Abnormal

Uterine
Bleeding
Ferrer, Guarin, Jara, Joson
 Objectives
● Present a case of Abnormal Uterine Bleeding (AUB)
● Discuss 4 differential diagnosis
● Discuss briefly the different etiologies of AUB based on FIGO
classification
● Discuss the cause of AUB of the patient as to the following:
○ Incidence
○ Risk factors
○ Pathogenesis
○ Diagnosis
○ Management
 General Data Chief Complaint

● A.W., 40 years old, G1P1 ● Heavy menstrual bleeding

(1001), female
● Married, Filipino, Roman
Catholic
● May 2, 1982 in Manila City
● Currently residing in
Valenzuela City
● Admitted for the first time
in our institution
 History of Present Illness

1 month prior to admission, the patient experienced heavy menstrual bleeding

using 6-7 pads per day, fully soaked lasting for 5 days without accompanying
symptoms such as dizziness, pallor, abdominal pain or dysuria. This prompted consult
with a private OBGYN in which the patient was requested with transvaginal ultrasound
revealing normal sized anteverted uterus, thickened endometrium (1.11 cm) with
hyperechoic structure connected to a single feeding vessel (0.8 x 0.6 x 0.5 cm)
suggestive of endometrial polyp, left antero-fundal myoma (2.4 x 2.6 x 2.1cm), FIGO 2.
She was advised to undergo hysteroscopy once cardiopulmonary (CP) cleared.
 1 day prior to admission, the patient followed up with CP
clearance stratified as low risk hence admitted to our institution
the next day.
Past Medical History Family History
● Complete childhood & Covid ● (+) HTN
19 immunization ● (+) DM - paternal
● (-) HTN, DM, BA ● (-) BA, TB
● (-) Thyroid disease, TB ● (-) Cancer
● (-) Cardiac, liver, kidney ● (-) Blood dyscrasias
disease ● (-) Hepatorenal diseases
● (-) Blood transfusions, ● (-) Thyroid diseases
surgery, trauma
● (-) Allergies to food &
medication
 Personal & Social
Obstetrical History
History

● Bank employee ● G1P1 (1001)

● Lives with her husband and ● G1
child for 19 years ○ 2003
● Non-smoker ○ Term
● Non-alcoholic beverage ○ NSD
drinker
○ Boy, 3000g
● (-) Drug use and abuse
 Gynecological History
● M:
9 years old ● Coitarche: 18 years old
● I:
28-30 days ● No. sexual partner: 1
● D:
4-5 days ● (-) contraceptive use
● A:
4-5 ppd, moderately ● (-) STI
soaked ● (+) Pap smear, March 2023,
● S: no associated unremarkable results
symptoms

LMP: January 29, 2023

PMP: December 4th week, 2022
 Review of Systems

General: (-) chills (-) weight change

Skin: (-) color changes (-) lesions (-) pruritus
HEENT: (-) tinnitus (-) sore throat (-) dysphagia (-) odynophagia
Respiratory: (-) cough (-) shortness of breath ,(-) crackle (-) wheezing (-) hemoptysis
Cardiovascular: (-) chest pain (-) occasional palpitations (-) orthopnea (-) PND (-) cyanosis (-) easy fatigability
GIT: (-) diarrhea (-) constipation (-) hematemesis (-) melena (-) hematochezia
GUT: (-) urgency (-) frequency (-) hematuria (-) oliguria (-) anuria
Musculoskeletal: (-) muscle/joint pain (-) stiffness (-) swelling (-) bone deformity (-) weakness (-) atrophy
Endocrine: (-) heat or cold intolerance (-) polyuria (-) polydipsia (-) polyphagia
Hematologic: (-) easy bruisability (-) epistaxis (-) pallor
Neurologic: (-) tingling sensation (-) numbness (-) pains (-) tremors
 Physical Examination

General Survey: Conscious, coherent, afebrile, not in cardiorespiratory distress

Vital Signs: BP: 110/70 mmHg HR: 89 bpm RR: 19 cpm T: 36.7C
Weight: 68 kg Height: 155cm BMI: 28.3 kg/m2

Skin: Skin is warm, with good turgor, no active dermatoses

HEENT: Anicteric sclerae, pink palpebral conjunctiva , (-) nasoaural discharge, (-) tonsillopharyngeal
congestion, (-)cervical lymphadenopathies, (-) palpable neck mass

Chest & Lungs: Symmetrical chest expansion, (-) crackles(-) retractions, vesicular breath sounds, (-) wheezes

