professor Miami Abdul Hassan - PowerPoint Presentation

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professorMiami Abdul Hassan F.I.C.O.G2019-2020 

Abnormal uterine bleeding

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Regular cyclic menstruation results from the relationship between the endometrium and its regulating factors. Changes in either of these frequently results in abnormal bleeding

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Normally the menstrual cycle occurs at each 28 days (the normal range is 21 to 35 days)

and lasting for average

5

days (the normal range is 2 to 8 days)

Characteristics of normal and abnormal menstruation

:

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and the average loss of blood in each cycle is 40 ml (the normal range 20-80ml).

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So any alteration in this normal pattern will be regard as (AUB) this AUB is a symptom, not a disease and it occur in various forms:

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Menorrhagia: is a cyclic bleeding at normal interval, but it is excessive in amount (>80 ml) and /or duration (>8 days).(excessive bleeding at regular interval over several consecutive cycle ).

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Heavy menstrual bleeding (HMB) is now a preferred description. It replaces the older term ‘menorrhagia

HMB is defined as excessive menstrual blood loss (over several consecutive cycles)

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Polymenorrhea: (frequent cycle) is cyclic bleeding which is normal in amount but occurs at too frequent interval (<21 days).

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Oligomenorrhea:( infrequent cycle). is a regular cycle but occur at intervals of >35 days to 6 months (i.e. infrequent cycle), or less than 8 cycles per year.

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Metorrhagia: uterine bleeding occurring at completely irregular but frequent intervals, the amount being variable.

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Intermenstrual bleeding: bleeding of variable amounts occurring between regular menstrual periods.  

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may be associated with polypi or submucus fibroid. If regular cyclic, it is often dysfunctional due to fall of estrogen following ovulation

Intermenstrual

bleeding

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Careful examination of the CX.is essential , any suspicious finding s are indication for colposcopy.In young woman Chlamydia infection should be excluded especially if bleeding is confined to midcycle

Intermenstrual

bleeding

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bleeding after sex. Often associated with: cervical abnormalities .Premalignant and malignant disease of the lower genital tract).PCB:

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Causes of AUB: are divided into

organic and non

–

organic

.

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Organic cause Reproductive Tract Disease .systemic

pregnancy related Complications.

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Organic cause

Reproductive Tract Disease

systemic

pregnancy related Complications

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Benign pelvic lesions

Leiomyomata

.

Endometrial or

endocervical

polyps.

Adenomyosis

and

endometrios

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Pelvic infections (PID)Intrauterine contraceptive device (IUCD)Trauma

Foreign bodies (IUD, sanitary products)

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PID

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Malignant pelvic lesionsEndometrial hyperplasia

Endometrial cancer

Cervical cancer

Less frequently: vaginal,vulvar

, fallopian tube cancers

estrogen secreting ovarian tumors

granulosa

-theca cell tumors

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endom.ca

.

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Cervical ca

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Systemic disorderEndocrine disorderHematological disorders

Liver disorders

Renal disease

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Medications: such assteroid hormones

Anticoagulants

neuroleptics

, and cytotoxic agents.

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: these may affect the hypothalamus and the higher centersEmotional stress and psychological upset

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These are the most common cause of AUB in females of 20-40 years age . These include: Ectopic pregnancy,

Miscarriage

Gestational

trophoblastic

disease

.

 

pregnancy complications

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some time the bleeding is not from the genital tract but it comes from the urethra or rectum, so these causes should be taken in a consideration.

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DUB :Is an abnormal uterine bleeding in the absent of apparent organic cause, so the diagnosis is made by exclusion of all organic cause of AUB.

B) Non – organic cause i.e. dysfunctional uterine bleeding (DUB):

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One system that is increasingly recognized is the PALM–COEIN system developed by (FIGO), in which the nemonic PALMPolyps, Adenomyosis,

Leiomyoma

, MalignancyCOEIN for causes unrelated to structural anomalies:

Coagulopathy

,

Ovulatory

disorders,

Endometrial,

Iatrogenic,

Not classified

causes.

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HMB of endometrial origin Bleeding of endometrial origin (BEO)

New definition

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Age,

menstrual pattern,

sexual activity,

trauma, infection,

systemic disease,

stress

history of bleeding tendency,

hormonal therapy or IUD

Evauation

of DUB

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( Endometrial or cervical polyp)

Irregular bleeding

Intermenstrual

bleeding

Postcoital

bleeding

.

Symptoms which can be associated with HMB and related pathologies

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(Coagulation disorder)Excessive bruising/bleeding from other sites History of postpartum

haemorrhage

(PPH)

Excessive postoperative bleedingExcessive bleeding with dental extractionsFamily history of bleeding problems

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Unusual vaginal discharge(Pelvic inflammatory disease )(Urinary symptoms (Pressure from fibroids

Weight change, skin changes, fatigue (

Thyroid disease

)

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examination:General: signs of anaemia

, evidence of systemic

coagulopathy

(bruising, petechiae) and thyroid disease (goitre

).

