Abnormal Uterine Abnormal Uterine BleedingBleeding

Dr. Mashael ShebailiDr. Mashael Shebaili

Asst. Prof. & ConsultantAsst. Prof. & Consultant

Ob/Gyne DepartmentOb/Gyne Department

Normal menstruationNormal menstruation

Rhythm:Rhythm: regular from 21-35 regular from 21-35

daysdays

Duration:Duration: 3-7 days 3-7 days

Amount:Amount: between 30-50 mls between 30-50 mls

Flow:Flow: non clotted fluid blood non clotted fluid blood

Disorders in rhythm, Disorders in rhythm, amount or durationamount or durationMenorrhagia

Polymenorrhea

Oligomenorrhea

Metrorrhagia

Causes of MenorrhagiaCauses of Menorrhagia

DUBDUB

Pelvic pathologyPelvic pathology

MedicalMedical

Clotting defectClotting defect

Dysfunctional uterine Dysfunctional uterine bleedingbleeding

Definition:Definition: uterine bleeding in uterine bleeding in

the absence of an organic the absence of an organic

diseasedisease

Incidence:Incidence: 10-20% usually at 10-20% usually at

extremes of reproductive life.extremes of reproductive life.

Diagnosis (by exclusion)Diagnosis (by exclusion) HistoryHistory

General examinationGeneral examination

Abdomino-pelvic examinationAbdomino-pelvic examination

Investigations (mainly to Investigations (mainly to

exclude organic causes)exclude organic causes)

TreatmentTreatment I.I. Medical treatmentMedical treatmentA.A. Non-steroidal anti-inflammatory Non-steroidal anti-inflammatory

drugsdrugs Mechanism of action: inhibit cyclo-Mechanism of action: inhibit cyclo-

oxygenase enzyme and the oxygenase enzyme and the production of prostaglandinsproduction of prostaglandins

Phospholipids Phospholipids phospholipase Aphospholipase A22 arachidonic acid arachidonic acid cyclo-oxygenasecyclo-oxygenase prostaglandinsprostaglandins

Possible PathophysiologyPossible Pathophysiology

1)1) Shift in the endometrium conversion Shift in the endometrium conversion of the endoperoxide from vaso-of the endoperoxide from vaso-constrictor PGFconstrictor PGF22

2)2) Increase in the levelIncrease in the level and activity of and activity of the endometrium fibrinolytic systemthe endometrium fibrinolytic system

3)3) Effect of other endometrial derived Effect of other endometrial derived factors as cytokines, growth factors factors as cytokines, growth factors and endothelins.and endothelins.

EffectivenessEffectiveness::

1.1. Decrease measured menstrual Decrease measured menstrual

loss by 40% in 75% of patientsloss by 40% in 75% of patients

2.2. Relief dysmenorrhoeaRelief dysmenorrhoea

3.3. Little effect on regularity of Little effect on regularity of

cycle or duration of bleedingcycle or duration of bleeding

Side effectsSide effects::

Mainly mild gastrointestinal Mainly mild gastrointestinal

tract irritationtract irritation

The treatment should start The treatment should start

immediately with the start of immediately with the start of

bleeding.bleeding.

B.B. Antifibrinolytic agentsAntifibrinolytic agents

Mechanism of action: :

Prevent conversion of Prevent conversion of

plasminogen into plasmin which plasminogen into plasmin which

dissolve the fibrin clots dissolve the fibrin clots

occluding the blood vessels.occluding the blood vessels.

Effectiveness:

Reduce measured loss by Reduce measured loss by

40-50%. The effect is dose 40-50%. The effect is dose

related. It should be given related. It should be given

with the start of with the start of

menstruation and continue menstruation and continue

for 3-4 days.for 3-4 days.

Comparative studies suggested Comparative studies suggested

that tranexemic acid is more that tranexemic acid is more

effective than PG synthetase effective than PG synthetase

inhibitors (Milsom et al.1991; inhibitors (Milsom et al.1991;

Bonnar and Shepard 1996).Bonnar and Shepard 1996).

Side effects:

1.1. Mild gastrointestinal tract Mild gastrointestinal tract

irritationirritation

2.2. Serious adverse effect has been Serious adverse effect has been

documenteddocumented (intracranial (intracranial

thrombosis – central venous thrombosis – central venous

stasis retinopathy) but they stasis retinopathy) but they are are

extremely rare.extremely rare.

