PANEL DISCUSSION on ABNORMAL UTERINE BLEEDING Moderator :- Dr. Jyoti Agarwal Dr. Sharda Jain

1. PANEL DISCUSSION
on
ABNORMAL UTERINE BLEEDING
THROUGH CASE DISCUSSIONS
Moderator :- Dr. Jyoti Agarwal
Dr. Sharda Jain

2. AUB PANEL—15 nov 2017
Moderator :- Dr. Jyoti Agarwal
Dr Shard Jain
Panelists
Dr.Meenakshi Sharma , Dr.Ila Gupta
Dr.Deepti Nabh , Dr.Surjit Kapoor
Dr. Jyoti Bhaskar Dr. Vandana Gupta

3. PEERS
OBSERVATION
MY
EXPERIENCE
EVIDENCE
AND
GUIDELINES

4. Case 1
• 13 yr old girl comes to OPD
• c/o continous ,moderate , painless bleeding for last 22
days
• Menarche 22 days back
• No h/o easy bruisibility, epistaxsis , or gum bleeding
• No significant personal and family history or any drug
intake
• Not sexually active ,
• Salient features O/E vitals stable
• Pallor mild , No petechiae , Wt 50 kg ,
• P/A soft, no organomegaly ,P/S , P/V not done

5. First Menarchal Bleed
What will be your approach towards
this little girl ??

6. Investigations Required
• CBC
• Thyroid profile
• Coagulation profile - Platelet
count ,PT , APTT , INR ,
VWfactor , Factor 8
• S. Prolactin – galactorrhoea
or h/o headaches
USG pelvis
To rule out any
structural problems
Testing Should Be Done Before Starting Therapy

7. AUB – O in Adolescents
• CBC Hb 10.5 gm %
• Thyroid profile normal
• Coagulaton profile
normal
• USG pelvis (TAS) shows
• Uterus normal in size
and echotexture
• ET 6 mm
• Both ovaries are
normal
• No free fluid
What’s your impression and how will you manage ?

8. Most common cause of
AUB in adolescents is
Immaturity of HPO axis
40 - 50% of adolescents with first
heavy menarchal bleed have coagulopathy
AGE AT MENARCHE DURATION TO
OVULATORY CYCLES
< 12 years 1 year
12-13 3 years
> 13 4.5 years
Wilkinson, Kadir: Management of Abnormal Uterine Bleeding in
Adolescents. J Pediatr Adolesc Gynecol (2010) 23:S22-S30

9. In adolescents with AUB-O
Both Hormonal And Non-Hormonal therapies can be
given (Grade A; Level 4)
• Non hormonal
treatment is the
primary option
• Tranexamic acid 1g qid
for 5 days
(Grade A; Level 2)
• Hormonal treatment-
COC , secondary option
• Role of progesterone
only pills ??
Reassurance and Counseling

10. Hormone Therapy
Monophasic Combined Oral Contraceptives
with a minimum of 30 -35 mcg Ethinyl Estradiol
Moderate bleeding
• One tab tds till the
bleeding stops
(usually within 48 hrs )
• One pill bd for 5 days, then
• One pill once a day for a
total of at least 21 days
• If bleeding recurs when the dose
is decreased to once per day,
twice per day dosing is necessary
for the full 21 days
Severe Bleeding
• Inj conjugated Estrogen 25
mg 4-6 hrly
(not more than 6 inj /day )
• One pill qid till the
bleeding stops
• One pill tds for 3 days,
then
• One pill bd for up to 2
weeks

11. Rationale of Hormone Therapy
I
•Administration of exogenous estrogen causes
endometrial proliferation, which heals the sites of
endometrial bleeding, and provides haemostasis
• Administration of progestin stabilizes the
endometrial lining
Progestin only pills are indicated only when
COC are contraindicated or not tolerated

12. OUR CONCERN
• High-dose estrogen therapy can cause nausea, which
may result in decreased adherence …. Consider
antiemetic
• High doses of estrogen may cause premature closure
of the growth plates, reducing ultimate adult height
• However, by the time of menarche, most female
adolescents have already undergone their growth
spurt and achieved approximately ≥ 95 percent of
adult height

13. Close Follow-up is essential
• In person or by phone while the pills are
being taken
• Should maintain a menstrual calendar to
monitor response to therapy and subsequent
episodes of bleeding
• Several smart phone "apps," available at no
cost, may facilitate recording

14. MONITORING RESPONSE
• First follow up at subsequent period
• Thereafter 3 monthly
• Assess response after one yr to decide to
continue or discontinue the treatment

15. Same girl with deranged coagulation profile
Treatment Guidelines: AUB-C
In consultation with haematologist
Treatment remains the same
NSAIDs are contraindicated as they can alter
platelet function and interact with drugs that might
affect liver function and production of clotting factors
I/M Injection are to be avoided,if given, prolonged
pressure should be applied at injection site

