Abnormal uterine bleeding prof jamiyah hassan

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Abnormal uterine bleeding prof jamiyah hassan

  1. 1. Powerpoint Templates Abnormal Uterine Bleeding Jamiyah Hassan UMMC
  2. 2. Powerpoint Templates Page 2  Causes  FIGO Classification of Abnormal Uterine Bleeding (AUB)  Investigations  Management ◦ Medical ◦ Surgical ◦ Interventional
  3. 3. Powerpoint Templates Page 3  Uterine fibroids  DUB  Adenomyosis/endometriosis  Uterine hyperplasia  Uterine malignancies  Genital infections  Coagulation disorders  Idiopathic  Polyps
  4. 4. Powerpoint Templates Page 4  Term “DUB” discarded  Menorrhagia replaced with heavy menstrual bleeding
  5. 5. Powerpoint Templates Page 5 New Classification of abnormal menstrual bleeding 2009
  6. 6. Powerpoint Templates Page 6
  7. 7. Powerpoint Templates Page 7 Notation. A. In all cases, the presence or absence of each criterion is noted using “0” if absent, “1” if present, and “?” if not yet assessed. Each of the cases shown has 1 abnormality identified. From the top: at least one submucosal leiomyoma (LSM); adenomyosis (A)—focal and/or diffuse; endometrial polyps (P); and an absence of any abnormality, leaving endometrial causes (E) as a diagnosis of exclusion. B. Each of the cases shown has more than 1 positive category. From the top: submucosal leiomyoma and atypical endometrial hyperplasia (M), as diagnosed by endometrial sampling; endometrial polyps and adenomyosis; endometrial polyps and subserosal leiomyoma (LO); and adenomyosis, subserosal leiomyoma and coagulopathy (C), as determined by positive screening test and subsequent biochemical confirmation of von Willebrand dis
  8. 8. Powerpoint Templates Page 8
  9. 9. Powerpoint Templates Page 9
  10. 10. Powerpoint Templates Page 10  General assessment ◦ Full blood count  Determine ovulatory status ◦ Detail structured history ◦ Progesterone assessment mid luteal  Screening for systemic hemostasis ◦ Bleeding disorders ◦ Von Willebrand factor  Evaluation endometrium ◦ Adequate endometrial sampling  Evaluation endometrial cavity ◦ Transvaginal ultrasound
  11. 11. Powerpoint Templates Page 11  Blood tests ◦ FBC, thyroid, coagulation abnormalities  Pap test  Endometrial biopsy  Ultrasound scan
  12. 12. Powerpoint Templates Page 12  Exclusion of malignant causes is vital i.e. endometrial cancer or hyperplasia.  Benign organic causes of menorrhagia include endometrial polyps and sub mucous fibroids.
  13. 13. Powerpoint Templates Page 13 People with risk factors for endometrial cancer or hyperplasia. The following were found to be independently associated. 1. Obesity(>90kg); 2. Infertility 3. Nulliparity; 4. Age >45 yrs; ( At 40 yrs 5/100,000, 45 yrs 13/100000, 55 yrs 32/100000) 5. Family history of colon cancer
  14. 14. Powerpoint Templates Page 14  D&C is not performed as an initial work up. Should be performed in conjunction with hysteroscopy to evaluate endometrial cavity.  Pipelle endometrial biopsy appears at least as accurate as D&C, has high levels of patient acceptability, lower complication rates and do not require inpatient admission or GA.
  15. 15. Powerpoint Templates Page 15
  16. 16. Powerpoint Templates Page 16
  17. 17. Powerpoint Templates Page 17
