal Fibroid:

• Family Not Complete:
• Hysteroscopic myomectomy (Type 0 and 1 fibroid).
• Laparoscopic myomectomy (Type 2 fibroid).

• Family Complete:
• Total Abdominal Hysterectomy (TAH).

Subserous/Intramural Fibroid:

• If Fails (Surgery/Procedures):
• Myomectomy.
• Hysterectomy.
• Uterine artery embolization.
• Magnetic resonance-guided Focused Ultrasound Surgery
  (MRgFUS).

Degenerations of Fibroid

1. Hyaline (m/c)

2. Calcific
• Postmenopausal women

3. Red Degeneration:
• Leiomyoma appears beefy red due to acute hemorrhagic infarction.
• Common in pregnant women with pain/fever.

• Most Common Degeneration: Hyaline degeneration.

• Least Common Degeneration: Malignant transformation.

Red Degeneration:

• Occurrence:
• Seen in pregnant women
• most common in 2nd trimester > 3rd trimester

• Cause:
• Aseptic thrombosis in blood vessels
• cause necrosis of fibroid

• Clinical Features (C/F):
• Abdominal pain
• nausea
• vomiting with/without fever

• Investigations (Ix):
• Increased ESR,
• increased WBC.

• Treatment (Rx):
• Conservatively (Analgesics, anti-emetics).
• If orally not tolerating, IV fluids.

• Notes:
• Never give antibiotics.
• Never terminate pregnancy.
• Never do myomectomy.

Polyp

• Definition:
• Localized outgrowth of endometrium.

• Age Groups:
• Seen in all age groups.

• Trends:
• Increased incidence with age.
• Most common age: 40-49 years.

• Medication:
• Increased incidence with tamoxifen.

Symptoms

• Menstrual Cycle:
• Reproductive or perimenopausal age: Irregular/intermenstrual bleeding.

• Most common cause of postmenopausal bleeding.

Gross Appearance

• Red, mucosal outgrowth.

• Smooth.

• Narrow base

• Hanging in uterine cavity.

Per Abdominal (P/A) Examination

• Findings:
• No specific findings usually.

Per Vaginal (P/V) Examination

• Bimanual Palpation:
• Normal findings usually.

IOC (Investigation of Choice):

• Hysteroscopy: Diagnostic and therapeutic.

• Appearance:
• Red with smooth contour.
• No surface blood vessels. → Unlike Fibroids

• Saline Infusion Sonography (SIS)

Ultrasound Findings

 

• Echogenic mass in endometrium.

• Doppler: Feeding vessel sign
• vessel supplying mass
• (most common in endometrial polyp).

• Saline infusion sonography:
• Saline surrounds polyp

• Hyperechoic
• made of endometrial gland tissue

Hysterosalpingography (HSG)

• Findings:
• Filling defect
• regular smooth outlines

Management (Mx)

• Endometrial Polyp:
• Hysteroscopic polypectomy

• Endocervical Polyp:
• Polypectomy hook

Adenomyosis

• Definition:
• Endometrial tissue in myometrium.

• Age:
• More than 40 years old.

• Parity:
• Multiparous women (most common).

• Co-occurrence:
• Endometriosis and fibroids.

Symptoms

• Most Common Symptom:
• Menorrhagia
• secondary dysmenorrhea.

• Other Symptoms:
• Chronic pelvic pain (CPP).

Gross Appearance

• Overall:
• Globular, symmetrically enlarged.

• Cut Section:
• Multiple petechial hemorrhages
  (due to menstrual bleeding of endometrial tissue).

Per Abdominal (P/A) Examination

• Findings:
• No specific findings usually.

• Uterus:
• Globular, symmetrically enlarged.
• Tender (Halban sign).

• Size:
• 10 - 12 weeks pregnant uterus (never more than 14 weeks).

• Tenderness:
• Adnexal tenderness (+/-).

Ultrasound Findings

• Images:
• Myometrial cyst.
• Venetian blind appearance (alternating dark and light bands).

Investigations (Ix)

• IOC (Investigation of Choice):
• MRI (usually not required).
• If done:
• Transition zone (TZ): ≥ 12 mm = Adenomyosis.



• Transition zone (TZ): < 8 mm = Rules out adenomyosis.

• Gold Standard Ix:
• HPE (Histopathological Examination) (post hysterectomy).

Management (Mx)

• Best Treatment:
• Total Abdominal Hysterectomy (TAH).

• Alternative (if patient refuses TAH):
• LNG-IUD (Mirena).