Abnormal Uterine Bleeding -Update

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  • 1. Abnormal Uterine Bleeding inReproductive Age“Evidence Based Management “Dr Hassan A Nasrat FRCS, FRCOGProfessor of Obstetrics and GynecologyFaculty of MedicineKing Abdelaziz University1Tuesday, June 18, 13
  • 2. The Jeddah Ultrasound Club ForObstetrics and Gynecology“JUCOG”On “LinkedIn”2Tuesday, June 18, 13
  • 3. Vision:Ultrasound skill is the backbone of safe and professionalpractice of Obstetrics and Gynecology. But proper utilizationand understanding of its application must be wellappreciated.Aminimumstandardof skillisamustforeveryObstetricianandGynecologist.Mission:To disseminate knowledge and promote interest in theproper use and application of sonography in Obstetrics andGynecology.“JUCOG”3Tuesday, June 18, 13
  • 4. The Normal Menstruation ....Abnormal Uterine Bleeding“AUB” Types and Terminology.Causes of AUBWork up in AUBManagement of AUB-o4Tuesday, June 18, 13
  • 5. NORMAL MENSTRUALCYCLE D1 D28:D1Normal RegularityNormal FrequencyNormal VolumeNormal DurationNormal Menstrual Cycle and MenstruationMBL/MlTotal MBL=37Total MBL=415Tuesday, June 18, 13
  • 6. NORMAL MENSTRUALCYCLE D1 D28:D1Normal RegularityNormal FrequencyNormal VolumeNormal DurationNormal Menstrual Cycle and MenstruationMBL/MlTotal MBL=37Total MBL=41Regular5Tuesday, June 18, 13
  • 7. NORMAL MENSTRUALCYCLE D1 D28:D1Normal RegularityNormal FrequencyNormal VolumeNormal DurationNormal Menstrual Cycle and MenstruationMBL/MlTotal MBL=37Total MBL=41Frequency28 days(24-35 days)Regular5Tuesday, June 18, 13
  • 8. NORMAL MENSTRUALCYCLE D1 D28:D1Normal RegularityNormal FrequencyNormal VolumeNormal DurationNormal Menstrual Cycle and MenstruationMBL/MlTotal MBL=37Total MBL=41Volume30-40 mL.(Range 10-80 mL)Frequency28 days(24-35 days)Regular5Tuesday, June 18, 13
  • 9. NORMAL MENSTRUALCYCLE D1 D28:D1Normal RegularityNormal FrequencyNormal VolumeNormal DurationNormal Menstrual Cycle and MenstruationMBL/MlTotal MBL=37Total MBL=41Volume30-40 mL.(Range 10-80 mL)Frequency28 days(24-35 days)Duration(5-7 days)Regular5Tuesday, June 18, 13
  • 10. Hypothalamic-Pituitary-Ovarian AxisAnd Control of Menstrual Cycle6Tuesday, June 18, 13
  • 11. Cycle variability 5-7years after menarcheLittle Variabilitybetween 20 and 40years of agecycle variability for the10 years beforeMenopause50 % anovulatory.Mean Length 34 days,38 % exceed 40 days7 percent occurring < 20 daysWHO ReportNormal Cycle Variablity7Tuesday, June 18, 13
  • 12. Establishment of regular ovulatory cycles and age ofmenarcheWHO ReportCycle Regularity<12 yearsAge at Menarche12- 13years>13 years50% byoneyearOvulatory Cycles50% by3 years50% by4.5 years8Tuesday, June 18, 13
  • 13. 25 % Of Women WithNormal Periods ConsideredTheir Blood Loss Excessive.40 % With ExcessiveB l e e d i n g ( > 8 0 M L )Described Their Periods AsLight Or Moderate.Estimation of MB Loss9Tuesday, June 18, 13
  • 14. Abnormal Uterine Bleeding“AUB”Types and Terminology .....10Tuesday, June 18, 13
  • 15. For Women: 1/3 Of Outpatient Visits To TheGynecologist.For Gynecologists: > 70% Of All GynecologicConsults.Abnormal Uterein Bleeding“AUB”Epidemiology11Tuesday, June 18, 13
  • 16. APGO educational series on womens health issues. Clinical management of abnormal uterine bleeding. Association of Professors of Gynecologyand Obstetrics, 2006.What Is Abnormal UtereinBleeding “AUB”?12Tuesday, June 18, 13