Abdominal:

Pelvic&abdominal

swelling, liver, spleen

Pelvic:

infections, lesions, lacerations, polyps, fibroids

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Investigations:

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1-Full blood count (should be send for all the patient)

2.Coagulation screen

.

Referral for a haematological opinion should

be considered in women with a history consistent with a coagulation disorder

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3-β-hCG4- PAP smear.5-Hormone testing should not be performed routinely

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5.A pelvic ultrasound scan (USS) should be performed:

when a pelvic mass is palpated on examination (suggestive of fibroids);

when symptoms suggest an endometrial polyp,

e.g.irregular

or

intermenstrual

bleeding;

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TV U/STV/US to:

detect any pelvic pathology

and to assess the thickness of the

endometrium

especially in postmenopausal women (

< 5 mm, endometrial cancer is unlikely

)

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6.High vaginal and endocervical swabs

High vaginal and

endocervical

swabs should be taken:• when unusual vaginal discharge is reported or

observed on examination;

• where there are risk factors for PID

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7-Endometrial samplingIt is recommended in the evaluation of AUB in:

1.Woman aged > 45 years

2.Those with high risk for endom.ca (obesity, hypertension, diabetes, chronic an ovulation,

nulliparity with history of infertility, family history of colonic& endom.ca &

tamoxifen

therapy Plan your Lecture

44

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7-Endometrial sampling3.In younger woman it is indicated when the AUB doesn't resolved with medical treatment or when inter menstrual bleeding persist

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The most common methods for endom.sampling are:

1.Aspiration curettage (

pipelle

, vabra

,

sharman

).

2. D&C

3.Hysteroscopy .

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pipelle

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D&C

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hysteroscope

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: when an organic cause is detected treatment is directed to it, e.g. :Fibroids:

GnRH

agonists,

myomectomy or hysterectomy, uterine artery embolization.

Treatment of abnormal uterine bleeding

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myomectomy

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Uterine artery embolisation

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Treatment Adenomyosis: Hysterectomy or medical (

progestins

,

GnRH analogues) Endometrial polyps:

curettage

Endometrial carcinoma:

TAH + BSO +/- radiation

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When an organic cause can not be detected, it is considered (DUB)

Medical management of dysfunctional uterine bleeding include:

A

.

NON HORMONAL

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First line treatment in primary care. Using either

NSAID

or

antifibrinolytic

.both can be used, referral considered if neither the above drugs were effective

:

after 3 months

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Hormonal therapy of DUB

Progestins

:

oral

injectable

intrauterine

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b) Estrogens:- Given in acute heavy bleeding- Conjugated

oestrogen

– 25 mg every 4 to 12 hours

for 24 hours I.V until bleeding stops.

Hormonal therapy of DUB (cont.)

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c) For woman requiring contraception or for whom hormonal agents are acceptable (COCP) are effective in decreasing MBL, cycle regulation, relieving dysmenorrhea.

Estrogen + Progestin ( combined oral contraceptive pill):

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Androgens:Danazol, ethamsylate and gestrinone

are no longer recommended for routine use in the treatment of HMB

owing to their unacceptable side effects.

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e) Gonadotropin releasing hormone analogues (Gn Rha):

- Used in special circumstances

Disadvantages:Expensive

Troublesome side-effects (hypo-estrogenic, bone loss, hot flushes, vaginal dryness)

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Severe acute heavy menstrual bleedingInitial management is based on haemodynamic stability.One reported regimen is

ethinyl

oestradiol 30μg/ norgestrel 0.3mg :

four times daily for 4 days,

followed by

three times daily for 3 days,

followed by

two times daily for 2 days

,

followed by

once daily for 3 weeks

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II) Surgical therapy of DUB: if medical therapy for 3‑6 months failed

electrocoagulation

1.Transcervical endometrial resection

ablation of the endometrial lining of

the uterus to sufficient depth prevents

regenerationof

the

endometrium

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Endometrial ablation techniques:cryoablation

Electrocautery

,

laser,

cryoablation

, or

thermoablation

Become an alternative to hysterectomy for treatment of DUB.

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Hysterectomy

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Hysterectomy: is the final step

Advantages:

1‑ complete cure

2‑ Avoid medical treatment

3- Remove any missed pathology

Major operative procedure

2- Long hospitalization

3- Significant morbidity

4- Long term sequel (pain ‑ urinary dysfunction ‑ sexual dysfunction

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Arrest of the bleeding, if it is severe or persistent, particularly hyperplastic endometrium.Curettage is essentially a diagnostic & not a therapeutic procedure.

Dilatation and curettage:

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Thank you for

your attention