Abnormal Uterine Bleeding (AUB) - As per DC Dutta's Framework

Note: DC Dutta's Textbook of Gynecology is not in the library database. However, the content below is compiled from Berek & Novak's Gynecology and Sabiston Textbook of Surgery, which cover exactly the same framework DC Dutta uses (PALM-COEIN classification, older DUB terminology, investigation, and management). The DC Dutta-specific nuances from his textbook are supplemented from my training knowledge.

Definition

• Normal menstrual cycle: 24-38 days frequency
• Normal duration of flow: 4-8 days
• Normal blood loss: <80 mL per cycle

Menstrual Terminology (DC Dutta)

PALM-COEIN Classification (FIGO 2011)

Structural Causes - PALM

Non-structural Causes - COEIN

Each Cause in Detail

AUB-P: Polyps

• Endometrial polyps are overgrowths of endometrial glands and stroma (sessile or pedunculated)
• Causes: intermenstrual bleeding, heavy menstrual bleeding, postmenopausal bleeding, and rarely dysmenorrhea
• Associated with: tamoxifen use, obesity, hypertension, PCOS, increasing age
• Incidence increases with age throughout the reproductive years
• Malignant transformation: up to 5% of polyps; risk higher in postmenopausal women (0% to 13% malignancy; 0.2% to 24% premalignant change)
• Diagnosis: transvaginal ultrasound (endometrial thickening), sonohysterography, hysteroscopy
• Treatment: hysteroscopic polypectomy; smaller polyps may regress spontaneously (27% at 1 year)
• (Berek & Novak's Gynecology)

AUB-A: Adenomyosis

• Endometrial glands and stroma within the myometrium
• Presents with heavy menstrual bleeding, dysmenorrhea, and an enlarged, globular, tender uterus
• Diagnosis: MRI (most accurate); ultrasound shows heterogeneous myometrium
• Treatment: Medical (progestins, LNG-IUS, NSAIDs); Definitive - hysterectomy

AUB-L: Leiomyoma (Fibroids)

• Most common benign gynecologic tumor; affects up to 70% of patients by age 50
• Higher prevalence and severity in Black patients (earlier onset, more numerous, larger)
• FIGO classification by location:
  • Type 0: Pedunculated intracavitary
  • Types 1-2: Submucosal
  • Types 3-5: Intramural
  • Types 6-7: Subserosal
  • Type 8: Cervical
• Submucosal fibroids (types 0, 1, 2) are most likely to cause AUB
• Diagnosis: Pelvic ultrasound, saline infusion sonography, MRI
• Treatment: Hysteroscopic myomectomy (submucosal), abdominal/laparoscopic myomectomy, uterine artery embolization (UAE), GnRH agonists, hysterectomy
• (Sabiston Textbook of Surgery)

AUB-M: Malignancy and Hyperplasia

• Endometrial hyperplasia (with or without atypia) and endometrial carcinoma
• Non-structural causes include the COEIN group; structural causes include PALM
• Endometrial biopsy is mandatory for:
  • All women ≥45 years with AUB
  • Women <45 with risk factors: obesity, anovulation, unopposed estrogen, family history of Lynch syndrome
• 90% of patients with endometrial cancer present with abnormal uterine bleeding
• (Sabiston Textbook of Surgery)

AUB-C: Coagulopathy

• Coagulation disorders account for a significant proportion of heavy menstrual bleeding
• von Willebrand disease is the most common inherited coagulation disorder causing AUB
• Others: thrombocytopenia, platelet function disorders, factor deficiencies
• Screen if: heavy bleeding since menarche, family history of coagulopathy, signs of systemic bleeding (easy bruising, nosebleeds), anticoagulant use
• (Berek & Novak's Gynecology)

AUB-O: Ovulatory Dysfunction

• Anovulatory cycles are the most common cause of AUB in reproductive age women
• Causes of anovulation:
  • PCOS (most common in reproductive age)
  • Thyroid disorders (hypothyroidism / hyperthyroidism)
  • Hyperprolactinemia
  • Hypothalamic dysfunction (stress, exercise, weight loss)
  • Perimenopause
• Mechanism: Lack of progesterone leads to unopposed estrogen stimulation of the endometrium, causing irregular shedding and heavy bleeding
• DC Dutta's older editions classified most of these as DUB (Dysfunctional Uterine Bleeding)
• (Berek & Novak's Gynecology)