3. No such complications occurred

in Scandinavia over 19 years

(1st line of treatment there

4. Should not prescribed for

women with history of thrombo-

embolism.

II.II. Hormonal treatmentHormonal treatment::

1.1. Oral contraceptive pillsOral contraceptive pills

One of the most effective treatments One of the most effective treatments

available for both menorrhagia and available for both menorrhagia and

dysmenorrhoeadysmenorrhoea

Can be used safely in women over 40 Can be used safely in women over 40

years if they are of low risk categoryyears if they are of low risk category

Mechanism of action: :

Mainly locally by inducing endometrial Mainly locally by inducing endometrial

atrophy with reduction in both PG synthesis atrophy with reduction in both PG synthesis

and fibrinolysis.and fibrinolysis.

Side effects::

i.i. That of oral contraceptive pills in generalThat of oral contraceptive pills in general

ii.ii. Socially unaccepted in single unmarried Socially unaccepted in single unmarried

women.women.

2.Progestogens

Norethisterone – medroxy-Norethisterone – medroxy-

progesterone acitate.progesterone acitate.

Are the most commonly Are the most commonly

prescribed preparations in UK prescribed preparations in UK

because it was wrongly thought that because it was wrongly thought that

the majority of women with DUB are the majority of women with DUB are

anovulatoryanovulatory

Mechanism of action::

1.1. In anovulatory cycle it induce secretory In anovulatory cycle it induce secretory

changes but in ovulatory cycle it changes but in ovulatory cycle it

produce minimal changesproduce minimal changes

2.2. Norethisterone is given as 5mg t.d.s. for Norethisterone is given as 5mg t.d.s. for

21 days while Provera is given as 10 mg 21 days while Provera is given as 10 mg

for 10-14 days during luteal phase. for 10-14 days during luteal phase.

Effectiveness:

1. If given in high dose for 21 days especially in anovulatory cycle it reduce menstrual loss by 80% (Irvin et al., 1998)

2. In anovulatory cycle it convert irregular, unpredictable bleeding into regular controlled one which is an attractive feature for many women.

Side effects: Side effects:

Usually minimal as abdominal Usually minimal as abdominal

bloating and weight gainbloating and weight gain

Progesterone releasing devicesProgesterone releasing devices

Produce marked reduction in menstrual Produce marked reduction in menstrual

blood loss up to 80%blood loss up to 80%

Mechanism of actionMechanism of action: mainly locally : mainly locally

leading to atrophic endometrium with leading to atrophic endometrium with

very minimal systemic effectvery minimal systemic effect

EffectivenessEffectiveness: Scandinavian study : Scandinavian study

(milson et al.,1991) showed decreased (milson et al.,1991) showed decreased

menstrual loss by 90%.menstrual loss by 90%.

Side effectsSide effects: irregular bleeding is : irregular bleeding is

common especially in the in the early common especially in the in the early

months.months.

DanazolDanazol::

Is an extremely effective drug for Is an extremely effective drug for

treatment of menstrual problems but its treatment of menstrual problems but its

use is limited by its high androgenic use is limited by its high androgenic

side effectsside effects

Gonadotrophin releasing hormone agonistGonadotrophin releasing hormone agonist

Mechanism of actionMechanism of action: produce down : produce down

regulation of pituitary gland that regulation of pituitary gland that

decrease gonadotrophins and ovarian decrease gonadotrophins and ovarian

steroidssteroids

EffectivenessEffectiveness: relief amenorrhoea in : relief amenorrhoea in

90% of cases. Also relief PMS90% of cases. Also relief PMS

Side effectsSide effects: :

Hypo-estrogenic state and osteoporosis Hypo-estrogenic state and osteoporosis

(add estrogen and progesterone if used (add estrogen and progesterone if used

for long period)for long period)

Unless used to prepare the patient for Unless used to prepare the patient for

endometrial ablation it is not accepted endometrial ablation it is not accepted

by most patients for long term.by most patients for long term.

Surgical treatmentSurgical treatmentSuitable for older patients who have no Suitable for older patients who have no

further wish to conceive.further wish to conceive.