  • 17. APGO educational series on womens health issues. Clinical management of abnormal uterine bleeding. Association of Professors of Gynecologyand Obstetrics, 2006.What Is Abnormal UtereinBleeding “AUB”?Abnormal Uterine Bleeding Can Occur When AWoman Experiences:A Change In Her Menstrual LossOrDevelop Vaginal Bleeding Pattern (Regularity,Frequency, Volume, Duration) Differs FromThat Experienced By The Age- Matched GeneralFemale Population.12Tuesday, June 18, 13
  • 18. Disturbances ofRegularityInfrequent MenstrualBleedingOne or two episodes in a 90days period.Frequent menstrualbleeding> 4 episodes in a 90 days(including erraticintermenstrual bleeding)Oligomenorrhea Polymenorrhea13Tuesday, June 18, 13
  • 19. Disturbances ofRegularityInfrequent MenstrualBleedingOne or two episodes in a 90days period.Frequent menstrualbleeding> 4 episodes in a 90 days(including erraticintermenstrual bleeding)13Tuesday, June 18, 13
  • 20. Irregular Non-Menstrual Bleeding•Premenstrual and postmenstrual spotting (or staining):•Intermenstrual bleeding:Normal RegularityNormal FrequencyNormal VolumeNormal DurationInter-menstrual bleedingD1 D28:D1Total MBL=39 mlTotal MBL=8 mlTotal MBL=6 mlTotal MBL=39 mlTotal MBL=7 mlMetrorrhagia14Tuesday, June 18, 13
  • 21. Irregular Non-Menstrual Bleeding•Premenstrual and postmenstrual spotting (or staining):•Intermenstrual bleeding:Normal RegularityNormal FrequencyNormal VolumeNormal DurationInter-menstrual bleedingD1 D28:D1Total MBL=39 mlTotal MBL=8 mlTotal MBL=6 mlTotal MBL=39 mlTotal MBL=7 ml14Tuesday, June 18, 13
  • 22. Disturbances of Heaviness ofFlowHeavy MenstrualBleeding (HMB)HOMB is less common and may have different etiologies andtherapeutic modalities than HMBHeavy and ProlongedMenstrual Bleeding(HPMB)LightR a r e l ypathological,usually a culturalcomplaint IHeavyHeavy, Regular ± Prolonged Normal RegularityNormal FrequencyNormal VolumeNormal DurationTotal MBL=106 mlTotal MBL=110 mlD1 D28:D1MenorrhagiaMenorrhagia15Tuesday, June 18, 13
  • 23. Disturbances of Heaviness ofFlowHeavy MenstrualBleeding (HMB)HOMB is less common and may have different etiologies andtherapeutic modalities than HMBHeavy and ProlongedMenstrual Bleeding(HPMB)LightR a r e l ypathological,usually a culturalcomplaint IHeavyHeavy, Regular ± Prolonged Normal RegularityNormal FrequencyNormal VolumeNormal DurationTotal MBL=106 mlTotal MBL=110 mlD1 D28:D1Menorrhagia15Tuesday, June 18, 13
  • 24. Disturbances Of DurationOf FlowProlongedMenstrualBleedingShortenedMenstrualBleeding"Menstrual Periods ThatExceed 8 Days In DurationOn A Regular Basis.""Menstrual Bleeding Of NoLonger Than 2 Days InDuration. The Bleeding IsAlso Usually Light InVolume And Is UncommonlyAssociated With SeriousP a t h o l o g y ( s u c h A sIntrauterine Adhesions AndEndometrial Tuberculosis"16Tuesday, June 18, 13
  • 25. AUBCauses .....17Tuesday, June 18, 13
  • 26. APGO educational series on womens health issues. Clinical management of abnormal uterine bleeding. Association of Professorsof Gynecology and Obstetrics, 2006.Abnormal uterine bleeding (AUB)✴Genital Tract Diseases.✴Non-genital Tract Diseases.✴Systemic Disorders.✴Medications.18Tuesday, June 18, 13
  • 27. NeonatePremenarchalEarly-PostmenarchalReproductiveYearsPerimenopausalMenopausaUsual Causes ofAUB by Throughoutwomen life19Tuesday, June 18, 13
  • 28. NeonatePremenarchalEarly-PostmenarchalReproductiveYearsPerimenopausalMenopausaEstrogenwithdrawalForeign BodyTrauma (sexual abuse)InfectionUrethral prolapseSarcoma botryoidesOvarian TumorPrecocious PubertyAnovulationBleeding DiathesisStress (psychogenic,exercise induced)PregnancyInfectionAnovulationPregnancyCancerPolyps, fibroids, adenomyosisInfectionEndocrine Dysfunction(PCO, Thyroid, Pituitary)Bleeding diathesisMedication (eg,Contraceptive agents)AnovulationPolyps, fibroids,adenomyosisCancerUsual Causes ofAUB by Throughoutwomen life19Tuesday, June 18, 13
