dub (uterine bleeding)

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  • 1.Abnormaluterine bleeding Prof. Aboubakr Elnashar Benha University Hospital, Egypt E-mail: elnashar53@hotmail.com

2. DEFINE Any deviation in normal frequency, duration or amount of menstruation in women of reproductive age. NORMAL MENSES Frequency:21-35 d Duration:3-7 d Volume:30-80 ml 3. CLINICAL TYPES Polymenorrhoea:frequent (80 ml) & / or prolonged menstruation, at regular intervals Metrorrhagia: Excessive (>80 ml) & / or prolonged menstruation at irregular intervals. Menometrorrhagia: both. Intermenstual bleeding:episodes of uterine bleeding between regular menstruations Hypomenorrhoea: scanty menstruation. Oligomenorrhoea: infrequent menstruation (>35 d) 4.

  • CAUSES
      • .Dysfunctional uterine bleeding
      • .Pregnancy complications:
      • Abortion, Ectopic pregnancy, Trophoblastic disease
      • .Genital disease:
      • .Tumors:
      • Benign: fibroid, polyps (cervical, endometrial, fibroid)
  • Malignant: cervical, endometrial, ovarian(estrogen secreting)
      • .Infection: PID
      • .Endometriosis ,adenomyosis
      • .IUCD
      • .Marked uterovaginalprolapseorretroversion

5.

      • .Extragenital:
      • .Endocrine :hypo- or hyperthyroidism
      • .Haematological: Idiopathic thrombocytopenic purpura, Von-Willebrand disease
      • .Chronic systemic disease:liver failure, renal failure, hypertension with uterine artery atherosclerosis.
      • .Iatrogenic: Sex hormones, anticoagulants.
      • .Emotional:(change of country, climate & work; stress; psychosomatic disorders)
      • .Obesity: [increased peripheral estrogen conversion]

6.

      • Dysfunctional uterine bleeding
  • Define
    • Abnormal uterine bleeding in absence of pelvic organ disease or a systemic disorder
      • Incidence
  • 60 % of AUB

7. PathologyEndocrine abnormality Endometrium Anovulatory 90% Insufficient folliclesInadequate proliferative or atrophic Persistent follicles Proliferative or hyperplastic Ovulatory 10% Short proliferative phaseNormal Long proliferative phaseNormal Insufficient C. luteumIrregular or deficient secretory leading to short luteal phase Persistent C luteum leading toIrregular shedding long luteal phase 8. 9.

  • Risk of endometrial cancer
  • Chronic anovulationhas 3 times increased risk (Coulam,1989). Chronic proliferation of the endometrium leading to adenomatous hyperplasia, leading to atypical adenomatous hyperplasia, leading to endometrial carcinoma.Transitioncan take up to 10 yrs or more.

10.

      • Diagnosis
  • Aim:
  • 1. Nature & severity of bleeding
  • 2. Exclusion of organic causes
  • 3. Ovulatory or anovulatory
  • How:

11. I. History: 1. Personal:age, wishes of the patient 2. Menstrual 3. Obstetric 4. Past 5. Present:amount, duration, color, smell, relation to sexual intercourse, associated symptoms 12. II. Examination: 1. General: pallor, endocrinopathy, coagulopathy, pregnancy 2. Abdominal: liver, spleen, pelvic abdominal mass 3. Pelvic: origin of the bleeding, cause 13.

          • III.Investigations
  • Systemic:
  • 1. CBC (for all, Grade A)
  • 2. BHCG
  • 3. Prolactin & TSH
  • 4. Prothrombin time, partial thromboplastin time, bleeding time, platelets, Von Willebrand factor