16. Case 2
• 15 yr old girl comes with her mother c/o
Heavy periods for 8 months
• Menarche at 12 yrs
• Cycles are 7-10 days /40 -42 days
• Not sexually active
• No significant personal and family history
• Salient features O/E
• Wt 78 kg , BMI 30.4
No clinical features of hyperandrogenism

17. What will be your approach ??

18. To be done in all cases of AUB
• CBC
• Thyroid profile
• Coagulation profile
• USG pelvis

19. • CBC Hb 10.5 gm %
• Thyroid profile normal
• Coagulaton profile
normal
• USG pelvis (TAS) shows
• Uterus normal in size
and echotexture
• ET 5 mm
• Both ovaries shows
multiple small follicles
• No free fluid

20. In adolescents with AUB-O
• Both Hormonal And Non-Hormonal
therapies can be given (Grade A;Level 4 )
• Reassurance and Counseling
• Weight reduction and Lifestyle modification
• Correction of anaemia

21. Case 3
• 28 yr old female had lSCS 3 month back
• Antenatal , postnatal period uneventful
• She is breastfeeding
• Now complains that her bleeding has not yet
stopped since delivery ,not very heavy ,has to use
one pad every day
• O/E pallor mild , afebrile , vitals stable , wt 70 kg
• P/A ut not palpable, bld p/v +,os closed , ut bulky, fx
clear

22. • CBC
• Hb 10.5 gm %
• TLC is 7000
• Thyroid profile normal
• Coagulaton profile
normal
• TVS shows
• Uterus bulky with
normal echotexture
• ET 7 mm , cavity is
empty , No POC
• Both ovaries normal
• Small free fluid + in
POD

23. Treatment Guidelines: AUB-O
Options available
• LNG Insertion
• DMPA / Pg only pills
• Ormeloxifene (centchroman )
• COC
LNG-IUS is recommended if she wishes to use it
for at least 1 year (Grade A; Level 1)

24. Ormeloxifene
• 60 mg tablet twice a week for 3 months followed by
one tablet of 60 mg once a week for another 3 mnths
• Effective upto 1 year after stopping it
• In lactating women, it is excreted in milk in quantities
considered unlikely to cause any deleterious effect on suckling
babies
• Not recommended for women suffering from recent history of
hepatitis or liver disorders
Increases endometrial thickness and
forms ovarian cysts on USG

25. Case 4
• 34 yr old c/o painless heavy periods for 1 yr
• Associated with premenstrual spotting for 3-5 days
• Cycles are 10 – 12days /18 – 30 days
• P2 ,both LSCS , not ligated
• No h/o any drug intake
• P/S superficial erosion all around
• Hb 9 gm% TSH normal
• Pap’s smear is normal
• TVS shows bulky uterus, ET 8 mm ,small clear cyst of
2x2 cm in right ovary ,rest all normal

26. Ultrasound Imaging – Mandatory
USG should be done in all patients of AUB to
evaluate uterus, adnexa and endometrial
thickness (Grade A; Level 1)
Role of
D & C / Endometrial biopsy /aspirate ??

27. GCPR- Endometrial Assessment and Biopsy
recommended in
women with AUB
Older than 40
years of age
(Grade A; Level 2)
Less than 40 years
who are at risk of
endometrial cancer
(Grade A; Level 2)
Risk factors of endometrial cancer
• Irregular bleeding
• Obesity associated with hypertension
• Endometrial thickness > 12 mm
• Polycystic Ovarian syndrome (PCOS)
• Diabetes Mellitus
• H/O malignancy of ovary/breast/
endometrium/colon
• Use of Tamoxifen for HRT or breast cancer
• AUB-unresponsive to medical management
• HNPCC syndrome (hereditary nonpolyposis
colorectal cancer or Lynch Syndrome)
Endometrial assessment (EA)
Endometrial histopathology Dilatation and curettage Hysteroscopy
Performed if
endometrium is
thick on imaging
but HPE is
inadequate, to
rule out polyps
(Grade A; Level
2)
Not be a procedure of choice
for EA (Grade A; Level 3)
Endometrial aspiration is the
preferred procedure for obtaining
endometrial sample for HPE

28. Treatment Guidelines: AUB-O
Options available
• LNG Insertion
• DMPA / Pg only pills
• Ormeloxifene (centchroman )
• COC
• Rx erosion
LNG-IUS is recommended if she wishes to use it
for at least 1 year (Grade A; Level 1)

29. Case 5
• 40 yr old female c/o heavy and painful periods
for last 2 yrs
• Cycles are 5-6 days / 18 – 23 days
• Hb 9 gm% , vitals stable , wt 70 kg
• TVS shows uterus uniformly enlarged to 8 wks
• Myometrium shows salt and pepper appearance
• ET 9 mm
• Rt ovary shows a small hemorrhagic cyst of 1.8 x
2.0 cm, rest normal

30. • Endo aspirate shows
Secretory endometrium
What’s your impression and how will
you manage this case ??

