ABNORMAL UTERINE BLEEDING

INTRODUCTION
Common in women of all ages AUB prevelention about 11-13% from population, and increased, up to 24% in 36-40 years old

DEFINITION OF AUB

AUB is defined as any bleeding that differs in interval, frequency, duration or volume from a patients usual menstrual flow.

Abnormal uterine bleeding includes both bleeding from structural causes and dysfunctional uterine bleeding

ETIOLOGY ABNORMAL UTERINE BLEEDING

Structural anomalies (polyps, leimyoma, adenomyosis, malignancy) Non-structural anomalies (Hormonal disorder) DUB (exclusionum Diagnosis of AUB)

DUB: DEFINITION
Excessive uterine bleeding No demonstrable organic cause Most frequently due to anovulation DUB is the most common type of abnormal uterine bleeding.

DUB...

Dysfunctional bleeding can be anovulatory, which is characterized by irregular unpredictable bleeding, or ovulatory, which is characterized by heavy but regular periods (ie, menorrhagia).

Most abnormally heavy uterine bleeding has no underlying anatomical cause and is considered DUB Dysfunctional uterine bleeding (DUB), which is associated with, functional abnormalities of the hypothalamic-pituitary axis.

Klasifikasi PUA
(FIGO)

PALM

COEIN

A. Polip

E. Coagulopathy

B. Adenomiosis

F. Ovulatory dysfunction

C. Leiomioma

G. Endometrial

D. Malignancy and hyperplasia

H. Iatrogenik

I. Not yet classified

Bleeding Pattern of Abnormal Uterine Bleeding

Oligomenorea Polimenorea Menoragia Perdarahan uterus yang terjadi dengan interval > 35 hari dan disebabkan oleh fase folikuler yang memanjang. Perdarahan uterus yang terjadi dengan interval < 21 hari dan disebabkan oleh defek fase luteal. Perdarahan uterus yang terjadi dengan interval normal jumlah darah haid > 80 ml atau > 7 hari. ( 21 35 hari) namun

Menometroragia
Amenorea Metroragia atau perdarahan antara haid

Perdarahan uterus yang tidak teratur, interval non-siklik dan dengan darah yang berlebihan (>80 ml) dan atau dengan durasi yang panjang ( > 7 hari).
Tidak terjadi haid selama 6 bulan berturut-turut pada wanita yang belum masuk usia menopause. Perdarahan uterus yang tidak teratur diantara siklus ovulatoir dengan penyebab a.l penyakit servik, AKDR, endometritis, polip, mioma submukosa, hiperplasia endometrium, dan keganasan. Bercak perdarahan yang terjadi sesaat sebelum ovulasi yang umumnya disebabkan oleh penurunan kadar estrogen. Perdarahan uterus yang terjadi pada wanita menopause yang sekurang-kurangnya sudah tidak mendapatkan haid selama 12 bulan. Perdarahan uterus yang ditandai dengan hilangnya darah yang sangat banyak dan menyebabkan gangguan hemostasisis (hipotensi , takikardia atau renjatan). Perdarahan uterus yang bersifat ovulatoir atau anovulatoir yang tidak berkaitan dengan kehamilan, pengobatan, penyebab iatrogenik, patologi traktus genitalis yang nyata dan atau gangguan kondisi sistemik.

Bercak intermenstrual Perdarahan pasca menopause Perdarahan uterus abnormal akut

Perdarahan uterus disfungsi

Structural Anomalies
Polyps, Adenomyosis, Leimyoma, Malignancy

Endometrium hyperplasia Disturbing of contractility miometrium Increasing of endometrial surface Endometrial atrofi hipervascularity endometrium

PUA

CRITERIA DIAGNOSIS

Medical history menstrual pattern. Includes the interval between, the duration of, and the amount of menstrual flow for several months.
information consumes medications and nonprescription drugs a sexual history (including pregnancy and contraception information),

CONTINUED

MEDICAL HISTORY

symptoms of infection gynecologic disorders)

and

disease

(including

recent surgery, and a history of injury to the area Weight loss, eating disorders, stress, and excessive exercise

PHYSICAL AND PELVIC EXAMINATIONS

The doctor examines the thyroid, breasts, liver, and hirsutism (excessive hair growth in unusual places), obesity. The pelvic examination involves evaluating the external and internal organs to identify the source and degree of bleeding, determine the size and shape of the uterus, and detect abnormalities.

LABORATORY TESTS

pregnancy test (for women who may be pregnant), a complete blood count (coagulation factor), and Pap smear. Other tests may also be done, depending on the circumstances and the differential diagnosis.

Imaging tests USG. Ultrasound produces an image of the endometrium, sonohysterography Biopsy (D & C)

Differential Diagnosis
Complications of pregnancy Intrauterine pregnancy Ectopic pregnancy Spontaneous abortion Gestational trophoblastic disease Placenta previa Infection Cervicitis Endometritis Trauma Laceration, abrasion Foreign body Malignant neoplasm Cervical Endometrial Ovarian Benign pelvic lesions Cervical polyp Endometrial polyp Leiomyoma Adenomyosis Systemic disease Hepatic disease Renal disease Coagulopathy Thrombocytopenia von Willebrand's disease Leukemia Medications/iatrogenic Intrauterine device Hormones (oral contraceptives, estrogen, progesterone) Hormonal imbalance Anovulatory cycles Hypothyroidism Hyperprolactinemia Cushings disease Polycystic ovarian syndrome Adrenal dysfunction/tumor Stress Excessive exercise

TREATMENT OF AUB
Medical management NSAID Antifibrinolytic Agents Danazol (steroid Syntetic) Progestin (Medroxyprogesterone) OCP (ethinyl estradiol) GnRH agonist

Surgical management Dilatation & curatage Endometrial Ablation Myomectomy Hysterectomy

MANAGEMENT OF AUB
Tabel 4 . Penatalaksanaan Medikamentosa PUD anovulatoir
Obat Pil kontrasepsi Dosis Etinil estradiol 20 35 mcg + progestin monofasik tiap hari Maksud Mengatur siklus haid Kontrasepsi Mencegah hiperplasia endometrium Penatalaksanaan perdarahan Pil 35 mcg 2 4 kali sehari selama yang banyak namum tidak 5 7 hari sampai perdarahan bersifat gawat darurat berhenti dan diikuti dengan penurunan secara bertahap sampai 1 pil 1 kali perhari dan dilanjutkan dengan pemberian pil kontrasepsi selama 3 siklus Mengatur siklus haid 5 10 mg / hari selama 5 10 hari Mencegah setiap bulan hiperplasia endometrium

Progestin : Medroxyprogesteron asetat (Provera, Prothyra)

AUB WITH PALM-COEIN