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AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
AbnormalVaginalBleeding
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AbnormalVaginalBleeding

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Abnormal vaginal bleeding

Abnormal vaginal bleeding

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  1. Arb-aroon Lertkhachonsuk Srithean Lertvikool Department of Obstetrics and Gynecology Faculty of Medicine, Ramathibodi Hospital
  2. Abnormal vaginal bleeding • Genital tract – Lower genital tract (vulva, perianal region, vagina, and cervix) – Upper genital tract (Uterus, fallopian tubes and ovaries) • Nongenital tract – Urethra, bladder, and bowel
  3. Abnormal uterine bleeding (AUB) “Uterine bleeding outside of the normal parameters”
  4. Objective • อธิบายกลไกการเกิดประจาเดือนปกติได้ • นิยามคาต่อไปนี้ menorrhagia, metrorrhagia, menometrorrhagia, hypermenorrhea, hypomenorrhea, oligomenorrhea ได้ • ระบุกลุ่มสาเหตุของเลือดออกผิดปกติทางช่องคลอด
  5. Objective • อธิบายความสาคัญของอายุผู้ป่ วยในการช่วยการวินิจฉัยแยกโรค • ระบุอาการและอาการแสดงของกลุ่มสาเหตุต่างๆ • อธิบายหลักการวินิจฉัยจาแนกสาเหตุจากการซักประวัติ ตรวจร่างกาย • ระบุเลือกสั่งและแปรผลการตรวจทางห้องปฏิบัติการเพื่อสนับสนุนการวินิจฉัยโรค • ตระหนักความสาคัญของการขูดมดลูกแยกส่วนในการวินิจฉัย
  6. กลไกการเกิด ประจาเดือน
  7. Normal Menstruation • Interval • Duration • Volume • Characteristic • 28 + 7 days • 2 – 7 days • <80 mL • Dark red, no clots
  8. The “Natural” History of Menstrual Cycle Menarche Menopause Anovulatory, irregular cycles Regular ovulatory cycles Pregnancy Lactation Cycle disturbances in peri-menopause
  9. Terms Used to Describe Abnormal Uterine Bleeding Pattern Interval Duration Amount Menorrhagia Metrorrhagia Menometrorrhagia Hypermenorrhea Hypomenorrhea Oligomenorrhea Polymenorrhea Regular Normal or less Less Infrequent Variable Scanty Frequent (irregular) Normal Normal Regular Prolonged Excessive Irregular +/- Prolonged Normal Irregular Prolonged Excessive Regular Normal Excessive
  10. Premenstrual spotting Postmenstrual spotting 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4week Metrorrhagia Amenorrhea followed by heavy bleeding 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4week Normal Oligomenorrhea Polymenorrhea 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4week Normal Hypomenorrhea Hypermenorrhea 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4week Menstrual Calendar : Mapping
  11. Causes of abnormal uterine bleeding Uterine Bleeding Pregnancy Complication Organic Lesion Medical Causes DUB Contraceptive Complication
  12. Pregnancy and pregnancy related conditions • Ectopic pregnancy • Miscarriage • Trophoblastic disease
  13. Contraceptive Complications • Oral pills • Injectables (DMPA) • Hormonal implants • IUDs
  14. Medications and iatrogenic causes • Anticoagulants • Antipsychotics • Corticosteroids • Herbal and other supplements:ginseng, ginkgo, soy • Hormone replacement • Intrauterine devices • Oral contraceptive pills, including progestin-only pills • Selective serotonin reuptake inhibitors • Tamoxifen (Nolvadex) • Thyroid hormone replacement
  15. Systemic conditions • Adrenal hyperplasia and Cushing’s disease • Blood dyscrasias, including leukemia and thrombocytopenia • Coagulopathies • Hepatic disease • Hypothalamic suppression (from stress, weight loss, excessive exercise) • Pituitary adenoma or hyperprolactinemia • Polycystic ovary syndrome • Renal disease • Thyroid disease
  16. Genital tract pathology • Infections: cervicitis, endometritis, myometritis, salpingitis • Neoplastic entities – Benign anatomic abnormalities: adenomyosis, leiomyomata, polyps of the cervix or endometrium – Premalignant lesions: cervical dysplasia, endometrial hyperplasia – Malignant lesions: cervical squamous cell carcinoma, endometrial adenocarcinoma, estrogen-producing ovarian tumors, testosterone- producing ovarian tumors, leiomyosarcoma • Trauma: foreign body, abrasions, lacerations, sexual abuse or assault
