Abnormal uterine bleeding (AUB)
A 35 year old lady para 2 presented to the clinic with a 6 months history of irregular bleeding lasting up to 14 days per month. She also requested contraception. Her medical history includes uncontrolled hypertension . Upon examination, the vagina and cervix were normal. Her blood pressure was reported as 160/110 and BMI is 33.
- Irregular bleeding
- Contraception request
- Obese (>= 30.0)
- Full blood count (FBC)
- Thyroid function test(TFT)
- Endometrial biopsy
- And pregnancy test
- Hemoglobin level : 10 g/dl (anemic)
- TFT : normal
- Pregnancy test: negative
- USG : showed a regular uterus, PCOS ovaries with no other pathologies
- Endometrial biopsy: revealed disordered proliferative phase endometrium
- Depot medroxyprogesterone acetate
- Copper IUD
- Levonorgestrel IUD
- Combined oral contraceptives
Chronic abnormal uterine bleeding is bleeding from the uterine endometrium that is abnormal in volume, regularity, or timing for most of the past 6 months.
Anovulatory bleeding is the most common cause of noncyclic menstrual blood flow that may range in volume from spotty to excessive. It is attributed to anovulatory sex steroid production.
Medical treatment is the best management for anovulatory bleeding.
Estrogen-containing contraceptives, eg.Combined oral contraceptives, are contraindicated in women with a history of uncontrolled hypertension. They are considered to be UKMEC category 4.
Levonorgestrel IUD and the copper IUD are both UKMEC Category 1 for uncontrolled hypertension. However, on the levonorgestel IUD would be effective for this patients irregular bleeding and anemia.
On a different note, PCOS patients are found to be 3 times as likely as the general population to develop endometrial cancer. Conservative management via levonorgestrel IUD in cases of precancerous and early well differentiated endometrial neoplasia has displayed viability in patients concerned with preserving their fertility. (Keeping in mind Rotterdam Criteria for PCOS diagnosis.)
- ACOG Committee on Practice Bulletins–Gynecology. American College of Obstetricians and Gynecologists.. ACOG practice bulletin: management of anovulatory bleeding. Int J Gynaecol Obstet. 2001 Mar;72(3):263-71. doi: 10.1016/s0020-7292(01)00357-5. PMID: 11296797.
- FSRH. (2016). Uk Medical Eligibility Criteria Fo R Contr Acept I Ve U Se | U K Me C 2016. 2016, 1–170. https://www.fsrh.org/standards-and-guidance/documents/ukmec-2016/
- Haoula Z, Salman M, Atiomo W. Evaluating the association between endometrial cancer and polycystic ovary syndrome. Hum Reprod 2012;27:1327-1331.
Ndefo UA, Eaton A, Green MR. Polycystic ovary syndrome: A review of treatment options with a focus on pharmacological approaches. P T 2013;38:336–55.