Heart: Adynamic precordium, apex beat at 5th LICS MCL, normal rate, regular rhythm, no murmur

Abdomen: Flabby abdomen, normoactive bowel sound , no tenderness upon palpation

 Physical Examination

Pelvic exam:
Inspection: Normal appearing external female genitalia, no lesions, no erosions, no masses, no varicosities
Speculum Exam: Normal appearing vaginal mucosa, cervix pinkish with smooth surface, no erosions/lesion,
Bimanual Exam: cervix is firm, parrous, uterus not enlarged, no adnexal masses or tenderness noted, with no
bleeding as per examining finger, no cervical motion tenderness
Rectovaginal Examination: Good sphincteric tone, intact rectovaginal septum, parametria pliable, no mass or
nodulations noted

Extremities: Grossly normal extremities, no edema, no cyanosis, no pallor, with bilateral and full equal pulses
at the upper and lower extremities
 Salient Features
● A.W., 40 years old, G1P1 (1001), female ● PMH: unremarkable
● Heavy menstrual bleeding, 6-7 pads per day, ● FMH: (+) HTN, (+) DM, (-) Blood dyscrasias
fully soaked lasting for 5 days without ● PSH: unremarkable
accompanying symptoms such as dizziness, ● OB: G1, 2003, Term, NSD, Boy, 3000g
pallor, abdominal pain or dysuria ● GYNE: M: 9 years old
● LMP: January 29, 2023 I: 28-30 days
PMP: December 4th week, 2022 D: 4-5 days
● transvaginal ultrasound (March 2023): normal A: 4-5 ppd, moderately soaked
sized anteverted uterus, thickened S: no associated symptoms
endometrium (1.11 cm) with hyperechoic Coitarche: 18 y/o; 1 sexual partner
structure connected to a single feeding vessel (-) contraceptive use; (-) STI
(0.8 x 0.6 x 0.5 cm) suggestive of endometrial (+) Pap smear (March 2023): unremarkable
polyp, left antero-fundal myoma (2.4 x 2.6 x ● ROS: unremarkable
2.1cm), FIGO 2 ● PE: BMI 28.3 kg/m2 Obese I
 Admitting Diagnosis

G1P1 (1001), Abnormal uterine bleeding- Polyp, Leiomyoma

PLAN: For admission, For hysteroscopy

COURSE IN THE WARD

● NPO
● VENOCLYSIS
● EVENING PRIMROSE
 COURSE IN THE WARD

● Induction: spinal anesthesia

● Dorsal lithotomy
● Asepsis/antisepsis technique
● Vaginal vault cleaned with povidine-iodine
● Placement of catheter
 COURSE IN THE WARD

PELVIC EXAMINATION

normal appearing external female genitalia, no lesions, no erosions,

INSPECTION no masses, no varicosities.

Normal appearing vaginal mucosa, cervix pinkish with smooth

SPECULUM surface, no erosions/lesion,

cervix is firm, parrous, uterus not enlarged, no adnexal masses,

BIMANUAL with no bleeding as per examining finger

Good sphincteric tone, intact rectovaginal septum, parametria

RECTOVAGINAL pliable, no mass or nodulations noted
 COURSE IN THE WARD

● Application of posterior vaginal retractor; Allis forceps

on the anterior lip of cervix.
● Diagnostic hysteroscopy:
○ Hysteroscope with 30 degrees angle was inserted gradually from the
endocervical canal following the direction of the internal cervical os and into
the uterine cavity
 COURSE IN THE WARD

Intraoperative Findings:

● Multiple endometrial Polyp

○ Anterior
○ Posterior
● Polypoid endometrium
● Submucous myoma seen on the
○ left side of fundus
● Right ostium seen
● Left ostium (obscured by myoma)
 COURSE IN THE WARD

● Operative Hysteroscopy with 12 degrees angle:

○ Resectoscope loaded with 90 degrees loop
electrode was inserted carefully into the uterine
cavity.
○ submucous myoma and endometrial polyps were
resected at the base using bipolar loop
electrodes until completely removed.

Patient tolerated the procedure well.

 COURSE IN THE WARD

Recovery room

● Vital signs were monitored every 15 minutes until stable.