  • 29. NeonatePremenarchalEarly-PostmenarchalReproductiveYearsPerimenopausalMenopausaEstrogenwithdrawalForeign BodyTrauma (sexual abuse)InfectionUrethral prolapseSarcoma botryoidesOvarian TumorPrecocious PubertyAnovulationBleeding DiathesisStress (psychogenic,exercise induced)PregnancyInfectionAnovulationPregnancyCancerPolyps, fibroids, adenomyosisInfectionEndocrine Dysfunction(PCO, Thyroid, Pituitary)Bleeding diathesisMedication (eg,Contraceptive agents)AnovulationPolyps, fibroids,adenomyosisCancerAtrophyCancerHRTUsual Causes ofAUB by Throughoutwomen life19Tuesday, June 18, 13
  • 30. AUBPALMStructural CausesPolyp(AUB-P)Adenomyosis(AUB-A)Leiomyoma(AUB-L)Malignancy &hypreplasia(AUB-M)Smucosal(AUB-Lsm)Others(AUB-Lo)COEINNonstructural CausesCoagulopathy(AUB-C)Ovulatory Dysfunction(AUB-O)Endometrial(AUB-E)Iatrogenic(AUB-I)Not yet classified(AUB-N)June 7, 2011 — (FIGO)20Tuesday, June 18, 13
  • 31. AUBPALMStructural CausesPolyp(AUB-P)Adenomyosis(AUB-A)Leiomyoma(AUB-L)Malignancy &hypreplasia(AUB-M)Smucosal(AUB-Lsm)Others(AUB-Lo)COEINNonstructural CausesCoagulopathy(AUB-C)Ovulatory Dysfunction(AUB-O)Endometrial(AUB-E)Iatrogenic(AUB-I)Not yet classified(AUB-N)June 7, 2011 — (FIGO)20Tuesday, June 18, 13
  • 32. AUBPALMStructural CausesPolyp(AUB-P)Adenomyosis(AUB-A)Leiomyoma(AUB-L)Malignancy &hypreplasia(AUB-M)Smucosal(AUB-Lsm)Others(AUB-Lo)COEINNonstructural CausesCoagulopathy(AUB-C)Ovulatory Dysfunction(AUB-O)Endometrial(AUB-E)Iatrogenic(AUB-I)Not yet classified(AUB-N)June 7, 2011 — (FIGO)DysfunctionalUterine BleedingDUB20Tuesday, June 18, 13
  • 33. Dysfunction Uterine Bleeding“Coagulopathy, Ovulatory, andEndometiral (AUB)”A Spectrum Of Disorders, Can Be Associated WithAmenorrhea, Heavy Menstrual Bleeding Or IrregularBleeding.Ovulatory (AUB-O)Condition of Edocrinopathy e.g.PCO, adolescent and menopausaltransitionEndometiral Disorders(AUD-E)(Diagnosed After Exclusion OfOther Abnormalities In ThePresence Of Normal OvulatoryFunction)• E.g. Abnormal Prostaglandin Synthesis• Receptor Upregulation,• Increased Local Fibrinolytic Activity• Increased Tissue Plasminogen ActivatorActivity.Coagulopathy(AUB-C)Occur in 13% of womenwith heavy menstrualbleeding21Tuesday, June 18, 13
  • 34. Anovulatroy DysfunctionalUterine Bleeding (DUB)Noncyclic Endometrial Bleeding Unrelated ToAnatomical Lesions Of The Uterus Or ToSystemic Disease22Tuesday, June 18, 13
  • 35. Anovulatroy DysfunctionalUterine Bleeding (DUB)Noncyclic Endometrial Bleeding Unrelated ToAnatomical Lesions Of The Uterus Or ToSystemic DiseaseDiagnosed ByExclusion22Tuesday, June 18, 13
  • 36. Dysfunctional UterineBleeding (DUB)Epidemiology20% inAdolescence50%inPremenopausal40-50Years23Tuesday, June 18, 13
  • 37. Dysfunctional UterineBleeding (DUB)Epidemiology20% inAdolescence50%inPremenopausal40-50Years23Tuesday, June 18, 13
  • 38. Failure of LHSurge in Responseto E2 ProductionEndometiralProliferation underE2 LevelThe CL is notFormed andProgesterone levelremains lowIrregularEndometrialSheddingProlonged and Heavy Bleeding“E2 BreakthroughBleeding”Decline in OvarianFollicular FunctionVariable Level ofE2Variable Degree ofBleeding“Light or Heavy” E2Withdrowal bleeding”Climacteric AdolescenePathophysiology Of DUB24Tuesday, June 18, 13
