Aub from dc dutta
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I now have comprehensive information to give a thorough answer on AUB. Note that DC Dutta's textbook is not in the library, but the content below is aligned with standard gynecology teaching as covered in DC Dutta and other authoritative sources.
Abnormal Uterine Bleeding (AUB)
Note: DC Dutta's Textbook of Gynecology is not available in the library. The information below is drawn from Rosen's Emergency Medicine, Sabiston's Textbook of Surgery, and Berek & Novak's Gynecology - all of which present AUB consistent with DC Dutta's teaching.
Definition
AUB is any change in the frequency, regularity, duration, or volume of uterine bleeding that deviates from normal. A normal menstrual cycle occurs every 24-38 days, with flow lasting 4-8 days. A cycle shorter than 21 days or longer than 35 days, or flow lasting less than 2 or more than 7 days, is classified as abnormal.
The older terms - menorrhagia, menometrorrhagia, and dysfunctional uterine bleeding (DUB) - are now obsolete and have been replaced by the PALM-COEIN classification (FIGO, 2011).
PALM-COEIN Classification (FIGO 2011)
This system divides AUB causes into structural and non-structural groups:
PALM - Structural Causes
(Diagnosed by imaging or histology)
| Acronym | Cause |
|---|---|
| P | Polyp (AUB-P) |
| A | Adenomyosis (AUB-A) |
| L | Leiomyoma (AUB-L) - submucosal (AUB-LSM) or other (AUB-LO) |
| M | Malignancy and hyperplasia (AUB-M) |
COEIN - Non-structural Causes
(Medical/non-structural diagnoses)
| Acronym | Cause |
|---|---|
| C | Coagulopathy (AUB-C) |
| O | Ovulatory dysfunction (AUB-O) |
| E | Endometrial causes (AUB-E) |
| I | Iatrogenic (AUB-I) |
| N | Not yet classified (AUB-N) |
Causes by Age Group
| Age Group | Common Causes |
|---|---|
| Prepubertal | Infection, trauma, vaginal foreign body, structural lesion |
| Adolescent | Anovulation (HPO axis immaturity), coagulopathy (von Willebrand disease - up to 20% of heavy bleeding at menarche), PCOS |
| Reproductive age | PCOS, leiomyoma, polyps, endometrial hyperplasia, anovulation |
| Perimenopause (>40) | Anovulatory bleeding, leiomyoma, endometrial carcinoma |
| Postmenopause | Atrophy (most common), endometrial carcinoma (must exclude) |
Key systemic associations: hypothyroidism, hyperprolactinemia, liver disease, PCOS, anorexia nervosa, obesity/metabolic syndrome.
Von Willebrand disease is the most common coagulopathy, found in up to 13% of AUB cases.
Investigation
History
- Cycle length, flow duration, volume, intermenstrual bleeding
- Postcoital bleeding (suggests cervical pathology)
- Symptoms of PCOS (obesity, acne, hirsutism, acanthosis nigricans)
- Family/personal history of bleeding disorders
- Drug history (anticoagulants, hormones, tamoxifen)
- Risk factors for endometrial cancer: obesity, nulliparity, diabetes, age >55, unopposed estrogen
Examination
- Signs of hypovolemia/anemia (if acute)
- Thyroid examination
- Skin: petechiae, ecchymosis (coagulopathy)
- Speculum: vaginal/cervical lesions
- Bimanual: uterine size, fibroids, adnexal masses
Investigations
- Pregnancy test - always first in reproductive age
- CBC - assess anemia
- TSH - thyroid dysfunction
- Prolactin - if suspected hyperprolactinemia
- Coagulation screen (PT, aPTT, platelets) - if coagulopathy suspected
- STI screen (Chlamydia) - endometrial inflammation
- Transvaginal ultrasound (TVUS) - structural causes; endometrial thickness
- Postmenopausal: endometrium <4-5 mm on TVUS reliably excludes endometrial cancer
- Endometrial biopsy - indicated in:
- Age ≥45 with AUB
- Age <45 with risk factors: obesity, anovulation, unopposed estrogen, refractory AUB, family history of cancer
- Hysteroscopy - for direct visualization if ultrasound unclear or bleeding persists
Management
Acute/Emergent Hemorrhage
- Resuscitation: IV fluids, blood products
- Conjugated equine estrogen 25 mg IV every 4-6 hours for up to 24 hours (until bleeding stops)
- Intrauterine tamponade with 26F Foley catheter + 30 mL saline
- Surgical: urgent D&C, uterine artery embolization, endometrial ablation, or hysterectomy
Medical Management (Non-emergent)
| Drug | Use |
|---|---|
| Combined OCP (35 mcg ethinyl estradiol) | Ovulatory dysfunction, anovulation; regulates cycle |
| Norethindrone 5 mg 3x/day for 1 week | Progestin-only alternative (estrogen contraindicated) |
| Tranexamic acid (antifibrinolytic) | 1.3 g orally 8-hourly x 5 days; or 10 mg/kg IV (max 600 mg) |
| NSAIDs | Reduce flow and dysmenorrhea; less effective than tranexamic acid or LNG-IUD |
| Levonorgestrel IUD | Excellent for heavy menstrual bleeding + contraception |
| Medroxyprogesterone 20 mg 3x/day for 1 week | Alternative hormonal option |
Surgical Management
- Endometrial ablation - for those not desiring fertility (29% require hysterectomy by 5 years)
- Hysteroscopic polypectomy - for polyps
- Myomectomy or uterine artery embolization - for fibroids
- Hysterectomy - reserved for failure of medical/conservative therapy
Key Points for Exams (DC Dutta style)
- DUB is obsolete - use AUB-O (ovulatory dysfunction)
- Most common cause of AUB in reproductive age: anovulation (PCOS)
- Most common cause in postmenopause: atrophy; but must exclude carcinoma
- Endometrial biopsy before hysterectomy is mandatory
- Von Willebrand disease is the commonest coagulopathy causing AUB
- TVUS endometrial thickness <4 mm in postmenopausal women = low risk of malignancy
- Tranexamic acid is non-hormonal and effective for heavy menstrual bleeding
(Sources: Rosen's Emergency Medicine; Sabiston Textbook of Surgery; Berek & Novak's Gynecology)
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