  17. Organic Lesions: Vulva • Trauma • Infection • Neoplasm
  18. Organic lesions: Vagina • Trauma • Foreign body • Atrophic • Tumour (sarcoma botryoides)
  19. Organic lesions: Cervix • Cervicitis • Endocervical polyps • Cervical cancer
  20. Organic lesions: Uterus • Endometritis • Tumour – Benign • Endometrial polyps • Myoma • Adenomyosis – Endometrial Hyperplasia – Endometrial cancer/sarcoma
  21. Organic lesions: Ovary/ Tube • Hormone-producing ovarian tumour • Tube: infection/ CA (rare)
  22. Dysfunctional uterine bleeding • Abnormal uterine bleeding in absence of pelvic organ disease or a systemic disorder • 60 % of AUB • About 10% of the outpatients • Occur in • Before the menopause (50%) • After menarche (20%) • In reproductive times (30%)
  23. DUB • Anovulatory • Ovulatory
  24. Anovulatory DUB
  25. Etiology • About 85% of all DUB • In adolescents Immaturity of the hypothalamic-pituitary-ovarian axis. Especially, low response of hypothalamus and pituitary gland to positive feedback from estrogen. • In transitional period to menopause (premenopausal/premenopausal) Low response of the remaining follicles to gonadotropins. • Women of reproductive age Stress, fear, etc. interferes with ovulation
  26. Conditions associated with anovulation and abnormal bleeding • Eating disorders – Anorexia nervosa – Bulimia nervesa • Excessive physical exercise • Chronic illness • Ovarian insufficiency/Premature ovarian failure • Alcohol and other drug abuse • Stress • Thyroid disease – Hypothyroidism – Hyperthyroidism • Diabetes mellitus • Androgen excess syndromes (e.g. PCOS)
  27. Approximate Duration of Anovulation Puberty 3-5 years Post partum up to 6 months Post abortion up to 3 months Recovery from amenorrhea up to 3 months Post pill 3-6 months Post DMPA 6-12 months Perimenopause 3-5 years Polycystic ovary syndrome mostly persistent
  28. 1. Patterns of bleeding – Withdrawal bleeding • Decrease in estrogen – Breakthrough bleeding • Low level of estrogen • High level of estrogen Pathophysiology
  29. 2. Mechanism of the bleeding Lack of progesterone causes defects in the self- limiting mechanism of menstruation 1) Friability of tissue Lack of stromal support. 2) Incomplete shedding of endometrium Not enough stimulation for epithelial regeneration. (Complete loss of tissue is an effective stimulant for epithelial regeneration.)
  30. 3) Abnormal structure and function of blood vessels Lack of spiralization of the arteries. 4) Abnormal production of vascular factors PGE2, PGI2  causing dilation of blood vessels. (Proliferative endometrium produces PGE2) 5) Abnormal coagulation and Fibrinolysis Defects in TF and PAI-I
  31. Ovulatory DUB
  32. • Luteal phase defect, LPD • Irregular shedding of endometrium
  33. Luteal phase defect Low production of progesterone leading to shortening of the luteal phase (<11 days) Causes 1. Dysplasia of ovarian follicles 2. Insufficiency of the LH peak 3. Defects in the lower LH impulse after LH peak
  34. Pathophysiology Endometrium not well differentiated (secretory). Clinical manifestation 1. Polymenorrhea 2. Short high temperature phase in BBT 3. Infertility or loss of early pregnancy
  35. Diagnosis 1. Diphase in BBT, but high temperature phase is short ( < 11 days) 2. Biopsy of the endometrium shows late development of the secretory phase (≥ 2 days)
  36. Irregular shedding of endometrium Prolongation of the luteal regression process leading to slow or incomplete shedding of the endometrium Pathophysiology Incomplete regression of the corpus luteum. Existence of secretory endometrium on day 5-6. Clinical manifestation Length of menstrual cycle is normal, but menstruation period is prolonged.
  37. Diagnosis 1. Diphase in BBT, but slow returning to the lower temperature phase. 2. Endometrial biopsy at day 5 of the menstrual cycle shows presence of secretory endometrium.