  • 39. Chronic Stimulation ByHigher Levels Of E2Lead To Episodes OfHeavy BleedingNon-cycling E2 SecretionEndometrial Proliferation Without Periodic Shedding.The Endometrium Outgrow Its Blood Supply.Tissue Breaks Down With Irregular Healing.Chronic Stimulation ByLow Levels Of E2 ResultIn Infrequent LightBleedingAnovualtory AUBClinical Presentation25Tuesday, June 18, 13
  • 40. Morbidity and Mortiality“DUB”Iron deficiency anemia: occur in 30% of cases. Adolescents areparticularly vulnerable. Up to 20% of patients in this age group presenting withmenorrhagia might have a disorder of hemostasis.Endometrial adenocarcinoma: About 1-2% of women withimproperly managed anovulatory bleeding eventually might develop endometrial cancer.Infertility:associated with chronic anovulation, with or without excess androgenproduction.Patients (e.g. PCO, older age, Obese..etc areparticularly at risk.26Tuesday, June 18, 13
  • 41. AUBWork-up .....27Tuesday, June 18, 13
  • 42. Chronic AUB3+months of excessiveduration, volume,frequency, unpredictableNo Not ChronicYesExamination+InitialInvestigationsAncillaryInvestigationsStructuralHistory28Tuesday, June 18, 13
  • 43. Examination+InitialInvestigationsAncillaryInvestigationsStructuralHistoryChronic AUB•Menstrual history: Menarche,Frequency, duration, severity, regularityDuration of current problem•Associated Symptoms:•Medical History:•Medications:•Family history:•Social Factors:•Systemic Review:29Tuesday, June 18, 13
  • 44. Examination+InitialInvestigationsAncillaryInvestigationsStructuralHistoryChronic AUB•Menstrual history: Menarche,Frequency, duration, severity, regularityDuration of current problem•Associated Symptoms:•Medical History:•Medications:•Family history:•Social Factors:•Systemic Review:bleeding disorders, PCO,age of menarche in motherand sisters .29Tuesday, June 18, 13
  • 45. Examination+InitialInvestigationsAncillaryInvestigationsStructuralHistoryChronic AUB•Menstrual history: Menarche,Frequency, duration, severity, regularityDuration of current problem•Associated Symptoms:•Medical History:•Medications:•Family history:•Social Factors:•Systemic Review:social stressors, weightchange, athleticcompetition, substance use.bleeding disorders, PCO,age of menarche in motherand sisters .29Tuesday, June 18, 13
  • 46. Examination+InitialInvestigationsAncillaryInvestigationsStructuralHistoryChronic AUB•Menstrual history: Menarche,Frequency, duration, severity, regularityDuration of current problem•Associated Symptoms:•Medical History:•Medications:•Family history:•Social Factors:•Systemic Review:social stressors, weightchange, athleticcompetition, substance use.bleeding disorders, PCO,age of menarche in motherand sisters .hirsutism, acne, visualchanges, and headaches,bleeding from other sites,symptoms of acute or chronicanemia.29Tuesday, June 18, 13
  • 47. Examination+InitialInvestigationsAncillaryInvestigationsStructuralHistoryChronic AUB30Tuesday, June 18, 13
  • 48. Examination+InitialInvestigationsAncillaryInvestigationsStructuralHistoryChronic AUBGeneralExaminationHt., Wt. And Arm Spam.Body type and Fat distributionVital sings.Thyroid examinationSings of androgen excess.Optic Fundi and visual fieldsTanner staging of breasts andGalactorrheaAcanthosis nigricansSing of abnormal bleedingAbdomen for masses30Tuesday, June 18, 13
  • 49. Examination+InitialInvestigationsAncillaryInvestigationsStructuralHistoryChronic AUBGeneralExaminationHt., Wt. And Arm Spam.Body type and Fat distributionVital sings.Thyroid examinationSings of androgen excess.Optic Fundi and visual fieldsTanner staging of breasts andGalactorrheaAcanthosis nigricansSing of abnormal bleedingAbdomen for massesPelvicExaminationExternal andInternal includingPap smear30Tuesday, June 18, 13
