Abnormal Uterine Bleeding
Khalid Sait FRCSC
Professor, Faculty of Medicine
King Abdulaziz University
NORMAL MENSES
Frequency: 21-35 d
Duration: 3-7 d
Volume: 30-80 ml
Polymenorrhoea: frequent (<21 d) menstruation, at
regular intervals
Menorrhagia: Excessive (>80 ml) & / or prolonged
menst...
Abnormal Uterine Bleeding
•  More than 10 millions women in the USA suffer
from abnormal Uterine bleeding (AUB)
•  World w...
AUB
•  It is a debilitating and common medical
problem that:
adversely impacts a women s health,
daily activity and respon...
AUB
•  Approx. 4 out of 5 women with AUB have
no anatomic pathologic condition
•  About 50 % of patient with abnormal
uter...
Common presentation
•  40 years old women , Para 3 + 1
•  Presented with the complain of abnormal
vaginal bleeding for the...
Abnormal Uterine Bleeding
Anatomic/Organic Pregnancy
Systemic conditions DUB
DUB
• Uterine bleeding that occurs
outside of normal menstruation,
or disruptions in cyclic
menstruation
DUB
• Ovulatory
• Unovulatory
Ovulatory AUB
•  Regular heavy period
•  Unknown etiology( Mostly an endocrine abnormality: -
ALTERED PROSTAGLANDIN SYNTHE...
Anovulatory AUB
•  usually caused by : ESTROGEN -
PROGESTERONE IMBALANCE (mostly
estrogen dominance)
1- Bleeding due to es...
Anovulatory AUB
Bleeding due to estrogen –withdrawal
•  Recurrent mid cycle bleeding or spotting
just before ovulation dur...
Anovulatory AUB
Bleeding due to estrogen breakthrough
•  Occur in women with PCO with no
influence from progesterone on th...
Anovulatory AUB
Bleeding due to progesterone - breakthrough
•  Occure when the progeterone to estrogen
ratio is relatively...
Abnormal Uterine Bleeding
•  History and Physical Examination
•  Pregnancy test
•  Blood work: FSH.LH.Prolactine, TSH
•  U...
D & C
•  Diagnostic and therapeutic technique,
diltation and curttage ( D&C) is now
considered obsolete for the evaluation...
TVS
11.SAG Uterus (Transvaginal)
Endometrial Polyps
12. SAG Uterus (Transvaginal)
Endometrial Polyp
11 12
COR Uterus (3D Reconstruction)
Endometrial Polyp
Endometrial Biopsy
•  Pipelle cathter
•  Accurette
•  Z sampler
•  Tis – u- trap
•  Novak curatte
•  Randall curatte
•  Va...
Saline infusion sonography
HYSTEROSCOPY
Hysteroscopy
•  Gold standard
MRI
•  Powerful non invasive
•  Sub mucus fibroid
•  Adenomyosis
•  But not polypi
Treatment
•  Medical
•  Surgical
Ø Treatment has to be indivisualised
Ø Not suitable for all ages
Ø Response is erratic and unpredictable
Ø SIDE EFFECT...
Medical
•  Iron
•  Hemopiotin
•  Blood transfusion
Antifibrolynitcs
•  Antifibrolynitcs Transxamic acid
Cyklokopron
•  Side effect leg cramps and nausia
•  Reduce menst cycl...
Antifibrolynitcs
•  Competitively inhibits the activation of
plasminogen to plasmin and counter acts the high
fibrinolytic...
Cyclo oxygenase inhibitor
•  With endometriun cycooxygenase convet arachidonic acid into PGS and lead
to vasoditation
•  I...
Progesteron
•  It will lead to predictable bleeding but heavy unless the therapy used
for several months
•  May increase f...
IUCD caoted progeteron
mirena( levonorgesteral)
•  Anderson et al 1990
Reduction in MBL after 3 month by 86 %
and 97 % aft...
Combined birth control pills
•  Ovul and unovul AUB
•  Suppress ovulation, and over time , thin the
endometrium lining to ...
Combined birth control pills
•  Excessive bleeding
•  Ovral 1 tab tid for 1 week
Bid for 2nd weeks and once per week for
t...
Estrogen
•  Acute excessive bleeding
•  Conjugated equine estrogen (cees)
•  Ovu and unovu
•  Stop bleeding in 71 % of wom...
Androgen
•  Danazol+ a synthetic derivastive of 17 alpha
– ethinyl testosterone
•  Ovul AUB
•  Danazol resduce blood flow ...
GnRh agonist
•  Act by produce unovulation
•  Ovul and unovu
•  Second week of injection bleeding increase
due to gondotro...
antiprogesterone
•  Mifepristone
•  50 mg/day
•  Induce ammenorrhae
Cost per cycle
•  Nsaid 16$
•  Provera 16 $
•  Ocp 16 $
•  Cyclokopron 60 $
•  Danazol 70 $
ENDOMETRIAL ABLATION: -
•  TCRE – Tran Cervical Resection Of
Endometrium
•  ELA – Endrometrial Laser Ablation
•  HTEA – Hy...
•  TBEA – Thermal Balloon Endometrial Ablation
ENDOMETRIAL ABLATION: -
v NON HYSTREOSCOPIC METHODS: -
Surgical Treatment ...
•  VAGINAL HYSTERECTOMY
•  LPAROSCOPICALLY ASSISTED V H
•  Lap Hys.- Total / Subtotal
•  Abdominal / MINILAP Hysterectomy-...
Hysterectomy
•  Hystrectomy is a commonly used and
effective treatment for AUB , but it is the
most expensive surgical option avaliable...
Summary
§  Dysfunctional Uterine Bleeding is a very common
disorder at all ages from menarche to menopause.
§  Though it...
