Abnormal Uterine Bleeding (AUB)

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It is the uterine bleeding after menopause, in between menstrual periods or abnormally heavy and or  prolonged  menstrual  bleeding.  Abnormal  uterine  bleeding  (AUB)  is  a  common  condition  affecting  women that has significant social and economic impact.  

The causes of AUB are classified and summarized into an Acronym; PALM-COEIN 

  • P-Polyps
  • A-Adenomyosis
  • L-Leiomyosma
  • M-Malignancy
  • C-Coagulopathy
  • O-Ovulatory dysfunction
  • E-endometrial causes
  • I-Iatrogenic
  • N-Not yet Classified

Clinical presentation 

  • Polyps 
    • Contact vaginal bleeding
    • Abdominal discharge
  • Adenomyosis 
    • Premenstrual uterine cramps
    • Dysmenorrhea
  • Leiomyoma 
    • Abdominal mass and distension
    • Heavy or prolonged menstrual bleeding
  • Malignancy 
    • Presentation depend on type of malignant
    • Abnormal intermenstrual or postmenopausal contact bleeding (cervical cancer)
    • Heavy menstrual bleeding
    • Lower abdominal pain and discomfort
    • Foul smelling bloody or mucoid
    • Vaginal discharge
    • Weight loss, loss of appetite, early satiety
  • Coagulopathy 
    • History of bleeding tendencies                                       
    • Heavy and or prolonged menstruation
  • Anovulatory dysfunction 
    • Irregular bleeding, often heavy                                       
    • Infertility or subfertility
  • Endometrial causes 
    • Heavy or prolonged menstruation
    • Irregular menstruation associated with endometrial hyperplasia

Investigations 

  • Investigate according to the possible cause of AUB basing on clinical suspicion
  • A complete blood count (CBC)
  • Pregnancy test in reproductive age to exclude pregnancy
  • Examination under anaesthesia and biopsy in case of malignancy
  • Cervical and vaginal swab
  • Abdominal pelvic Ultrasound, CT scan, MRI, Xray as indicated
  • LFT, RFT, Electrolytes
  • Hysteroscopy, Cystoscopy,
  • Proctoscopy in case of suspected malignancy
  • Biopsy in case of suspected malignancy
  • Specific Tumor markers in certain suspected malignancies e.g. ovarian tumors.
  • Testing for coagulation disorders should be considered only in women who have a history of heavy menstrual bleeding beginning at menarche or who have a personal or family history of abnormal bleeding

Pharmacological Treatment 

The treatment will depend of the causative factor. 

C:  tranexamic  acid  (PO)  500  –1000mg  6–8hourly  as  required  until  the  bleeding  is controlled 

OR 

A: combined oral contraceptives (PO) Useful for anovulatory bleeding. 

OR 

A:  medroxyprogesterone  acetate  (PO)  5–10mg  24hourly  for  10–14days  initially  and repeated for 10days each month thereafter 

OR 

C: norethisterone (PO) 5mg 24hourly for 10days. Then 5mg 12hourly from days 19 to 26 of the two subsequent cycles, should be given to prevent recurrence of the condition. 

Surgical management 

AUB due to organic causes may be amenable to surgical intervention. The decision regarding the  approach and the timing for surgical intervention should depend on final diagnosis, expertise and  other resources.  

Referral 

Immediately refer to the next level facility with capable for appropriate evaluation and management recommended