  38. Characteristics DUB Anovulatory Ovulatory Bleeding pattern : Metrorrhagia Menorrhagia Short period of Pre-or post-menstrual amenorrhea spotting followed by excessive bleeding Age Teenage and Reproductive year climacterium Dysmenorrhea No Yes PMS No Yes DUB : Anovulatory vs Ovulatory
  39. Evaluation of Abnormal Uterine Bleeding
  40. Evaluation of Abnormal Uterine Bleeding • History • Physical examination • Laboratory tests • Imaging and tissue sampling
  41. 1. ประวัติประจาเดือนปกติ • LMP/PMP • Menarche/menopause • duration • volume • interval • ลักษณะเลือดที่ออก : สี ปริมาณ clot • ความสัมพันธ์ระหว่างเลือดที่ออกกับการมีเพศสัมพันธ์ • อาการอื่น ๆ ร่วม เช่น ปวดประจาเดือน คัดเต้านม ตกขาว คลื่นไส้ อาเจียน เบื่ออาหาร น้าหนักลด ปัสสาวะแสบขัด สีปัสสาวะเปลี่ยนแปลง มีหนองไหลจากท่อปัสสาวะ ปวดหลัง อุจจาระเปลี่ยนแปลง มีมูกเลือดปน ท้องอืดแน่นท้อง 2. ประวัติการตั้งครรภ์/คลอด/แท้ง/การขูดมดลูก 3. การมีเพศสัมพันธ์/โรคติดต่อทางเพศสัมพันธ์ 4. การคุมกาเนิด History taking
  42. History taking • คลาได้ก้อน : ตาแหน่ง ระยะเวลา ขนาด การเปลี่ยนแปลง ผิว การ เคลื่อนไหว เจ็บ • ประวัติอุบัติเหตุและการผ่าตัด • ประวัติการละเมิดทางเพศ • ประวัติเพศสัมพันธ์ • ประวัติการคุมกาเนิด • การใช้ยาหรือฮอร์โมนทดแทน
  43. Physical Examination • Vital sign • GA : pale, sign of volume depletion • HEENT : thyroid , LN • Abdomen : mass , pain • PR : content , mass • Pelvic examination : mass , pain
  44. การตรวจภายใน ในสตรีอายุน้อย ไม่เคยมีเพศสัมพันธ์ อาจวินิจฉัยเบื้องต้นและให้การรักษาไป ก่อน หรือพิจารณาตรวจทางทวารหนัก หรือตรวจ คลื่นเสียงความถี่สูงเพื่อช่วยในการวินิจฉัย Pelvic examination
  45. Laboratory tests Pertinent test Conditions Beta-subunit human chorionic gonadotropin Pregnancy Complete blood count with platelet count and coagulation studies Coagulopathy Liver function tests, prothrombin time Liver disease Thyroid-stimulating hormone Hypothyroidism, hyperthyroidism Prolactin Pituitary adenoma Blood glucose Diabetes mellitus DHEA-S, free testosterone, 17α- hydroxyprogesterone if hyperandrogenic Ovarian or adrenal tumor Papanicolaou smear Cervical dysplasia Cervical testing for infection Cervicitis, PID
  46. Imaging and tissue sampling Pertinent test Conditions Endometrial biopsy or dilatation and curettage Hyperplasia, atypia, or adenocarcinoma Transvaginal ultrasonography Pregnancy, ovarian or uterine tumors Saline-infusion sonohysterography Intracavitary lesions, polyps, submucous fibroids Hysteroscopy Intracavitary lesions, polyps, submucous fibroids
  47. การขูดมดลูก (Curettage) • คือการใช้เครื่องมือสอดเข้าโพรงมดลูกเพื่อขูดเอาเยื่อบุโพรงมดลูกหรือ เนื้อเยื่อในโพรงมดลูกออก การขูดมดลูกแบบแยกส่วน (fractional curettage) • เป็นการขูดมดลูกเพื่อวินิจฉัยพยาธิสภาพระหว่างส่วนของเยื่อบุปาก มดลูกและเยื่อบุโพรงมดลูก (เก็บส่วน endocervix และ endometrium แยกจากกัน) ความสาคัญของการขูดมดลูก -เพื่อวินิจฉัย -เพื่อรักกษา
  48. Treatment
  49. Treatment Goals • Alleviation of any acute bleeding • Prevention of future noncyclic bleeding • Decrease in the patient’s future risk of long-term health problems secondary to anovulation – Promoting ovulation – Preventing cancer • Improvement in the patient’s quality of life
  50. Treatment • Medical • Surgical
  51. Medical treatment • Hormonal: – Progestagen – Oestrogen – OCP – Danazol – GnRH agonist – LNG-IUS • Non –hormonal – Prostaglandin synthetase inhibitors (PSI) – Antifibrinolytics