● WOF postoperative complications, any signs and symptoms
of hemodynamic instability.
● Stable vital signs
● (-) Postoperative complications
 COURSE IN THE WARD

At the ward

■ vital signs remained stable without

■ (-) signs and symptoms of postoperative complications
■ (-) episodes of hemodynamic instability
■ deemed to be clinically fit for discharge.
■ sent home with medications
● Doxycycline 100 mg/tab, one tablet every 12 hours for 7 days
● Dexketoprofen 25mg/tab 1tab q8 for pain
● Ferrous sulfate one tablet once a day for 3 months
● Sodium Ascorbate + zinc 500mg/tab, one capsule once a day
 Differential
Diagnosis
Abortion • PCOS • Endometriosis • Uterine Malignancy
 ABORTION

Heavy menstrual flow No record of pregnancy test taken

missed menses for 2months No presumptive evidence of pregnancy

(ex. dizziness, vomiting, breast
tenderness, urinary frequency)
No history of contraceptive use
No passage of meaty tissue

Within the reproductive age

group
 PCOS

Reproductive age No Hirsutism

40 years old

Menstrual irregularity No weight gain

LMP: January 29, 2023

Heavy menstrual bleeding, March

2023

Obesity
BMI 28.3 kg/m2 Obese I
 Endometrial Cancer

Early Menarche - 9 years old 40 years old

Heavy menstrual bleeding No family history of any

malignancy

Thickened endometrium (1.11cm) No comorbidities

(DM, HTN)
 Adenomyosis

Heavy Menstrual Bleeding Chronic Pelvic Pain

Age > 40 years old Single Parity

Late productive years Uterine enlargement

 Final Diagnosis
G1P1 (1001) AUB- P; L(sm) Hysteroscopy - Surgical
transcervical resection of polyp and submucous myoma
followed by endometrial curettage under spinal anesthesia
Discussion
 Structural Changes

P - Polyp L - Leiomyoma
Growths of endometrial glands Benign tumors that arise from the
and stroma that protrude into the smooth muscle cells of the
uterine cavity - and they’re myometrium, and they’re the most
usually benign. common pelvic tumor in
reproductive age females

A - Adenomyosis M - Malignancy
In females of reproductive,
Endometrial tissue develops
endometrial cancer is rare; and
ectopically in the myometrium - or
cervical cancer is relatively more
the muscular layer of the uterus.
common.
 Non-structural Changes

01 02 03
C- Coagulopathy O - Ovulatory E - Endometrial
dysfunction

04 05
I - Iatrogenic N - Not yet
classified
 Result of Histopath

4/26/2023 HISTOPATHOLOGIC REPORT

● Endometrial polyp
● Proliferative phase endometrium
● Fragments of Leiomyoma uteri

AUB P1A0L1M0-C0O0E1I0N0
 INCIDENCE

Endometrial polyps Leiomyomas Endometrial hyperplasia

● About 20-40 percent in women with ● Most common indication for ● Hyperplasia without atypia:
abnormal uterine bleeding gynecologic admission. ○ 50-54yrs
● Peak incidence is 40-49yrs old ● 24% total gynecological cases in ● Hyperplasia with atypia:
● Premenopausal women are less likely Philippines (2019) ○ 60-64yrs
to have polyps. ● Earlier menarche, late-onset
menopause
● Most common in black, least in
asians
 RISK FACTORS

Endometrial polyps Leiomyomas Endometrial hyperplasia

● Tamoxifen use
● Early menarche ● Age
○ Selective estrogen receptor
● Parity age and intervals ● Nulliparity
● Obesity
● Hormonal contraception ● Obesity
○ Higher body fat, more
○ Early age use ● Genetic
aromatase
○ Inhibits postpartum fibroid ● Diabetes mellitus
● Hormone replacement therapy
regression ● Anovulatory cycles
○ Postmenopausal hormone
● Ovarian tumors
therapy
● Estrogen-only therapy
● Lynch syndrome
● Lynch syndrome
Pathophysiology
Pathophysiology
 Diagnosis
CBC (3/30/23)
1. History and Physical Examination Hemoglobin 134
2. Laboratiories
a. CBC Hematocrit 0.46

b. hCG WBC 7.8

c. Thyroid and liver function tests
Neutrophils 0.69
3. Imaging
a. Ultrasound - first line diagnostic tool Lymphocytes 0.18

b. Saline Infusion sonography Monocytes 0.09

4. Endometrial biopsy Eosinophils 0.04
5. Hysteroscopy - Gold standard
Platelet 295

ABO O+
 Management

Endometrial Polyp Leiomyoma

● < 1cm spontaneously regress ● GnRH agonist

● Hysteroscopic guided polypectomy ● Myomectomy
● Hysterectomy
Thank yo u!