Abnormal Uterine Bleeding

Muhammad Redzwan081303583

MMMC

today

CASE

Patient’s ProfileName: Puan ZAAge: 42Parity Index: Para 4Occupation: TeacherAddress: Malim Jaya, MelakaEducation: DegreeLMP: 30th March 2014Date of Admission: 7th April 2014Date of Examination: 8th April 2014

Chief ComplaintHeavy menstruation for 6 months

History of Presenting IllnessPatient went to KK Cheng due to heavy menstruation for 6 months. She is apparently well and asymptomatic until 6 months ago when there is increase in flow and quantity of menstruation. Before that her flow was 4-5 days with 2 pads daily, but now it is 7-9 days with 3-4 pads daily. There is minimal blood clot. For current cycle, bleeding already stopped 2 days ago. She also experienced dysmenorrhea, but it started since menarche. Her cycle is regular of 28 days. No inter-menstrual or post-coital bleed.No similar history before.Systemic review reveals that she is lethargic and has palpitations. Other systems are unremarkable. After admission, blood was taken for investigations. She undergo abdominal and transvaginal ultrasound. IV saline has been infused, and tablet iron has been prescribed.

Past Obstetric History

Blood Group: A Rhesus Positive

Past Gynaecology HistoryNo significant.

Menstrual HistoryAs mentioned in HOPIPap’s Smear was done, twice in 2001,2008. No significant findingsOCP was used after each pregnancy. Last 2010.

Year Gender Birth Weight Mode of Delivery Breastfed Complications

2000 Male 2.9 kg Term SNVD 6 months nil

2002 Male 3.0 kg Term SNVD 6 months nil

2005 Female 2.8 kg Term SNVD 6 months Anaemia

2008 Female 3.1 kg Term SNVD 6 months Anaemia, GDM

Past Medical/Surgical HistoryHas appendicectomy done in 1998 under GA at HTAA, no complication.No other significant history

Personal HistoryNo changes in Bowel and Bladder movement.No L.O.A, L.O.WNo change in sleep patternNo known drug and food allergies

Family HistoryShe is first of 6 siblings.Her father has diabetes mellitus and hypertension.Mother and other siblings are healthy.Her aunty of maternal side has GI carcinoma (not sure gastric/colorectal)No blood disorders and other gynaecology problems in her family/relatives.

Social HistoryPatient lives with her husband and children at Malim about 15 minutes to

MGH. She owned a car. Her husband is also a teacher. They are financially and socially stable.

They are not smoking, do not consume alcohol and using recreational drug.

General Physical ExaminationPatient is alert, cooperative and lethargy. IV canula inserted into her dorsum of left

hand, connected to Normal SalineVitals:-Pulse: 108 bpm, regular, low volume, no collapsing pulse, no thickening of vessel wallBlood Pressure: 110/76 mmHg, right arm supine.Respiratory Rate: 16 breaths per minute.Temperature: Afebrile

Patient is pale. No koilonychia, platynychia.No cyanosis, jaundice, ulcer. No swelling of the neck, no cervical and axillary

lymphadenopathy.No swelling of the breast. No pedal edema.

Local gynaecological examination is unremarkable.

Summary42 years old Para 4 teacher came to the hospital for menorrhagia since 6 months ago. She also experiences lethargy and palpitations. O/E she is pale; pulse is 108 bpm. She was admitted for further investigations and management.

InvestigationsFBC: Hb levels 8.1 g/dL (7/4/2014 9.00am)

7.9 g/dL (7/4/2014 4.00pm)7.8 g/dL (8/4/2014)

Coagulation Profile: NormalUltrasound: No mass in vagina, uterus, ovary. Endometrial thickness: 6 mm.

Discussion

AUB - Definitions

In premenopausal women, AUB is diagnosed when there is a substantial change in frequency, duration, or amount of bleeding during or between periods1.

In postmenopausal women, any vaginal bleeding 6 months2 or 1 year1 after cessation of menses is considered abnormal and requires evaluation.

Approach to diagnosis and management of abnormal uterine bleeding; Canadian Family Physicians Journal

AUB – Causes2,3,6

• Dysfuctional Uterine Bleeding (DUB)• Pregnancy (Normal/Ectopic), Miscarriage• Adenomyosis• Use of birth control method (pills, IUCD)• Fibroid, Polyps• Endometrial Hyperplasia• Polycystic Ovarian Syndrome• Infection• Carcinoma

3FAQ095 AUB by The American College of Obstetricians and Gynecologists

How to Proceed?

