Aub pdf

Acute AUB is excessive bleeding that requires immediate intervention to prevent further blood loss. Acute AUB can occur on its own or superimposed on chronic AUB, which refers to irregularities in menstrual bleeding for most of the previous 6 months.

The first portion, PALM, describes structural issues. The second portion, COEI, describes non-structural issues. The N stands for "not otherwise classified. One or more of the problems listed above can contribute to a patient's abnormal uterine bleeding. Some structural entities, such as endocervical polyps, endometrial polyps, or leiomyomas, may be asymptomatic and not the primary cause of a patient's AUB.

Conditions to be included in not otherwise classified include pelvic inflammatory disease, chronic liver disease, and cervicitis.

AUB not otherwise classified contains rare etiologies and includes arteriovenous malformations AVMs , myometrial hyperplasia, and endometritis. The uterine and ovarian arteries supply blood to the uterus. These arteries become the arcuate arteries; then the arcuate arteries send off radial branches which supply blood to the two layers of the endometrium, the functionalis and basalis layers. Progesterone levels fall at the end of the menstrual cycle, leading to enzymatic breakdown of the functionalis layer of the endometrium.

This breakdown leads to blood loss and sloughing, which makes up menstruation. Functioning platelets, thrombin, and vasoconstriction of the arteries to the endometrium control blood loss. The clinician should obtain a detailed history from a patient who presented with complaints related to menstruation. Specific aspects of the history include:.

Laboratory testing can include but is not limited to a urine pregnancy test, complete blood count, ferritin, coagulation panel, thyroid function tests, gonadotropins, prolactin. Imaging studies can include transvaginal ultrasound, MRI, hysteroscopy. Transvaginal ultrasound does not expose the patient to radiation and can show uterus size and shape, leiomyomas fibroids , adenomyosis, endometrial thickness, and ovarian anomalies.

It is an important tool and should be obtained early in the investigation of abnormal uterine bleeding. MRI provides detailed images that can prove useful in surgical planning, but it is costly and not the first-line choice for imaging in patients with AUB. Hysteroscopy and sonohysterography transvaginal ultrasound with intrauterine contrast are helpful in situations where endometrial polyps are noted, images from transvaginal ultrasound are inconclusive, or submucosal leiomyomas are seen.

Hysteroscopy and sonohysterography are more invasive but can often be performed in office settings. Endometrial tissue sampling may not be necessary for all women with AUB but should be performed on women at high risk for hyperplasia or malignancy. An endometrial biopsy is considered the first-line test in women with AUB who are 45 years or older. Treatment of abnormal uterine bleeding depends on multiple factors, such as the etiology of the AUB, fertility desire, the clinical stability of the patient, and other medical comorbidities.

Treatment should be individualized based on these factors. In general, medical options are preferred as initial treatment for AUB. For acute abnormal uterine bleeding, hormonal methods are the first-line in medical management. Tranexamic acid prevents fibrin degradation and can be used to treated acute AUB. Tamponade of uterine bleeding with a Foley bulb is a mechanical option for the treatment of acute AUB. It is important to assess the patient's clinical stability and replace volume with intravenous fluids and blood products while attempting to stop the acute abnormal uterine bleeding.

Desmopressin, administered intranasally, subcutaneously, or intravenously, can be given for acute AUB secondary to the coagulopathy von Willebrand disease. Some patients may require dilation and curettage. Leiomyomas fibroids can be treated through medical or surgical management depending on the patient's desire for fertility, medical comorbidities, pressure symptoms, and distortion of the uterine cavity.

Surgical options include uterine artery embolization, endometrial ablation, or hysterectomy. Ovulatory dysfunction can be treated through lifestyle modification in women with obesity, PCOS, or other conditions in which anovulatory cycles are suspected. Endocrine disorders should be corrected using appropriate medications, such as cabergoline for hyperprolactinemia and levothyroxine for hypothyroidism.

If a certain contraception method is the suspected culprit for AUB, alternative methods can be considered, such as the levonorgestrel-releasing IUD, combined oral contraceptive pills in monthly or extended cycles , or systemic progestins.

If other medications are suspected and cannot be discontinued, the aforementioned methods can also help control AUB. Individual therapy should be tailored based on a patient's reproductive wishes and medical comorbidities.

Endometritis can be treated with antibiotics and AVMs with embolization. Any bleeding from the genitourinary tract or gastrointestinal tract GI tract can mimic abnormal uterine bleeding. Therefore, bleeding from other sources fits into the differential diagnosis and must be ruled out. The prognosis for abnormal uterine bleeding is favorable but also depends on the etiology. The main goal of evaluating and treating chronic AUB is to rule out serious conditions such as malignancy and improve the patient's quality of life, keeping in mind current and future fertility goals and other comorbid medical conditions that may impact treatment or symptoms.

Prognosis also differs based on medical versus surgical treatment. For women with heavy menstrual bleeding as their primary symptom of AUB, the levonorgestrel-releasing IUD has been proven to be more effective than other medical therapies and improves the patient's quality of life. However, injectable progestogens can produce the side effect of breakthrough bleeding, and GnRH agonists are usually only used for a 6-month course due to their side effects in producing a low estrogen state.

With the surgical techniques, randomized clinical trials and reviews have shown that endometrial ablation controlled bleeding more effectively at 4 months postoperatively, but at 5 years, there was no difference compared to medical management. When trials have compared hysterectomy versus levonorgestrel-releasing IUD, the hysterectomy group had better results at 1 year.

There was no difference in the quality of life seen at 5 and 10 years, but many women in the levonorgestrel-releasing IUD group had undergone a hysterectomy by 10 years.

Complications of chronic abnormal uterine bleeding can include anemia, infertility, and endometrial cancer. With acute abnormal uterine bleeding, severe anemia, hypotension, shock, and even death may result if prompt treatment and supportive care are not initiated.

Consultations with obstetrics and gynecology should be initiated early on for proper evaluation and treatment. Depending on the etiology of the abnormal uterine bleeding, other specialties may need to become involved in patient care. If the patient wishes to undergo a uterine artery embolization, Interventional radiology will need to be consulted. Worldwide, many women do not report abnormal uterine bleeding to their healthcare providers, so it is important to foster an environment of open discussion on menstruation.

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