  • 50. Examination+InitialInvestigationsAncillaryInvestigationsStructuralHistoryChronic AUBGeneralExaminationHt., Wt. And Arm Spam.Body type and Fat distributionVital sings.Thyroid examinationSings of androgen excess.Optic Fundi and visual fieldsTanner staging of breasts andGalactorrheaAcanthosis nigricansSing of abnormal bleedingAbdomen for massesPelvicExaminationExternal andInternal includingPap smearUterine Evaluation•TV Ultrasonography•Saline Sononhystrography (SIS)•MRI•Endometrial Biopsy30Tuesday, June 18, 13
  • 51. Risk Factor Relative Risk (RR)Increasing ageAge 50-70 years have a 1.4%RUDJ of endometiral cancerUnopposed estrogen therapy 2-10Late menopause (>55 years) 2Nulliparity 2PCO 3Obesity 2-4Diabetes mellitus 2Lynch Syndrome (hereditary non-polyposiscolorectal cancer )22-50 % life-time riskTamoxifen Therapy 2Early menarche NAEstrogen secreting tumor NAFamily history of endometrial, ovarian, breastor colon cancerNASmith RA,Von Eschenbach, Ender R et al American Caner Society Guideline for early endometiral cancerDetection: 200131Tuesday, June 18, 13
  • 52. Transvaginal UltrasoundMeasurement of Endometrial thickness: Has NO place in pre-menopausal women.32Tuesday, June 18, 13
  • 53. •Diagnosisof Adenomyosis:❖Heterogeneous Myometrium,MyometrialCysts❖Asymmetric MyometrialThickness,❖And Subendometrial EchogenicLinearStriations33Tuesday, June 18, 13
  • 54. TV Ultrasound Vs. SISSIS Is Superior To TV US InDetection Of Intracavitary Lesions.TV Sonography: Sensitivity 55-75% in exclusion ofuterine & endometiral pathology34Tuesday, June 18, 13
  • 55. The risk of endometrial hyperplasia andcarcinoma by age setting★Persistent AUB in setting of unopposedE2 (e.g. obesity, chronic anovulation)★Failed medical management★High risk of endometrial cancer (e.g.,tamoxifen, Lynch syndrome).When Should Endometiral Sampling bePerformed?45yearstomenopause> 45 year★First Line test(ACOG) guidelines05101520<45 >45196T h e P r i m a r y R o l e O fEndometrial Sampling Is ToDetermine Whether CarcinomaOr Premalignant Lesions ArePresent35Tuesday, June 18, 13
  • 56. Cancer can be missed (If itoccupies less than 50% of thesurface area)How Good is Endometiral Sampling?022.54567.590Positive Negative0.981.7Post-test Probability of endometiralcancer after36Tuesday, June 18, 13
  • 57. Cancer can be missed (If itoccupies less than 50% of thesurface area)How Good is Endometiral Sampling?022.54567.590Positive Negative0.981.7Post-test Probability of endometiralcancer after➡Endometrial Sampling is only anendpoint when they reveal cancer oratypicalcomplexhyperplasia.➡Persistent bleeding with a previousbenign pathology, such as proliferativeendometrium, requires further testingsuchasHysteroscopy.36Tuesday, June 18, 13
  • 58. Hystroscopy ?Hysteroscope•Allows direct visualization ofe n d o m e t r i a l c a v i t yabnormalities and the abilityto take directed biopsies.•Hysteroscopy is highlyaccurate in diagnosingendometrial cancer but lessus eful for d etectin ghyperplasia37Tuesday, June 18, 13
  • 59. Examination+InitialInvestigationsAncillaryInvestigationsStructuralHistoryChronic AUB➡Pregnancy test➡CBC (HB and Platelets)➡TSH➡Coagulation tests: PTT, PT➡Neisseria Gonorrhea andChlamydia➡Prolactin level➡Androgen level38Tuesday, June 18, 13
