ABNORMAL UTERINE BLEEDING (AUB)

• Any uterine bleeding beyond normal volume, duration, regularity, or frequency is considered AUB
• Patterns of AUB:
• Menorrhagia
• Metrorrhagia
• Polymenorrhea / Epimenorrhea
• Menometrorrhagia

• Menorrhagia – Cyclic bleeding with normal intervals, but bleeding is either excessive in amount (> 80 ml) or duration (> 7 days) or both
• Metrorrhagia – Irregular acyclic bleeding (of any amount) from the uterus (bleeding occurs between normal ovulatory cycles)
• Polymenorrhea –Cyclic bleeding where the cycle is reduced to an interval of less than 21 days and remains constant at that frequency. If it is associated with excessive and/or prolonged bleeding, it is called Polymenorrhagia / Epimenorrhagia
• Menometrorrhagia –Bleeding is so irregular & excessive that periods cannot be identified at all

• FIGO – 2011 introduced a newer classification system based on etiology known by the acronym AUB with PALM – COEIN.
• PALM – Structural causes
• Polyp (AUB – P)
• Adenomyosis (AUB – A)
• Leiomyoma (AUB – L)
• Malignancy & hyperplasia (AUB – M)
• COEIN – Systemic causes
• Coagulopathy (AUB – C)
• Ovulatory dysfunction (AUB – O)
• Endometrial causes (AUB – E)
• Iatrogenic (AUB – I)
• Not yet identified (AUB – N)

 Common causes

• Organic – Uterine fibroid, Endometriosis, Adenomyosis, Endometrial polyps, IUCD, Adnexal pathology (Ovarian cysts, Tubo ovarian mass), Ovarian neoplasm
• Haematological, Endocrine & Others – Platelet deficiency, Leukemia, Idiopathic thrombocytopenic purpura (ITP), Von Willebrand disease, Thyroid dysfunction, PCOS
• Non-menstrual - Foreign body, Urethral caruncles, Genital malignancy, Cervical pathologies, Miscarriage related, Breakthrough bleeding

 Postmenopausal bleeding

• Benign Conditions – Endometrial polyps, Cervical polyps, Senile vaginitis, Vulval dystrophy, Trauma, Hormone replacement therapy (HRT)
• Malignant conditions – Endometrial carcinoma, Carcinoma cervix, Carcinoma vagina, Vulval Ca

• Excessive bleeding – Assessed by number of pads used, clots passed
• Prolonged Duration
• Inter menstrual bleeding
• Post-coital bleeding

• Age < 20 - disturbance is usually functional (hormonal disturbances) and resolves spontaneously

Active reproductive age group

• Exclude pregnancy and investigate for any organic causes
• Perimenopausal age - functional disorders are common; must rule out benign & malignant lesions
• Postmenopausal bleeding - rule out malignant lesions as it is very common
• Bimanual examination- including speculum examination should be done in all cases to rule out any local pathology and any growths
• Blood test: CBC, Platelet count, PTT, serum ferritin (in selective cases), TFT, RFT if needed, LFT, Prolactin, FSH, LH, etc, according to the age & condition of the patient
• USG (TVS) – to rule out organic lesions, Endometrial hyperplasia (Endometrial thickness> 12 mm)
• Hysteroscopy – Evaluation & biopsy of endometrial lesions can be done under direct vision
• Endometrial sampling
• Laparoscopy
• Diagnostic uterine curettage (D & C)

• Progestins
• Androgens 
• Ethamsylate
• Mifepristone
• Antifibrinolytic agents (tranexamic acid)
• NSAIDs (mefenamic acid) 
• GnRH analogs
• Surgical management such as D&C, Endometrial ablation, Uterine artery embolization, and Hysterectomy

Ayurvedic Treatment

Internal Medicines

• Musalikhadiradi Kashaya + honey
• Ashoka twak ksheera Kashaya
• Nyagrodadigana Kashaya
• Darvyadi Kashaya
• Vasa kwatha+ Rasabhasma & honey
• Pushyanuga Chooorna + madhu & tandulodaka
• Thanduliyaka moola Kalka + madhu
• Rasanjana & laksha Choorna with goats milk
• Shatavari Guda
• Kushmanda Avaleha
• Jeeraka Avaleha
• Mahathikta Gritha
• Shatavari Gritha
• Ashoka Gritha
• Pradaranthaka Rasa
• Chandrakala Rasa
• Bola Parpati
• Gokshuradi Guggulu
• Chandraprabha Vati
• Silajath Vati
• Asokarishta
• Patrangasava
• Lakshmanarishta

Procedures

• Virechana - in Pittaja Asrigdhara
• Vasti – Chandanadi Niruhavasti, Rasnadi Niruhavasti, Musthadi yapanavasti 
• Vasa swarasa Nasya – to stop bleeding