I.I.Endometrial ablation/resectionEndometrial ablation/resection

To remove or destroy the endometrium To remove or destroy the endometrium producing changes similar to Asherman’s producing changes similar to Asherman’s syndrome (Laser – electrocautary - roller syndrome (Laser – electrocautary - roller ball - diathermy – microwave- hot ball - diathermy – microwave- hot balloon).balloon).

Advantage over hysterectomyAdvantage over hysterectomy

1.1. Short hospital stay and return to workShort hospital stay and return to work

2.2. 50% of patients were amenorrhoeic, 50% of patients were amenorrhoeic,

30-40% experienced marked reduction 30-40% experienced marked reduction

in menstrual lossin menstrual loss

3.3. 70% or more were satisfied70% or more were satisfied

DisadvantagesDisadvantages::

1.1. Needs experienceNeeds experience

2.2. Recurrence of about 20%Recurrence of about 20%

3.3. Operative complications as perforationOperative complications as perforation

4.4. Post operative painPost operative pain

II.II. HysterectomyHysterectomy

Definitive cure for menorrhagia Definitive cure for menorrhagia (Abdominal, vaginal or laparoscopic) (Abdominal, vaginal or laparoscopic) (total or subtotal)(total or subtotal)

DisadvantagesDisadvantages::

1.1. Mortality of 6/10000 proceduresMortality of 6/10000 procedures

2.2. Injury of ureter, bladder or bowel.Injury of ureter, bladder or bowel.

POSTMENOPAUSAL POSTMENOPAUSAL BLEEDINGBLEEDING

POSTMENOPAUSAL BLEEDINGPOSTMENOPAUSAL BLEEDINGIt is bleeding from the genital tract occurring 6 It is bleeding from the genital tract occurring 6 months or more after cessation of menstruation months or more after cessation of menstruation in a woman above the age of 40.in a woman above the age of 40. It is a serious symptom because in about 25% It is a serious symptom because in about 25% of cases, it is due to a malignant lesion in the of cases, it is due to a malignant lesion in the genital tractgenital tractPrevalencePrevalenceAbout 7 per 1000 postmenopausal women.About 7 per 1000 postmenopausal women.

AetiologyAetiology

((A)A) General CausesGeneral Causes

(1)(1) Oestrogen therapy (25%). Oestrogen given for Oestrogen therapy (25%). Oestrogen given for menopausal symptoms may lead to withdrawal menopausal symptoms may lead to withdrawal bleeding.bleeding.

(2)(2) hypertension.hypertension.

(3)(3) blood diseases as leukemia.blood diseases as leukemia.

(4)(4) anticoagulant therapyanticoagulant therapy..

(B)Local Causes(B)Local CausesVulva. Malignant tumour, fissured leucoplakia, Vulva. Malignant tumour, fissured leucoplakia, urethral caruncle, and direct trauma.urethral caruncle, and direct trauma.Vagina. Malignant tumour, senile vaginitis, Vagina. Malignant tumour, senile vaginitis, trophic ulcer in prolapse, and retained foreign trophic ulcer in prolapse, and retained foreign body or pessary in the vagina.body or pessary in the vagina.Cervix. Malignant tumour, erosion and ulcers.Cervix. Malignant tumour, erosion and ulcers.Uterus. Malignant tumour, senile endometritis, Uterus. Malignant tumour, senile endometritis, tuberculous eiidometritis, fibroidtuberculous eiidometritis, fibroid..

F.tube carcinoma. This leads to a watery F.tube carcinoma. This leads to a watery vaginal discharge which finally becomes vaginal discharge which finally becomes blood stainedblood stained Ovary. Ovary. Carcinoma with metastases in the Carcinoma with metastases in the endometrium and oestrogenic ovarian endometrium and oestrogenic ovarian tumours. tumours. ((C) In about 15% of cases no cause is C) In about 15% of cases no cause is found after physical examination and found after physical examination and uterine curettage which shows atrophic uterine curettage which shows atrophic endometriumendometrium

A.A. HistoryHistoryPersonal historyPersonal history

(a) Age: The commonest age incidence for carcinoma of (a) Age: The commonest age incidence for carcinoma of uterus is 55-70 years while that for carcinoma of the uterus is 55-70 years while that for carcinoma of the vulva is 60-70 years.vulva is 60-70 years.