  • 60. Age-Based Common Differential Diagnosis13-18 Years•Persistent Anovulation Due ToThe Immaturity Of The H-P-OAxis•Other Causes: OCP,Pregnancy, Pelvic Infection,Coagulopathies,OrTumors(20 % Of As Many As 19% OfAdolescents With AUB WhoRequire Hospitalization MayH a v e A n U n d e r l y i n gCoagulopathy)19-39 Years•Pregnancy.•Structural Lesions (e.g.,LeiomyomasOrPolyps.•Anovulatory Cycles (e.g.,PCOS).•UseOfOCP•Less Common: EndometrialHyperplasia. EndometrialCancer40 Years ToMenopause•Anovulatory Bleeding InResponse To DecliningOvarian Function.•EndometrialHyperplasia OrCarcinoma.•Endometrial Atrophy.•Leiomyomas.39Tuesday, June 18, 13
  • 61. DUBManagement .....40Tuesday, June 18, 13
  • 62. 41Tuesday, June 18, 13
  • 63. What Are The Goals Of Management Of DUB?41Tuesday, June 18, 13
  • 64. Confirm The Diagnosis Of DUB.What Are The Goals Of Management Of DUB?41Tuesday, June 18, 13
  • 65. Confirm The Diagnosis Of DUB.Prevent Short And Long Term Complications ( Acute OrChronic Anemia, Long-term Consequences OfAnovulation)What Are The Goals Of Management Of DUB?41Tuesday, June 18, 13
  • 66. Confirm The Diagnosis Of DUB.Prevent Short And Long Term Complications ( Acute OrChronic Anemia, Long-term Consequences OfAnovulation)Return To A Pattern Of Normal Menstrual CyclesWhat Are The Goals Of Management Of DUB?41Tuesday, June 18, 13
  • 67. Confirm The Diagnosis Of DUB.Prevent Short And Long Term Complications ( Acute OrChronic Anemia, Long-term Consequences OfAnovulation)Return To A Pattern Of Normal Menstrual CyclesPrevention Of RecurrenceWhat Are The Goals Of Management Of DUB?41Tuesday, June 18, 13
  • 68. The Choice Of ManagementDepends On:Age, Past History, And BleedingAmount.42Tuesday, June 18, 13
  • 69. General principles in Management OF DUB 43Tuesday, June 18, 13
  • 70. ➡Exclusion of Pregnancy (including ectopic pregnancy) andpelvic infections.General principles in Management OF DUB 43Tuesday, June 18, 13
  • 71. ➡Exclusion of Pregnancy (including ectopic pregnancy) andpelvic infections.➡Use of Menstrual Calendar for All adolescents.General principles in Management OF DUB 43Tuesday, June 18, 13
  • 72. ➡Exclusion of Pregnancy (including ectopic pregnancy) andpelvic infections.➡Use of Menstrual Calendar for All adolescents.➡Monitoring patients for iron deficiency anemia.General principles in Management OF DUB 43Tuesday, June 18, 13
  • 73. ➡Exclusion of Pregnancy (including ectopic pregnancy) andpelvic infections.➡Use of Menstrual Calendar for All adolescents.➡Monitoring patients for iron deficiency anemia.➡Long-term monitoring and follow-up are necessary toprevent the potential sequelae of DUB (eg, anemia, infertility,endometrial cancer).General principles in Management OF DUB 43Tuesday, June 18, 13
  • 74. ➡Exclusion of Pregnancy (including ectopic pregnancy) andpelvic infections.➡Use of Menstrual Calendar for All adolescents.➡Monitoring patients for iron deficiency anemia.➡Long-term monitoring and follow-up are necessary toprevent the potential sequelae of DUB (eg, anemia, infertility,endometrial cancer).➡Additional evaluation and consultation should be obtained ifbleeding cannot be controlled despite hormonal therapy.General principles in Management OF DUB 43Tuesday, June 18, 13
  • 75. Medical Therapy•Oral Contraceptives•Estrogen•ProgestinSurgical Care•D&C•Endometrial Ablation•HysterectomyHaemostaticagentsOptions for Management ofDUBNSAIDHormonalTherapy•Aminocaproic acid•Tranexamic Acid•DesmopressinMostcases of DUBcan betreated medically. Surgicalmeasures arereserved forsituations when medicaltherapyhas failed oris contraindicated44Tuesday, June 18, 13
  • 76. Moderate DUB Severe DUBMild DUBManagement of DUB45Tuesday, June 18, 13
  • 77. ➡longer than normal➡Shorter than normalfor > two monthsModerate DUB Severe DUBMild DUBManagement of DUB45Tuesday, June 18, 13