31. Treatment Algorithm: AUB-A
LNG IUS is
recommend
ed as 1st line
therapy
(Grade A;
Level 1)
In women with AUB due to
Adenomyosis
Women desirous of fertility
Unwilling for
immediate
conception
Resistant or
unwilling to use
LNG IUS
Gonadotropin releasing
hormone (GnRH) agonists
with add back therapy is
recommended as 2ndline
therapy (Grade A; Level 1)
GnRH agonists cannot be
indicated for symptomatic relief
Combined oral contraceptives,
Danazol, NSAIDS and progestogens
are recommended (Grade B; Level 4)
Women not desirous of fertility
Vaginal or laparoscopic
hysterectomy / Trans-
cervical resection of
endometrium is
recommended (Grade A;
Level 3)
LNG IUS 1st LINE
long-term GnRH agonists and
add-back therapy can be
initiated
Medical management
Failure or refusal for medical
management
L.IN.MA.WH.02.2016.0746
Adenomyomectomy  conservative surgery offered in selected cases with infertility or
with strong desire to retain uterus. (Grade B; Level 2)

32. What is Add Back therapy ?
++++++++

33. Add Back Therapy
• Estrogen and progesterone are given either sequentially or
combined so as to prevent osteoporosis
• Low dose estrogen
– CEE (premarin ) 0.625 /0.3 mgm OD or
– Estradiol valerate 1 mgm OD for 30 days
• Low dose Progesterone
– Medroxy progesterone acetate 2.5 mgm OD for 30 days or 10 mgm OD
for 10 days
– Norethisterone 1mg
– Micronised Progesterone 100 mg
• Tibolone (SERM) 2.5mgm OD

34. Case 6
• 42 yr old obese female c/o heavy periods for 3 yrs
• Diabetic , controlled with drugs
• No HT, TB or hypothyroidism
• Wt 86 kg
• TVS shows uterus enlarged to 6 wks size
• ET 11 mm
• Both ovaries have small,simple clear cyst of 2x2
cm
• No free fluid

35. • EB shows
• Endometrial hyperplasia without atypia
Role of Hysteroscopy ??

36. Recommendations:
Indications:
 Intermenstrual spotting
 Evaluation of intracavitary lesion
 Dys-synchronicity between symptoms, USG & HPE
(Grade A; Level 2)
 Increased Endometrial thickening on TVS, but HPE
inadequate/atrophic
 No response to medical management
HYSTEROSCOPY – NOT TO BE DONE ROUTINELY

37. Women with endometrial hyperplasia without atypia
should be informed that the risk of progression to
endometrial cancer is less than 5% over 20 years
Majority of cases of endometrial hyperplasia without
atypia will regress spontaneously during follow-up
REASSURANCE IS ESSENTIAL
New Term Coexistent Invasive
Endometrial Cancer
Progression To
Invasive
Cancer
Hyperplasia without
Atypia
<1% RR:1.01-1.03
Atypical
Hyperplasia
25-33% RR:14-45
Revised classification of Endometrial hyperplasia WHO 2014

38. AUB – Endometrial Hyperplasia
Without Atypia
• LNG IUS is recommended
as 1st line therapy
(Grade A; Level 1)
• If LNG IUS is
contraindicated or patient
unwilling to use LNG IUS
• Oral continuous
Progesterones can be
used(Grade A; Level 1)
• Medroxyprogesterone
10–20 mg/day or
• Norethisterone 10–15
mg/day
• Cyclical progestogens
should not be used
because they are less
effective in inducing
REGRESSION of
endometrial hyperplasia
without atypia

39. Follow up
• Oral progestogens or the LNG-IUS should be used
for a minimum of 6 months in order to induce
histological regression
• At least two consecutive 6-monthly negative
biopsies should be obtained
• Once two consecutive negative endometrial
biopsies have been obtained then long-term follow-
up should be considered with annual endometrial
biopsies , life long or till hysterectomy is indicated

40. Hysterectomy is indicated when
• Progression to atypical hyperplasia occurs during follow-up, or
• There is no histological regression of hyperplasia
despite 12 months of treatment, or
• There is relapse of endometrial hyperplasia after completing
progestogen treatment, or
• There is persistence of bleeding symptoms, or
• The woman declines to undergo endometrial surveillance or
comply with medical treatment

41. Case 7
• 58 yr old female c/o first episode of spotting 3 days
back
• Menopause at age of 50 yr
• Earlier cycles were regular
• P2 last delivery 26 yrs back
• No HT, DM ,TB UTI or hypothroidism
• No family h/o malignancy
• O/E Pallor mild ,BP 146/86, Wt 65 kg
• P/S ,P/V NAD , Breast normal
• NO evidence of vaginitis

42. • TVS shows uterus is
normal
• ET is 5 mm
• Both ovaries normal
• No cyst
• No free fluid
• No tenderness
• EB
Atrophic endometrium
• Hyteroscopy
Normal
No focal lesion seen

43. Reassurance : Reassurance : Reassurance
• Estrogen creams or pessaries can be used ,
although treatment may not be necessary if
symptoms are mild
(NHS.UK 2014)
• Regular Follow up is mandatory (TVS)

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