PERI-AND,POSTMENOPAUSAL UTERINE BLEEDING ‘PMB

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PERI-AND,POSTMENOPAUSAL UTERINE BLEEDING ‘PMB

  1. 1. www.doctor.sd
  2. 2.  Normal menstrual bleeding: Cyclic menses every 21-35 days, lasting less than 8 days with 20-80 ml blood loss.  Menopause: cessation of menses for 12 months due to ovarian follicle inactivity.  Average age = 50 [range 43 – 57].  Perimenopause:period before menopause and one year after menopause.  Abnormal uterine bleeding: excessive in amount, duration or frequency. www.doctor.sd
  3. 3.  INCIDENCE:13:1000 at 50 yrs to 2:1000 at 80 yrs of age.  Risk of Ca endometrium: rises from 1% at age 50, to 25% at age 80 years.  AETIOLOGY: Organic – a)reproductive tract disease, b)systemic disease, c)trauma d)pharmacologic alterations. Nonorganic – dysfunctional ‘DUB’, by exclusion of organic causes ; a)ovulatory, b)anovulatory www.doctor.sd
  4. 4. S Y S T E M I C L O C A L Bleeding disorders Exogenous oestrogens Endogenous oestrogens Benign Malignant / premalignant +Coagulo- pathy[vwd, itp,leuka] +Endocrin opathy[hyp othyrod.,h yperprol]. +Liver f. +HRT +Ginseng +Peripheral conversion of androstenedn +E2 producing tumours. +End.polyps Endometritis. +Cx polyps cervicitis cx trauma. +Atrophic vaginitis Vaginal trauma Vag inflamation Vaginal polyps. +Vulval dystrophy Vulval dermatitis Vulval trauma. +F.tube Ca +Leiomyosarcoma +End.Ca +End.hyperplasia +Cervical Ca +Vaginal Ca +Vulval Ca +Sec. tumours. www.doctor.sd
  5. 5. [I] HISTORY: 1)AGE: Risk of end.Ca = 5% at < 50 yrs 33% at > 70 yrs 2)RISK FACTORS: 80% --- Early menarche ( < 10 yrs ) 40-45% --- a) Late menopause (> 55 yrs ) b) Nulliparity c) Unopposed oestrogens 30-40% --- a) Bleeding; moderate or severe b) Obesity c) Hypertension d) Liver disease < 30% --- Persistent / recurrent bleeding 3)NUMBER OF RISK FACTORS: a) None = 2.5% ; b) Two = 20% ; c) Four = 85% [II] EXAMINATION: a) General b) Vaginal c) Cervical cytology ( Ca cx in 30% ) d) Colposcopy. www.doctor.sd
  6. 6.  The aim is to exclude : a) Endometrial carcinoma b) Atypical hyperplasia.  Methods : Outpatient ; 1) End.sampling 2) Hysteroscopy + End.biopsy 3) TVS ( End. Thickness ) 4) Sonohysteroscopy. Inpatient ; I] D & C II] Dilatation & Fractional curettage III] Hysteroscopy & curettage IV] Hysteroscopy + End.biopsy www.doctor.sd
  7. 7.  Continue investigations ;  Methods’evaluation : A) D & C ; (1)Expensive,(2)Associated with complications,(3)Inaccurate & may miss diagnosis. B) End.Sampling;(1)Vabra aspirator--better than D&C but samples 40% of surface.(2) Pipelle; better tolerated,samples 4% of surface,detection rate=90% (3)Novak curette; DR = 85-95%. C) Hysteroscopy +Sampling; Using rigid and flexible instruments.Possible complications are; [a] water intoxication, [b] pulmonary oedema, [c] Air embolism [d]Anaphylaxis, [e] Neoplastic implantation--??. D) Ultrasound; TVS is more reliable than TAS. Cut- offs are different ethnically = 3,4 or 5mm are used. Sensitivity is 80% at cut-off 5mm of endometrial thickness. E) Others; [1] MRI : high degree of sensitivity, low specificity, detects myometrial invasion, but costly. [2] Tumour m. www.doctor.sd
  8. 8.  {A} Observation & follow-up: 3-6 monthly, using TVS,TAS or SHG. Tissue sampling is occasionally needed.  {B} Medical: In typical end.hyperplasia – cyclic monthly progestins or COCs for 3-6 m.  {C} Minimal access techniques: In DUB – using different ablative techniques; 1]Hysteroscopic TCRE + ELA 2]MEA + Thermal Balloon Ablation; best evaluated. 3]Others: HTA(hydrothermal ablation), Cryo- ablation.Photodynamic therapy(PDT) and Levonorgestrel Intrauterine System(LNG-IUS).  {D} Surgical: In atypical end.hyperplasia – Hysterectomy is needed as 25% will progress to Ca end. Continuous progestins are used in few cases for 6 months with tissue sampling every 3-6 months. www.doctor.sd

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