DC Dutta's DUB Classification (Historical - still exam-relevant):

AUB-E: Endometrial Causes

• Primary disorders of the endometrium in the absence of other identifiable causes
• Includes disorders of:
  • Endometrial hemostasis (deficient local vasoconstriction)
  • Prostaglandin balance (increased PGE2/PGI2 relative to PGF2-alpha)
  • Fibrinolysis (increased endometrial fibrinolytic activity)
• These are essentially ovulatory women with heavy periods but no structural cause

AUB-I: Iatrogenic

• Bleeding caused by medications:
  • Exogenous hormones: OCP (breakthrough bleeding), progestin-only pills, implants, DMPA
  • LNG-IUS: irregular spotting especially in first 3-6 months
  • Anticoagulants: warfarin, heparin, NOACs
  • Copper IUD: increases menstrual blood loss
  • Tamoxifen: endometrial stimulation
  • Antipsychotics/dopamine antagonists: hyperprolactinemia causing anovulation

AUB-N: Not Yet Classified

• AVM (arteriovenous malformations) of the uterus
• Myometrial hypertrophy
• Endometritis (chronic)

Investigations

Step 1 - Basic Workup (all patients)

1. Detailed history - cycle characteristics, contraceptive use, medications, systemic illness
2. Pelvic examination - size/shape of uterus, adnexal masses, cervical lesions
3. Urine/serum β-hCG - exclude pregnancy
4. CBC - hemoglobin (to assess blood loss), platelet count
5. Thyroid function tests (TSH)
6. Prolactin level
7. Cervical smear (if not up to date)
8. STI screening (chlamydia, gonorrhoea) in at-risk patients

Step 2 - Imaging

• Transvaginal ultrasound (TVUS): First-line imaging; assesses endometrial thickness, fibroids, polyps, ovarian pathology
• Saline infusion sonography (SIS)/Sonohysterography: Better than TVUS for intracavitary lesions
• MRI: Best for adenomyosis, leiomyoma mapping, deep infiltrating endometriosis

Step 3 - Endometrial Sampling

• Indications (DC Dutta / ACOG):
  • Age ≥45 years
  • Age <45 with: obesity, PCOS, anovulation, tamoxifen use, Lynch syndrome, persistent AUB refractory to medical treatment
• Pipelle biopsy - office-based; 90-95% sensitivity for endometrial cancer
• Dilatation & Curettage (D&C) - if Pipelle fails; also diagnostic and sometimes therapeutic
• Hysteroscopy + biopsy - gold standard; allows directed biopsy of focal lesions

Step 4 - Coagulation Screen (selected cases)

• PT, APTT, platelet count
• Von Willebrand factor antigen and activity
• Bleeding time

Management

Principles (DC Dutta Framework)

1. Age and reproductive wishes
2. Severity of bleeding
3. Underlying etiology
4. Medical fitness

Medical Management

1. Hormonal Therapy

2. Non-hormonal Therapy

DC Dutta's Progesterone Regimen for DUB:

• Anovulatory DUB: Norethisterone 5 mg TDS from Day 5-25 of cycle (to impose cyclical withdrawal bleeding)
• Acute heavy bleeding: High-dose progestogens (norethisterone 5 mg TDS) or combined OCP to stop acute bleeding

Surgical Management

Indications for Surgery:

• Medical treatment failed or contraindicated
• Structural cause identified
• Patient does not wish to preserve fertility
• Suspected malignancy

Procedures:

• Destroys the endometrium
• 1st and 2nd generation techniques:
  • 1st generation: rollerball, laser, wire loop (hysteroscopic)
  • 2nd generation: thermal balloon (NovaSure), microwave, cryotherapy (office-based)
• Success rate: ~80% patient satisfaction; ~20-30% achieve amenorrhoea
• Important: Not appropriate if future pregnancy desired; must exclude endometrial cancer first
• 29% of patients who had ablation ultimately needed hysterectomy at 5 years (Berek & Novak's)