  • 78. ➡longer than normal➡Shorter than normalfor > two monthsModerate DUB✓hormonal therapy tostabilize endometrialp r o l i f e r a t i o n a n dshedding.✓Iron supplementationSevere DUBMild DUBManagement of DUB45Tuesday, June 18, 13
  • 79. ➡longer than normal➡Shorter than normalfor > two monthsModerate DUB✓hormonal therapy tostabilize endometrialp r o l i f e r a t i o n a n dshedding.✓Iron supplementationSevere DUBMild DUBManagement of DUB45Tuesday, June 18, 13
  • 80. ➡longer than normal➡Shorter than normalfor > two monthsModerate DUB✓hormonal therapy tostabilize endometrialp r o l i f e r a t i o n a n dshedding.✓Iron supplementationSevere DUBMild DUBManagement of DUB45Tuesday, June 18, 13
  • 81. ➡longer than normal➡Shorter than normalfor > two monthsModerate DUB✓hormonal therapy tostabilize endometrialp r o l i f e r a t i o n a n dshedding.✓Iron supplementationSevere DUBMild DUBManagement of DUB45Tuesday, June 18, 13
  • 82. ➡longer than normal➡Shorter than normalfor > two monthsModerate DUB➡Moderately Prolonged OrFrequent Menses Every One ToThree Weeks.➡Menstrual Flow Is Moderate ToHeavy.➡MildAnemia (Hb 10 To 12 G/dL)But Without Signs OfHypovolemia✓hormonal therapy tostabilize endometrialp r o l i f e r a t i o n a n dshedding.✓Iron supplementationSevere DUBMild DUBManagement of DUB45Tuesday, June 18, 13
  • 83. ➡longer than normal➡Shorter than normalfor > two monthsModerate DUB➡Moderately Prolonged OrFrequent Menses Every One ToThree Weeks.➡Menstrual Flow Is Moderate ToHeavy.➡MildAnemia (Hb 10 To 12 G/dL)But Without Signs OfHypovolemia✓hormonal therapy tostabilize endometrialp r o l i f e r a t i o n a n dshedding.✓Iron supplementationNot currentlybleeding✓ COPs or✓ progesterone-onlyhormonalSevere DUBMild DUBManagement of DUB45Tuesday, June 18, 13
  • 84. ➡longer than normal➡Shorter than normalfor > two monthsModerate DUB➡Moderately Prolonged OrFrequent Menses Every One ToThree Weeks.➡Menstrual Flow Is Moderate ToHeavy.➡MildAnemia (Hb 10 To 12 G/dL)But Without Signs OfHypovolemia✓hormonal therapy tostabilize endometrialp r o l i f e r a t i o n a n dshedding.✓Iron supplementationNot currentlybleeding✓ COPs or✓ progesterone-onlyhormonalcurrentlybleeding✓OC pills: 3 three timesper day until the bleedingceases (48 h) thentapered gradually for 21days of hormone therapy.✓Alternatively progestintherapySevere DUBMild DUBManagement of DUB45Tuesday, June 18, 13
  • 85. ➡longer than normal➡Shorter than normalfor > two monthsModerate DUB➡Moderately Prolonged OrFrequent Menses Every One ToThree Weeks.➡Menstrual Flow Is Moderate ToHeavy.➡MildAnemia (Hb 10 To 12 G/dL)But Without Signs OfHypovolemia✓hormonal therapy tostabilize endometrialp r o l i f e r a t i o n a n dshedding.✓Iron supplementationNot currentlybleeding✓ COPs or✓ progesterone-onlyhormonalcurrentlybleeding✓OC pills: 3 three timesper day until the bleedingceases (48 h) thentapered gradually for 21days of hormone therapy.✓Alternatively progestintherapySevere DUB➡ heavy bleeding thatcauses a decrease inhemoglobin (to <10mg/dL) and may orm a y n o t c a u s eh e m o d y n a m i cinstabilityMild DUBManagement of DUB45Tuesday, June 18, 13