  52. Medical Management of Anovulatory DUB Agent Dosage Purpose of treatment Combination OCP 20 to 35 mcg of ethinyl estradiol plus a progestin; monophasic or triphasic pill taken daily; transdermal forms also are available. 35-mcg pill from twice daily to every six hours for five to seven days until menses is stopped, followed by taper to one pill daily for bleeding completion of 28-day pack; then one OCP packet per month for three to six months Cycle regulation Contraception Prevention of endometrial hyperplasia Management of nonemergency heavy bleeding Conjugated estrogens, IV (Premarin) 25 mg IV every 4 to 6 hours until bleeding ceases, or for 24 hours; then OCP as above Management of acute emergency bleeding
  53. Medical Management of Anovulatory DUB Agent Dosage Purpose of treatment Progestins Medroxyprogesterone acetate (Provera) 5 or 10 mg per day for 5 to 10 days per month Cycle regulation Norethindrone acetate (Primolut-N) 2.5 to 10 mg per day for 5 to 10 days per month Prevention of endometrial hyperplasia Micronized progesterone (Utrogestan) 200 mg per day for 12 days per month
  54. Surgical treatment • Curettage • Endometrial ablation • Hysterectomy
  55. <20 yrs 20-40 yrs > 40 yrs Medical Always First resort after endometrial biopsy Temporizing & if surgery is refused or imminent menopause Surgical Never Seldom, only if medical treatment fail First resort if bleeding is recurrent Surgical Treatment
  56. History and physical examination Pregnancy ? Iatrogenic causes? Systemic condition? Medical management Discuss options; manage pregnancy. Discuss options and modify medications and herbal supplements. Obvious genital tract pathology? Yes No Yes No No Yes Abnormal uterine bleeding
  57. Obvious genital tract pathology? Yes No Presumed DUBFurther testing and management Cervical dysplasia Colposcopy Endocervical polyps Polypectomy Surgical consultation Cervicitis or endometritis Antibiotic therapy Traumatic injury Appropriate treatment, including psychosocial intervention Ultrasonography: ectopic pregnancy, leiomyoma, ovarian or endometrial tumor Enlarged uterus or adnexal mass
  58. Risk factors for endometrial cancer Presumed dysfunctional uterine bleeding Patient at low risk for endometrial cancer Patient at high risk for endometrial cancer Medical management Endometrial biopsy Bleeding continues.Bleeding stops Observe
  59. Risk factors for endometrial cancer • Chronic anovulatory cycles • Obesity • Nulliparity • Age greater than 35 years • Diabetes mellitus • Tamoxifen therapy
  60. Atypia or cancer Normal Another biopsy in 3 to 6 months Endometrial biopsy Hyperplasia Cycle with progestins SIS or Dx Hysteroscopy c Bx Bleeding continues. Normal Gynecologic referral Pathology or focal lesion Bleeding continues
  61. Bleeding continues. TVS Endometrial stripe  5 mm > 5 mm Obvious pathology Gynecologic referral SIS or Dx Hysteroscopy c Bx Bleeding continues. Normal Pathology or focal lesion Bleeding continues SIS
  62. SIS Normal Gynecologic referral Bleeding continues Uniform thickening of > 3 mm of a single layer of the endometrium or inconclusive results Focal lesion Atypia or cancer Normal Another biopsy In 3 to 6 months Hyperplasia Cycle with progestins Bleeding continues Endometrial biopsy
  63. Postmenopausal abnormal uterine bleeding No hormone therapy or hormone therapy for > 12 months with bleeding Adjust hormone therapy if indicated Hormone therapy for < 12 months Observe bleeding for 1 year before diagnosing abnormal uterine bleeding Dilatation and curettage Pathology Gynecologic referral Normal Bleeding continues
  64. Adjust hormone therapy if indicated SIS or hysteroscopy c Bx Pathology or focal lesion Bleeding continues Normal Bleeding continues Gynecologic referral
  65. Thank You For Your Attention

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