14. Local: 1. Pap smear 2. Endometrial biopsy 3. D & C 4. Hysteroscopy 5. U/S 15. 16. Assessment of the amount of the bleeding: 50% of excessive menstruation have normal amount of blood loss by objective methods 1.Subjective methods: history of passage of clots, flooding, use of large number of pads, do not reflect the actual blood loss 2.Semiobjective: i.Iron deficiency anemia ii.Menstrual calendar (August,1996)III. Pictorial blood loss chart (Higham,1990) : 17. Menstrual calender (August,1996) Saturday 7 14 21 28 Sunday 1 8 15 22 29 Monday2 9 16 23 30 Tuesday 3 10 17 24 31 Wednesday 4 11 18 25 Thursday 5 12 19 26 Friday 6 13 20 27 .Spotting -Slight loss O Moderate loss Very heavy loss 18. Pictorial blood loss chart: (Higham,1990) Days of the bleedingScore 12345678 Towel1 point 5 points 10 points Clots1p clot1 point 5p clot5 points Flooding 5 points Score >100 = Menorrrhagia 19. Endometrial biopsy: Indications: .Between 20 & 40 .If endometrial thickness on TVS is >12mm, endometrial sample should be taken to exclude endometrial hyperplasia (Grade A).Failure to obtain sufficient sample for H/P does not require further investigation unless the endometrial thickness is >12 mm (Grade B) Aim: diagnosis of the type of the bleeding 20. Methods:As an outpatient procedure, without general anesthesia. 1.Pipelle curette 2.Sharman curette, Gravlee jet washer, Isac cell sampler 3.Accrette 4.vabra aspirator Advantages:An adequate & acceptable screening procedure in females under 40 yrs 21. 22. D & C: Indications: 1. Mandatory after 40 yrs2. Persistent or recurrent bleeding between 20 & 40 yrs Aim: 1.Diagnosis of organic disease e.g. endometritis, polyp, carcinoma, TB, fibroid 2.Diagnosis of the type of the endometrium: hyperplastic, proliferative, secretory, irregular ripening, shedding, atrophic. This provides a guide to etiology & treatment 23. 3.Arrest of the bleeding, if the bleeding is severe or persistent, particularly hyperplastic endometrium.Curettage is essentially a diagnostic & not a therapeutic procedure. Disadvantages: 1.Small lesions can be missed 2.The sensitivity of detecting intrauterine pathology is only 65% 24. Fractional curretage: Indication:>40 yrs Method:3 samples: endocervical, lower segment & upper segment 25. Hysteroscopy: Indications: Mandatory after 40 yrs 1. Erratic menstrual bleeding 2. Failed medical treatment 3. TVS suggestive of intrauterine pathology e.g. polyp, fibroid (Grade B) 26. Aim: 1.Excellent view of the uterine cavity & diagnosis of polyps, submucous fibroid, hyperplasia. 2.Biopsy of the suspected areas 3.Treatment 27. Advantages over D &C 1.The whole uterine cavity can be visualized2.Very smalllesions such as polyps can be identified & biopsed or removed 3.Bleeding from ruptured venules & echymoses can be readily identified 4.The sensitivity in detecting intrauterine pathology is 98% (Loffer,1989) 5.Outpatient procedure 28. Disadvantages: 1.Cost of the apparatus 2.Lack of availability or experience 29. Ultrasonography: 1. TAS:can exclude pelvic masses, pregnancy complications 2. TVS:More informative than TAS. Measurement of the endometrial thickness is not a replacement for biopsy. All endometrial carcinoma in postmenopausal with endometrial thickness>4 mm (Osmers,1990) 3. Saline sonography:an alternative to office hysteroscopy in selected cases. It is better tolerated than office hysteroscopy or HSG 30. TVS is recommended in: 1. Weight >90 Kg 2. Age > 40 yrs 3. Other risk factors for endometrial hyperplasia or carcinoma e.g. infertility, nulliparity, family history of colon or endometrial cancer, exposure to unopposed estrogen (Grade B) 31.

      • Treatment
      • A. General
  • 1. Menstrual calendar
  • 2. Treatment of iron deficiency anemia

32.

          • B. Medical
  • I. Hormonal:
  • 1.Progestagen
  • 2.Oestrogen
  • 3.COCP
  • 4.Danazol
  • 5.GnRh agonist
  • 6.Levo-nova (Merina)
  • II. Non hormonal
  • 1.Prostaglandin synthetase inhibitors (PSI)
  • 2.Antifibrinolytics
  • 3.Ethamsylate

33.

          • C. Surgical
  • 1. Endometrial ablation
  • 2. Hysterectomy

34. Strategy of treatment 40 yrs MedicalAlways First resort after endometrial biopsy Temporizing & ifsurgery is refused orimminent menopause SurgicalNever Seldom, only if medical treatment fail First resort if bleedingis recurrent 35. Medical treatment: Antifibrinolytics Mechanism of action: The endometrium possess an active fibrinolytic system, & the fibrinolytic activity is higher in menorrhagia.Effect: Greater reduction of menstrual bleeding than other therapies (PSI, oral luteal phase progestagen & etamsylate)(Cochrane library,2002).Tranexamic acid is effective in treating menorrhagia associated with IUCD. 36. Side effects:is dose related.Nausea , vomiting, diarrhea, dizziness. Rarely: trans