  18. 18. Powerpoint Templates Page 18  No tissue found ◦ Most likely endometrium is atrophic and requires estrogen  Simple proliferative ◦ This is normal and does not require treatment  Endometrial hyperplasia ◦ Except atypical adenomatous requires progestins regimens ◦ Atypical adenomatous hyperplasia, hysterectomy advised  Endometrial carcinoma ◦ Refer onco team
  19. 19. Powerpoint Templates Page 19
  20. 20. Powerpoint Templates Page 20  Overall health and the medical history  Cause and severity of condition  Tolerance of medications  Future childbearing plans  Effect of condition on lifestyle
  21. 21. Powerpoint Templates Page 21  Iron supplements  Nonsteroidal anti-indflammatory drugs(NSAIDs)  Transnexamic acid  Oral contraceptives  Oral progestogen  Hormonal IUS (Mirena)  Danazol  GNRH
  22. 22. Powerpoint Templates Page 22  MIRENA – now is first line medical therapy
  23. 23. Powerpoint Templates Page 23 Days of cycle Ovulation Ovulation Menstruation
  24. 24. Powerpoint Templates Page 24  Bleeding patterns of LNG-containing intrauterine systems (Mirena®): -3 -2 -1 1 2 3 4 5 6 7 8 9 10 11  In the first 3-6 months irregular bleeding and spotting  shorter, lighter and less painful periods  about 20% of women may have no bleeding after 1 year
  25. 25. Powerpoint Templates Page 25 Mirena effectively reduces menstrual blood loss (MBL) 0 50 100 150 200 Before insertion 3 6 12 Months of Mirena use MedianMBL(mL) * * * * p<0.001 ─86% ─97%─91% % Reduction (80mL MBL = menorrhagia) Andersson JK, Rybo G. Levonorgestrel-releasing intrauterine device in the treatment of menorrhagia. Br J Obstet Gynaecol. 1990; 97: 690-4
  26. 26. Powerpoint Templates Page 26 126 128 130 132 134 136 138 140 0 1 2 3 4 5 6 7 8 9 10 11 12 Months of Mirena use Meanserum haemoglobin(g/L) **p<0.001# ##p<0.01
  27. 27. Powerpoint Templates Page 27 IUS 0 10 20 30 40 50 60 70 80 90 100 Mirena Control Proportionofwomen(%) *p<0.001; between groups . Lähteenmäki P, Haukkamaa M, Puolakka J, et al. Open randomised study of use of levonorgestrel releasing intrauterine system as an alternative to hysterectomy. BMJ 1998; 316: 1122-6
  28. 28. Powerpoint Templates Page 28  Compared to endometrial ablation ◦ Slightly less mean reduction of blood loss but equal patient satisfaction ◦ Similarly equal satisfaction to hysterectomy ◦ Higher continuation rate ◦ More cost effective ◦ Should be considered in women who failed medical therapy ◦ Added advantage of reliable contraception ◦ Risk of expulsion 10-20% ◦ Need trained staff for insertion
  29. 29. Powerpoint Templates Page 29  TCRE  Roller-ball  Laser  Thermal balloon  Heated free fluid  Cryoablation  Microwave endometrial ablation (MEA)  Radiofrequency electricity (NovaSure)
  30. 30. Powerpoint Templates Page 30  Better mean reduction of blood loss  Longer learning curve  Higher complication rate  Consider childbearing plan
  31. 31. Powerpoint Templates Page 31  Hysterectomy ◦ Vaginal ◦ Abdominal ◦ Laparoscopic  Myomectomy
  32. 32. Powerpoint Templates Page 32  Hysterectomy ◦ Provides definitive cure ◦ More expensive ◦ O.1 -1.1 cases of mortality per 1000 procedures ◦ Morbidity rate up to 40%
  33. 33. Powerpoint Templates Page 33
  34. 34. Powerpoint Templates Page 34 Percutaneous femoral artery puncture with selective catheterisation of each uterine artery in turn
  35. 35. Powerpoint Templates Page 35 Small vessels are accessed using a microcatheter Once the catheter is in place, PVA particles are introduced until the blood flow stopped
  36. 36. Powerpoint Templates Page 36

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