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Atypical Uterine Bleeding (AUB) - Medical Management

Source: Gynaecology v6.0 · Marrow 8.0 · 2024 | Pages 73-74

Mechanism of Action - Hormones on Endometrium

Hormone	Action
Estrogen (E)	Upregulates Progesterone (P) receptors on endometrium
Progesterone (P)	Acts only on E-primed endometrium; downregulates E receptors on endometrium

Indications of Drugs (Flowchart Logic)

Thick Endometrium

Cause: E upregulation + P
Treatment: OCP or P only

Thin Endometrium / Prolonged / Severe Bleeding

Cause: Decreased P receptors
Treatment:
- E followed by P (Estrogen given first)
- E + P OCP (combined oral contraceptive pill)

Key concept: In thin endometrium, estrogen must be given first to prime the endometrium before progesterone can act.

Progesterone - MOA (Detailed)

Supports endometrium → decreases shedding
Downregulates E receptors if given continuously → Endometrial atrophy → decreased blood loss → amenorrhea
Protects endometrium against proliferative effects of estrogen

Progesterone Supplementation Options

1. Oral Progesterone

Mode	Regimen	Effect	Notes
Continuous	3-6 months (without break)	Endometrial atrophy	Preferred mode in AUB
Cyclical	Day 14 to Day 25	Supports endometrium	Used in anovulatory DUB; less preferred (poor compliance, no contraceptive benefit)

2. IUCD: Mirena

Progesterone-containing IUCD
Causes endometrial atrophy
Relief of AUB in 30-40% of cases
Preferred for:
- Reproductive age females
- Perimenopausal females
- Protection against endometrial proliferation
Advantages:
- Good compliance
- Decreased need for hysterectomy
- Minimum 12 days/month needed for protective effect

If patient refuses Mirena → Continuous progesterone

Specific Management

Structural Lesion

→ Management of the underlying cause

Non-Structural Lesion

If bleeding controlled:

Oral iron + maintenance drugs

If bleeding persists:

Blood transfusion (if indicated)
2nd line medical management

Indication for Blood Transfusion

Condition	Threshold
Puberty menorrhagia	Hb < 7 g/dL

Key High-Yield Points to Remember

Progesterone can only act on E-primed endometrium - this is why thin endometrium needs estrogen first
Continuous progesterone (not cyclical) is the preferred mode for AUB because it causes endometrial atrophy
Cyclical progesterone (D14-D25) has no contraceptive benefit and poor compliance
Mirena provides relief in only 30-40% of AUB cases (not 100% - commonly tested!)
Blood transfusion threshold for puberty menorrhagia is Hb < 7 g/dL
Minimum 12 days/month of progesterone is needed for endometrial protection

Can you explain all those content which you are giving about in a very, very easy language and in a detailed way with explanation of each product treatment, from one end, how the treatment is active and all, everything as well?

Sure! Let me break this down in the simplest possible way, like explaining it to someone who has never studied medicine before, but then connecting it all back to the clinical details in your notes.

🩸 Atypical Uterine Bleeding (AUB) - Complete Easy Explanation

First, Let's Understand the Basics

What is AUB? AUB means a woman is bleeding from her uterus in an abnormal way - either too much, too long, too frequently, or at the wrong time in her cycle. The uterus has an inner lining called the endometrium. This lining grows every month and then sheds (that's your period). If something goes wrong with this process, you get AUB.

Two hormones control this lining:

Estrogen (E) - the "builder" hormone. It makes the lining grow thicker.
Progesterone (P) - the "stabilizer" hormone. It matures and stabilizes the lining so it doesn't shed randomly.

Think of it like building a wall:

Estrogen = lays the bricks (builds the lining)
Progesterone = cements the bricks together (stabilizes the lining)

If the balance between these two breaks, you get abnormal bleeding.

Part 1 - How These Hormones Work (MOA)

Estrogen's Job

"Estrogen upregulates Progesterone receptors on the endometrium"

In simple words: Estrogen acts like an invitation sender. It creates "doors" (receptors) on the uterine lining that allow progesterone to enter and do its job.

Without estrogen first, progesterone has NO doors to knock on - it simply cannot work.

This is the single most important concept in this whole chapter.

Progesterone's Job

"Progesterone acts only on E-primed endometrium"

In simple words: Progesterone is like a guest who can only enter if invited. It needs estrogen to have already opened the doors first. Once inside, progesterone:

Downregulates E receptors - it closes the doors for estrogen, so estrogen stops building more lining. It's like once the guest enters, it locks the door behind them.
Stabilizes the lining - prevents random shedding/bleeding.

Part 2 - Why Does AUB Happen? (The Root Cause)

In AUB, there are basically two scenarios based on what the uterine lining looks like:

Scenario A: THICK Endometrium

What happened? Too much estrogen, not enough progesterone. The lining kept growing (because estrogen kept building) but never got stabilized properly. Eventually it sheds in a chaotic, heavy way.