  • 86. ➡longer than normal➡Shorter than normalfor > two monthsModerate DUB➡Moderately Prolonged OrFrequent Menses Every One ToThree Weeks.➡Menstrual Flow Is Moderate ToHeavy.➡MildAnemia (Hb 10 To 12 G/dL)But Without Signs OfHypovolemia✓hormonal therapy tostabilize endometrialp r o l i f e r a t i o n a n dshedding.✓Iron supplementationNot currentlybleeding✓ COPs or✓ progesterone-onlyhormonalcurrentlybleeding✓OC pills: 3 three timesper day until the bleedingceases (48 h) thentapered gradually for 21days of hormone therapy.✓Alternatively progestintherapySevere DUB➡ heavy bleeding thatcauses a decrease inhemoglobin (to <10mg/dL) and may orm a y n o t c a u s eh e m o d y n a m i cinstability✓ ? hospitalization forstabilization ofhemodynamic status,✓ blood transfusion.✓ pharmacologic therapy,✓ Rarely, surgical therapy.Mild DUBManagement of DUB45Tuesday, June 18, 13
  • 87. COC Pills •High-dose CombinationPill Every Four HoursU n t i l T h e B l e e d i n gSubsides (usually Within 24Hours),•Then Four Times Per DayFor Four Days, ThenThree Times Per Day ForThree Days.•Then Two Times A DayFor Two Weeks.•I f H i g h - d o s e E s t r o g e n I sContraindicated (eg, Arterial Or VenousThromboembolic Disease, Estrogen-dependent Tumors, And HepaticDysfunction Or Disease). Progestin E.g.Norethindrone Acetate (5- To 10 Mg) OrMicronized Progesterone (200 Mg) EveryFour Hours Until The Bleeding Stops.•Then One Pill Four Times A Day ForFour Days•Then Three Times A Day For ThreeDays, Then Twice A Day For TwoWeeks.If Estrogen Is Contraindicated And Progestin-only Regimens Fail To ControlThe Bleeding, Aminocaproic Acid Or Desmpressin May Be Initiated.•Intravenous ConjugatedEquine Estrogen, 25 MgEvery Four To Six HoursUntil The BleedingStops.•No More Than Six DosesShould Be Administered.•Anti-emetics Should BePrescribed.Management Of Acute Severe DUBHospitalization For Stabilization Of Hemodynamic Status, BloodTransfusion, Pharmacologic Therapy, And, Rarely, Surgical Therapy.IV ConjugatedEstrogenProgestins46Tuesday, June 18, 13
  • 88. Take Home Message47Tuesday, June 18, 13
  • 89. 48Tuesday, June 18, 13
  • 90. Use Simple Descriptive Terminology For AUB.48Tuesday, June 18, 13
  • 91. Use Simple Descriptive Terminology For AUB.AUB-O Is The Most Common At Extreme OfReproductive Age.48Tuesday, June 18, 13
  • 92. Use Simple Descriptive Terminology For AUB.AUB-O Is The Most Common At Extreme OfReproductive Age.Workup Aims To Differentiate Structural FromNon-Structural Causes (PALM & COIEN).48Tuesday, June 18, 13
  • 93. Use Simple Descriptive Terminology For AUB.AUB-O Is The Most Common At Extreme OfReproductive Age.Workup Aims To Differentiate Structural FromNon-Structural Causes (PALM & COIEN).Appreciate The Place, Sensitivity Of VariousDiagnostic Tools.48Tuesday, June 18, 13
  • 94. Use Simple Descriptive Terminology For AUB.AUB-O Is The Most Common At Extreme OfReproductive Age.Workup Aims To Differentiate Structural FromNon-Structural Causes (PALM & COIEN).Appreciate The Place, Sensitivity Of VariousDiagnostic Tools.Appreciate High Risk Subjects (risk Of Cancer).48Tuesday, June 18, 13
  • 95. Use Simple Descriptive Terminology For AUB.AUB-O Is The Most Common At Extreme OfReproductive Age.Workup Aims To Differentiate Structural FromNon-Structural Causes (PALM & COIEN).Appreciate The Place, Sensitivity Of VariousDiagnostic Tools.Appreciate High Risk Subjects (risk Of Cancer).Treatment Is Highly Influenced By Age, Severity OfBleeding.48Tuesday, June 18, 13
  • 96. Use Simple Descriptive Terminology For AUB.AUB-O Is The Most Common At Extreme OfReproductive Age.Workup Aims To Differentiate Structural FromNon-Structural Causes (PALM & COIEN).Appreciate The Place, Sensitivity Of VariousDiagnostic Tools.Appreciate High Risk Subjects (risk Of Cancer).Treatment Is Highly Influenced By Age, Severity OfBleeding.In All Cases Follow Up Is Essential Part OfManagement.48Tuesday, June 18, 13
  • 97. 49Tuesday, June 18, 13
  • 98. Thanks49Tuesday, June 18, 13