• For symptomatic fibroids
• Non-surgical; fibroid infarction and shrinkage
• 31% ultimately required hysterectomy in long-term follow-up (Berek & Novak's)
• Preserves uterus but not recommended if future pregnancy desired

• For women with symptomatic fibroids who want to preserve fertility
• Hysteroscopic (type 0-2 submucosal), laparoscopic, or open (abdominal)

• Definitive treatment; curative
• Reserved for:
  • Failure of medical and conservative surgical treatment
  • No desire for future fertility
  • Confirmed or suspected malignancy
  • Adenomyosis (definitive)
• Routes: vaginal, abdominal, laparoscopic, robotic
• Endometrial sampling must be done before hysterectomy for AUB
• D&C alone is not effective for controlling AUB long-term and is not necessary before hysterectomy (Berek & Novak's)

Special Situations (DC Dutta)

Adolescent AUB

• Most commonly due to anovulation (immature HPO axis)
• Rule out coagulopathy (von Willebrand disease) - especially if heavy since menarche
• Manage conservatively with hormones (OCP or cyclical progestins)
• Endometrial biopsy rarely needed

Perimenopausal AUB

• Most common cause: anovulatory cycles due to declining ovarian reserve
• Must always exclude endometrial hyperplasia/carcinoma
• Endometrial biopsy is mandatory
• LNG-IUS is an excellent option if no malignancy

Postmenopausal Bleeding

• Not part of PALM-COEIN (classified separately)
• Any postmenopausal bleeding = malignancy until proven otherwise
• Most common cause overall: endometrial atrophy
• Most dangerous cause: endometrial carcinoma (90% of endometrial cancer patients present with PMB)
• Workup: TVUS (endometrial thickness) + endometrial biopsy
  • Endometrial thickness ≤4 mm: low risk; biopsy may be deferred

  • 4 mm or focal lesion: endometrial biopsy mandatory

  • Note: The 4 mm cutoff has been shown to underdiagnose endometrial cancer in Black patients (Sabiston)

Summary Algorithm

AUB in Reproductive Age
         |
   Exclude pregnancy
         |
History + Exam + CBC + TFT + Prolactin + TVUS
         |
   Structural cause (PALM)?     Non-structural (COEIN)?
         |                               |
  Polyp → polypectomy          Anovulatory → hormones
  Fibroid → medical/surgical   Coagulopathy → haematology
  Adenomyosis → LNG-IUS/Hx    Iatrogenic → adjust meds
  Malignancy → staging + Rx

Key DC Dutta High-Yield Points

1. DUB (now AUB-O/E) is a diagnosis of exclusion - all organic causes must be ruled out first
2. Anovulatory DUB is more common (75-80%); seen at extremes of reproductive life (adolescence + perimenopause)
3. Ovulatory DUB is less common (20-25%); affects women in their 30s; regular but heavy periods
4. The LNG-IUS (Mirena) is the most effective medical treatment for heavy menstrual bleeding with a uterine cause
5. Tranexamic acid reduces blood loss by ~50% and is the best non-hormonal option for ovulatory HMB
6. Endometrial biopsy before any surgical procedure for AUB
7. D&C is diagnostic, not therapeutic for AUB (does not provide long-term relief)
8. Postmenopausal bleeding: endometrial thickness ≤4 mm on TVS makes endometrial cancer very unlikely
9. TVUS is the first-line imaging in all cases of AUB

1. Initial Assessment - first-line workup every patient needs (β-hCG, CBC, TFT, TVUS)
2. Endometrial Biopsy Indications - age and risk-factor based criteria
3. PALM-COEIN Table - structural vs. non-structural causes, color-coded, each with its management direction
4. Management Ladder - three-tiered escalation from medical → minimally invasive → definitive surgical
5. Special Situations - adolescent, perimenopausal, and postmenopausal AUB in dedicated footer boxes