Think of it like: A wall that kept getting more bricks added but was never cemented - eventually it collapses in a big messy way.

Treatment goal: Stop the excessive estrogen effect and give progesterone to stabilize things.

Scenario B: THIN Endometrium / Prolonged or Severe Bleeding

What happened? The lining is too thin because progesterone receptors are reduced. There are not enough "doors" for progesterone to work even if it's present. Bleeding continues because the lining is fragile and unstable.

Think of it like: The wall is barely standing, the bricks are falling one by one (continuous slow bleeding). You need to first rebuild the wall (with estrogen), then cement it (with progesterone).

Treatment goal: First build up the lining with estrogen, THEN stabilize it with progesterone.

Part 3 - The Treatment Drugs Explained One by One

Treatment 1: OCP (Oral Contraceptive Pill - Combined)

Used when: Thick endometrium

What is OCP? OCP contains both estrogen AND progesterone together in a fixed, balanced ratio. When you give this combination, the progesterone in the pill overrides the body's own excess estrogen, stabilizes the lining, and controls the bleeding.

How it works step by step:

You swallow the pill
The synthetic progesterone in it overwhelms the lining
It downregulates estrogen receptors - tells estrogen to STOP building
The lining becomes thin, organized, and controlled
Bleeding becomes regular and predictable

Simple analogy: OCP is like hiring a professional cementer AND brick-layer together in a fixed team. They work in a balanced way and fix the chaotic wall.

Treatment 2: Progesterone Only (P only)

Used when: Thick endometrium (where estrogen has already primed the endometrium naturally)

Why can we use progesterone alone here? Because in thick endometrium, the body's OWN estrogen has already done its job - it has already created all those "doors" (P receptors). So you don't need to give extra estrogen. You just add progesterone to stabilize things.

How it works step by step:

You take progesterone tablets
Progesterone finds the receptors (already there because of the body's own estrogen)
It stabilizes the lining, reduces shedding
Bleeding is controlled

Simple analogy: The wall is already built (thick endometrium). You just need the cement (progesterone) to hold it together.

Treatment 3: Estrogen FIRST, then Progesterone (E → P)

Used when: Thin endometrium OR prolonged/severe bleeding

This is the most logical treatment once you understand the basics.

Why give estrogen first? Because the endometrium is thin and the progesterone receptors are very few. If you give progesterone alone now, it has nothing to act on. It's like sending the cementer to a site where there are no bricks - useless.

How it works step by step:

Give Estrogen first for a few days
Estrogen rebuilds the thin lining - makes it thicker
More importantly, estrogen creates LOTS of progesterone receptors (opens many doors)
Now you add Progesterone
Progesterone enters through all those doors, stabilizes the lining
Bleeding STOPS because the lining is now thick and organized
Progesterone then causes a controlled withdrawal bleed when stopped

Simple analogy: First lay the bricks (estrogen), THEN cement them (progesterone). This is the sequence that makes biological sense.

Treatment 4: E + P OCP (Combined OCP for thin endometrium)

Used when: Thin endometrium

This is similar to the above but given as a combined pill from the start. The OCP contains both estrogen and progesterone. The estrogen in the pill helps rebuild the thin lining AND creates receptors, while the progesterone component simultaneously starts stabilizing.

It is a convenient way to give both hormones together rather than sequentially.

Part 4 - Progesterone Supplementation in Detail

Once you decide to give progesterone, there are different WAYS to give it. Each method has a different effect on the body.

Method 1: Continuous Oral Progesterone (3-6 months, no break)

This is the PREFERRED method in AUB.

What happens when you take progesterone every single day without stopping?

Step by step:

Day 1: Progesterone enters, starts downregulating estrogen receptors
Week 2-3: Fewer and fewer estrogen receptors remain
Month 1-2: Estrogen can no longer stimulate the lining because there are almost no receptors left
Month 3-6: The lining becomes completely atrophied (shrinks down to almost nothing)

Endometrial atrophy = the lining has become so thin it can barely shed → almost NO bleeding → eventually amenorrhea (no periods)

Why is this the preferred mode?

Directly stops bleeding at the source (no lining = no bleeding)
No compliance issues (same tablet every day, easy to remember)
Protects against endometrial cancer (atrophied lining cannot grow into cancer)

Think of it like: If you stop watering a plant every day for months, the plant eventually dies. Continuous progesterone "stops watering" the endometrium by blocking estrogen's effect, and the lining withers away.

Method 2: Cyclical Oral Progesterone (Day 14 to Day 25 of the cycle)

What does this mean? You take progesterone only for 12 days in the middle-to-late part of the cycle (Day 14 to Day 25), mimicking what the natural cycle should be doing. Then you stop, have a withdrawal bleed, and repeat next month.