(b) parity: some tumours are more common among (b) parity: some tumours are more common among nulliparae e.g. endometrial and ovarian carcinoma.nulliparae e.g. endometrial and ovarian carcinoma.Present historyPresent historyAsk about the amount, character and duration of Ask about the amount, character and duration of bleeding, duration of menopause, and the presence of bleeding, duration of menopause, and the presence of other symptoms as pain and foul discharge, urinary and other symptoms as pain and foul discharge, urinary and gastrointestinal symptoms (malignant invasion of bladder gastrointestinal symptoms (malignant invasion of bladder or bowel).or bowel).

DiagnosisDiagnosis

Past historyPast history(a)(a)Oestrogen therapy.Oestrogen therapy.(b)(b) diseases as diabetes mellitus, diseases as diabetes mellitus,

hypertension and blood diseases as hypertension and blood diseases as leukemia.leukemia.

Endometrial carcinoma is more common Endometrial carcinoma is more common in diabetic hypertensive patients.in diabetic hypertensive patients.Family historyFamily history

Carcinoma of the body of the uterus and Carcinoma of the body of the uterus and ovary have a familial tendencyovary have a familial tendency

B.B. General ExaminationGeneral Examination(I) Signs of anaemia.(I) Signs of anaemia.

(2) signs of bleeding disorders.(2) signs of bleeding disorders.

(3) presence of cachexia.(3) presence of cachexia.

(4) examination of heart and chest for (4) examination of heart and chest for secondaries.secondaries.

(5) estimation of blood pressure(5) estimation of blood pressure

C C Abdominal ExaminationAbdominal ExaminationFor a pelvi-abdominal mass and ascites For a pelvi-abdominal mass and ascites

which is common with ovarian malignancy.which is common with ovarian malignancy.

D.Pelvic ExaminationD.Pelvic ExaminationTo detect a local cause for bleeding. The To detect a local cause for bleeding. The

urethra and anal canal are excluded as urethra and anal canal are excluded as being the source of bleeding.being the source of bleeding.

E.E. Special InvestigationsSpecial Investigations1.1. Transvaginal sonography. It excludes the Transvaginal sonography. It excludes the

presence of an ovarian tumour or apresence of an ovarian tumour or alesion in the uterus as endometrial carcinoma.lesion in the uterus as endometrial carcinoma.

2.2. Cervical smear. Taken in absence of bleeding Cervical smear. Taken in absence of bleeding to detect the presence of malignantto detect the presence of malignantcells which may come from the cervix, cells which may come from the cervix, endometrium, tubes, or ovaries.endometrium, tubes, or ovaries.

3.3. Endometrial biopsy. It must be done in every Endometrial biopsy. It must be done in every case of postmenopausal bleeding, ascase of postmenopausal bleeding, asit is the only sure method to exclude it is the only sure method to exclude endometrial carcinoma.endometrial carcinoma.

Endometrial biopsy is taken by one of three methods;Endometrial biopsy is taken by one of three methods;

Fractional uterine curettage,Fractional uterine curettage,

Endometrial aspiration, orEndometrial aspiration, or

HysteroscopyHysteroscopy..

4. 4. Biopsy is taken from any suspected lesion in Biopsy is taken from any suspected lesion in the vulva, vagina, or cervix.the vulva, vagina, or cervix.

5. Laboratory tests. These are done according to 5. Laboratory tests. These are done according to the clinical findings and include:the clinical findings and include:

a.a. Complete blood count.Complete blood count.

b.b. Platelet count, bleeding time, coagulation Platelet count, bleeding time, coagulation time, estimation of clotting factors if a time, estimation of clotting factors if a bleeding disorder is suspected.bleeding disorder is suspected.

TreatmentTreatment

It is treatment of the cause. It is treatment of the cause.

If no cause can be detected the patient If no cause can be detected the patient should be followed up. should be followed up.

If bleeding recurs it is better to do If bleeding recurs it is better to do hysterectomy and bilateral salpingo-hysterectomy and bilateral salpingo-oophorectomy which may reveal a missed oophorectomy which may reveal a missed early carcinoma of uterus or tubeearly carcinoma of uterus or tube..

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