Abnormal Uterine bleeding (AUB)

Abnormal Uterine Bleeding (AUB)

Abnormal uterine bleeding (AUB) is a prevalent issue encountered in gynecology clinics and can affect women at any stage of life, from adolescence to perimenopause and even post-menopause. In India, the prevalence is approximately 17.9%. Understanding what constitutes normal and abnormal bleeding is crucial for determining when treatment is necessary.

Normal Menstrual Parameters:

Clinical Parameter	Descriptive Term	Normal Limits (5–95th Percentiles)
Frequency of Menses (days)	Frequent	<24
	Normal	24–38
	Infrequent	>38
Regularity of Menses (Variation)	Absent	No bleeding
	Regular	Variation ± 2–20 days
	Irregular	Variation >20 days
Duration of Flow (days)	Prolonged	>8.0
	Normal	4.5–8.0
	Shortened	<4.5
Volume of Monthly Blood Loss (mL)	Heavy	>80
	Normal	5–80
	Light	<5

The International Federation of Gynecology and Obstetrics (FIGO) has classified abnormal bleeding using the PALM-COEIN system to facilitate accurate diagnosis.

Potential Causes of AUB:

• Hormonal imbalances, such as thyroid issues
• Pregnancy-related complications
• Polycystic Ovary Syndrome (PCOS)
• Fibroids
• Endometriosis or adenomyosis
• Polyps
• Ovarian cysts
• Endometrial hyperplasia or thickening
• Endometrial, uterine, or ovarian malignancies

Management of AUB:

Management depends on the woman's age and the severity of the issue. Common causes like stress and anxiety can lead to irregular cycles, and emergency contraceptive pills can also cause abnormal bleeding. After assessing the patient's history, various investigations might be recommended.

Investigations:

Ultrasonography: Essential for evaluating the uterus, adnexa, and endometrial thickness (ET).
Doppler Ultrasonography: Useful for detecting AV malformations, malignancies, and differentiating between fibroids and adenomyosis.
3D-USG: Helps in evaluating intramyometrial lesions and fibroid mapping.
SIS (Saline Infusion Sonography): Used for detecting intracavitary lesions when hysteroscopy is unavailable.
Hysteroscopy: The gold standard for diagnosing and characterizing intrauterine abnormalities, especially after the age of 35.
MRI: Used to differentiate between fibroids and adenomyosis and for precise fibroid mapping.
Endometrial Biopsy: Recommended for:

• Women over 40 years old
• Women under 40 with risk factors for endometrial cancer, irregular bleeding, obesity with hypertension, PCOS, diabetes, endometrial thickness >12 mm, family history of related cancers, use of tamoxifen, late menopause, unresponsive AUB

Endometrial Aspiration: Preferred over dilation and curettage. Ideally, an endometrial sample should be obtained during diagnostic hysteroscopy rather than a blind biopsy in women with heavy menstrual bleeding.

Treatment Options:

Etiology Treatment Options
Polyp: Hysteroscopic surgical removal. For multiple polyps or when fertility is not desired, LNG-IUS can be combined with surgical removal.
Adenomyosis: LNG-IUS, GnRH agonists with add-back therapy if LNG-IUS is not accepted, or OCP, NSAIDs, progestogens if it fails.
Malignancy: Atypical endometrial hyperplasia: Surgical treatment. If fertility is not desired, hysterectomy is recommended.
Hyperplasia without Atypia: LNG-IUS followed by oral progestins or PRMs.
COEIN: LNG-IUS, tranexamic acid, NSAIDs, followed by COCs or cyclic oral progestins. For failed or contraindicated treatments, GnRH agonists with add-back hormone therapy or Centchroman.
Intramural or Subserosal Myomas (Grade 2-6): Tranexamic acid, COCs, NSAIDs, LNG-IUS. If treatment fails, consider myomectomy depending on location. For women over 40, fertility is not desired, small fibroids (<4-5 cm), medical management followed by hysterectomy. Short-term management: GnRH agonists with add-back therapy followed by myomectomy. Long-term management: LNG-IUS. Newer medical options: Ulipristal acetate or low-dose mifepristone.
Submucosal Myoma (Grade 0-1): Hysteroscopic removal (<4 cm) or abdominal (open or laparoscopic for >4 cm).

This comprehensive approach ensures effective management of abnormal uterine bleeding, tailored to the patient's specific needs and circumstances.