1. Primary Survey and Resuscitation1

2. History taking1,2,4,5

To identify the type of AUB [ovulatory (cyclical), anovulatory (irregular, heavy), anatomical (e.g fibroids/polyps)]Past obstetric/gynaecology history – fibroids, h/o myomectomyFamily history of cervical/endometrial ca.Medications: ASA, Antidepressants, Anticoagulants, HRT, etc

3. Physical Examination1,2,4,5

To detect systemic involvements, mass per abdomen; pelvic and bimanual examination must be done. Vaginal swabs TRO infections, cervical cytology.

Investigations

• Pregnancy Test, Complete Blood Count, CoAgulation profile1,4.

• Other blood investigations must be according to differential diagnosis1.

• Ultrasound: Abdomen and Transvaginal for Ovarian/Uterine diseases (fibroid, polyps) 1,2

• Endometrial biopsy TRO endometrial cancer 1,2,4,5

• Other: Diagnostic hysteroscopy, sonohysterogram and Dilation and curettage (D&C) 1

Dysfunctional Uterine Bleeding

Dysfunctional uterine bleeding (DUB) is abnormal bleeding from the vagina that is due to changes in hormone levels6.

It is a diagnosis of exclusion where other possibilities (e.g growth, blood disorders) has been excluded1,2,4,6.

Commonly occurs when the ovaries do not release an egg. Changes in hormone levels cause period to be later or earlier and sometimes heavier than normal1,4,5.

DUB – Symptoms and Signs2,6

• Bleeding or spotting from the vagina between periods

• Cycle <28 days or >35 days• Cycle changes each month (irregular)• Heavier bleeding (such as passing large clots,

needing to change protection during the night, soaking through a sanitary pad or tampon every hour for 2 - 3 hours in a row)

• Bleeding lasts for more days than normal or for more than 7 days

DUB – Other Symptoms6

Due to hormonal imbalance:• Excessive growth of body hair in a male

pattern• Hot flashes• Mood swings• Tenderness and dryness of the vaginaSymptoms of Anaemia

DUB - Prognosis

Hormone therapy alone usually alleviates the symptoms4,6.

Other complications include:a. infertility6

b. anemia (due to blood loss)c. endometrial cancer6

Management

In Premenopausal and Perimenopausal Women1,4

• Menorrhagia assc. with ovulatory cycles can be treated with/without hormones. NSAIDs and Antifybrinolytics.

• Menorrhagia assc. with anovulatory cycles need to be treated by COCP, levonorgestrel intra-uterine system (LNG-IUS) or Cyclic Oral Progestin

• Menorrhagia assc. with fibroids can be treated by tranexamic acid, low-dose COCPs, androgens, or GnRH agonists.

In Postmenopausal Women1,4,5

• Causes includes: vaginal atrophy (50%), endometrial ca. (25%) and cervical ca. (2%)

• Endometrial biopsy and/or Transvaginal USG must be done.

• For vaginal atrophy: Topical Estrogen cream, tablet or vaginal ring; lubricans; or moisturizers

Surgical Options1,4,5,6,7

• Endometrial ablation (laser, electrical, thermal or radiofrequency energy) can be suggested [85% have fewer symptoms]. 1,4,7

• Hysterectomy (permanent cure) 1,5,7

• Uterine artery embolization and myomectomy can be used for fibroids. 1

• Dilation and Curettage (D&C) is no longer considered as treatment. 1

References1. D. E. Telner, D. Jakubovicz (2007), ‘Approach

to diagnosis and management of abnormal uterine bleeding’, Canadian Family Physicians Journal, Vol. 53 No. 1, pp 58-64.

2. ‘Disorders of Menstruation’ (2012), Gynaecology Today, 1st Ed., pp.197-240.3. The American College of Obstetricians and Gynecologists (2012), ‘Abnormal

Uterine Bleeding’, FAQ No.0954. G. A. Vilos et. al. (2001), ’

Guidelines for the management of Abnormal Uterine Bleeding’, J. Obstet. Gynaecol. Can., Vol. 23, No. 8, pp 704-709

5. The American College of Obstetricians and Gynecologists (2013), ‘Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women’, Committee Opinion No.557, Obstet Gynecol 2013;121:891–6.

6. MedlinePlus (2011) ‘Dysfunctional uterine bleeding (DUB)’, National Library of Medicine National Institute of Health

7. P. Bourdrez (2004), ‘Treatment of dysfunctional uterine bleeding: patient preferences for endometrial ablation, a levonorgestrel-releasing intrauterine device, or hysterectomy’, Fertility and Sterility, Vol. 82 Issue 1, pp 160-166

8. MedlinePlus (2011) ‘Endometrial Carcinoma’, National Library of Medicine National Institute of Health

Q & A

THANK YOU

P/s: Further reading: Gynaecology Today Chapter Disorders of Menstruation Page 197-240Slides can be retrieved in Slideshare