How it works:

Days 1-13: Estrogen builds the lining naturally
Days 14-25: You add progesterone - it stabilizes the lining
Days 25+: You stop progesterone - the lining sheds in a controlled, organized bleed
Repeat next month

Used for: Anovulatory DUB - where the woman is not ovulating (no natural progesterone being produced by the ovary), causing the lining to grow unchecked under estrogen.

Why is this LESS preferred?

Poor compliance - Taking a tablet only on specific days is harder to remember than every day
No contraceptive benefit - Does not prevent pregnancy
Does NOT cause endometrial atrophy - It only organizes the bleed, doesn't make the lining disappear

Think of it like: Cyclical progesterone is like a scheduled cleanout - you clean the house every month on fixed days. Continuous progesterone is like permanently minimizing how much mess accumulates - the house never gets dirty enough to need a big cleanup.

Method 3: Mirena IUD (Intrauterine Device)

What is Mirena? Mirena is a small T-shaped device inserted into the uterus. It slowly releases a small amount of progesterone locally inside the uterus, directly onto the endometrium, every day for 5 years.

How it works step by step:

Device is placed inside the uterus by a doctor
It releases a tiny, steady dose of progesterone directly onto the uterine lining
This local progesterone continuously downregulates estrogen receptors
Over months, the lining undergoes endometrial atrophy
Bleeding reduces dramatically or stops

Why is Mirena PREFERRED over oral progesterone in many women?

Advantage	Explanation
Great compliance	Once inserted, patient doesn't need to take pills - zero effort
Local action	Progesterone acts locally in uterus - very little gets absorbed into blood - fewer side effects
Contraceptive benefit	Also prevents pregnancy (unlike cyclical progesterone)
Reduces hysterectomy	Many women who would otherwise need surgery can avoid it

Who is Mirena preferred for?

Reproductive age females with AUB
Perimenopausal females
Women needing protection against endometrial proliferation

Important exam point: Mirena gives relief in only 30-40% of AUB cases - not 100%. This is a commonly tested fact. Many students assume it's a perfect solution, but it only works in about 1 in 3 women.

What if patient refuses Mirena? → Switch to continuous oral progesterone

Think of it like: Mirena is like a slow-release fertilizer stick you plant in soil - it works continuously for years without you doing anything, but it only works well in about a third of cases.

Important detail: Minimum 12 days/month for endometrial protection If giving progesterone in any form cyclically, you MUST give at least 12 days per month for it to protect the endometrium against estrogen-driven proliferation (and potentially cancer). Less than 12 days = inadequate protection.

Part 5 - Specific Management Based on the Type of AUB

If there is a STRUCTURAL cause (e.g., fibroid, polyp, cancer)

Hormones will NOT fix the structural problem
You must treat the cause directly - surgically remove the fibroid/polyp, etc.

If there is NO structural cause (hormonal/functional AUB):

If bleeding gets controlled with treatment:

Give oral iron to replace the blood lost (the woman is likely anaemic from heavy bleeding)
Continue maintenance drugs (the hormones that controlled the bleeding)

If bleeding PERSISTS despite treatment:

Consider blood transfusion (if haemoglobin is dangerously low)
Move to 2nd line medical management (stronger drugs, GnRH analogues, tranexamic acid, etc.)

Part 6 - Blood Transfusion: When to Give It?

For puberty menorrhagia (heavy periods in teenagers):

Blood transfusion is given only if Hb < 7 g/dL

Why this threshold? At Hb < 7, the body cannot carry enough oxygen to vital organs, and the risk of cardiac stress becomes real. Above 7, oral iron supplementation is sufficient in young healthy girls.

The Complete Story in One Flow

Woman comes with AUB
        ↓
Is there a structural cause (fibroid, polyp)?
        ↓
YES → Treat the structural cause surgically
        ↓
NO → Check the endometrium
        ↓
THICK endometrium          THIN endometrium / severe bleeding
(too much estrogen,         (too few P receptors,
not enough P)               lining is fragile)
        ↓                          ↓
Give OCP or P alone         Give E first (to build lining
                            + create P receptors)
                            THEN give P
                            OR give E+P OCP together
        ↓
Bleeding controlled? → Iron + maintenance
Bleeding persists? → Blood transfusion + 2nd line drugs

The One-Line Summary of Each Drug

Drug	When	Why
P only	Thick endometrium	Lining already primed, just needs stabilization
OCP (combined)	Thick endometrium	Balanced E+P controls chaotic lining
E then P	Thin endometrium	Must prime first, then stabilize
E+P OCP	Thin endometrium	Both together, estrogen primes while P stabilizes
Continuous progesterone	AUB in general	Causes atrophy - preferred mode
Cyclical progesterone D14-D25	Anovulatory DUB	Organizes cycle but less preferred
Mirena IUD	Any AUB, especially if contraception also needed	Local progesterone, great compliance, 30-40% success

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