Dysfunctional uterine bleeding
Dysfunctional uterine bleeding
Dysfunctional uterine bleeding
Dysfunctional uterine bleeding
Dysfunctional uterine bleeding
Dysfunctional uterine bleeding
Dysfunctional uterine bleeding
Dysfunctional uterine bleeding
Dysfunctional uterine bleeding
Dysfunctional uterine bleeding
Dysfunctional uterine bleeding
Dysfunctional uterine bleeding
Dysfunctional uterine bleeding
Dysfunctional uterine bleeding
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Dysfunctional uterine bleeding

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Dysfunctional uterine bleeding

  1. 1. Abnormal Uterine Bleeding Khalid Sait FRCSC Professor, Faculty of Medicine King Abdulaziz University
  2. 2. NORMAL MENSES Frequency: 21-35 d Duration: 3-7 d Volume: 30-80 ml
  3. 3. Polymenorrhoea: frequent (<21 d) menstruation, at regular intervals Menorrhagia: Excessive (>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. Oligomenorrhea: infrequent menstruation (>35 d)
  4. 4. Abnormal Uterine Bleeding •  More than 10 millions women in the USA suffer from abnormal Uterine bleeding (AUB) •  World wide AUB affects about 50 % of menstruating women •  The majority occur in peri-menopousal and after menarche when the ovaries are in the unstable responsive state.
  5. 5. AUB •  It is a debilitating and common medical problem that: adversely impacts a women s health, daily activity and responsibility ( quality of life )
  6. 6. AUB •  Approx. 4 out of 5 women with AUB have no anatomic pathologic condition •  About 50 % of patient with abnormal uterine bleeding will have fibroid or polyp •  10 % of post menopausal bleeding women will have cancer
  7. 7. Common presentation •  40 years old women , Para 3 + 1 •  Presented with the complain of abnormal vaginal bleeding for the last 2 days
  8. 8. Abnormal Uterine Bleeding Anatomic/Organic Pregnancy Systemic conditions DUB
  9. 9. DUB • Uterine bleeding that occurs outside of normal menstruation, or disruptions in cyclic menstruation
  10. 10. DUB • Ovulatory • Unovulatory
  11. 11. Ovulatory AUB •  Regular heavy period •  Unknown etiology( Mostly an endocrine abnormality: - ALTERED PROSTAGLANDIN SYNTHESIS IN FAVOUR OF E2 THAN F2α •  The ratio of PGE2:PGF2alpha and level of PGI 2 are increase lead to lead to vasodiltation •  In addition the fibroinolytic activity is significantly elevated in most women
  12. 12. Anovulatory AUB •  usually caused by : ESTROGEN - PROGESTERONE IMBALANCE (mostly estrogen dominance) 1- Bleeding due to estrogen –withdrawal 2-Bleeding due to estrogen breakthrough 3-Bleeding due to progesterone – breakthrough.
  13. 13. Anovulatory AUB Bleeding due to estrogen –withdrawal •  Recurrent mid cycle bleeding or spotting just before ovulation during the normal menstrual cycle due to pronounced dip in levels of estradiol at that time
  14. 14. Anovulatory AUB Bleeding due to estrogen breakthrough •  Occur in women with PCO with no influence from progesterone on the endometrium
  15. 15. Anovulatory AUB Bleeding due to progesterone - breakthrough •  Occure when the progeterone to estrogen ratio is relatively high •  Lead to frequent irregular bleeding
  16. 16. Abnormal Uterine Bleeding •  History and Physical Examination •  Pregnancy test •  Blood work: FSH.LH.Prolactine, TSH •  Uterine cavity assessment: Endometrial biopsy, TVS ,Hysteroscopy , saline infusion sonography , MRI
  17. 17. D & C •  Diagnostic and therapeutic technique, diltation and curttage ( D&C) is now considered obsolete for the evaluation and treatment of abnormal uterine bleeding, but it is unfortunately still used by many physicians for this purpose
  18. 18. TVS
  19. 19. 11.SAG Uterus (Transvaginal) Endometrial Polyps 12. SAG Uterus (Transvaginal) Endometrial Polyp 11 12
  20. 20. COR Uterus (3D Reconstruction) Endometrial Polyp
  21. 21. Endometrial Biopsy •  Pipelle cathter •  Accurette •  Z sampler •  Tis – u- trap •  Novak curatte •  Randall curatte •  Vabra aspiration •  Two studies shown that pipelle and novak has same sensitivity with pipelle cause less discomfort to the patient
  22. 22. Saline infusion sonography
  23. 23. HYSTEROSCOPY
  24. 24. Hysteroscopy •  Gold standard
  25. 25. MRI •  Powerful non invasive •  Sub mucus fibroid •  Adenomyosis •  But not polypi
  26. 26. Treatment •  Medical •  Surgical
  27. 27. Ø Treatment has to be indivisualised Ø Not suitable for all ages Ø Response is erratic and unpredictable Ø SIDE EFFECTS - Discontinuation and noncompliance Ø Failures are common Ø Cost effectiveness ? Medical Treatment for DUB Problems: -
  28. 28. Medical •  Iron •  Hemopiotin •  Blood transfusion
  29. 29. Antifibrolynitcs •  Antifibrolynitcs Transxamic acid Cyklokopron •  Side effect leg cramps and nausia •  Reduce menst cycle by 45% to 54 %(10 RCT placebo control)
  30. 30. Antifibrolynitcs •  Competitively inhibits the activation of plasminogen to plasmin and counter acts the high fibrinolytic activity in the endometrium which may be one of the causes •  Dose :1 gm every 6 hour po for 3 days of heavy period
  31. 31. Cyclo oxygenase inhibitor •  With endometriun cycooxygenase convet arachidonic acid into PGS and lead to vasoditation •  Inhibit cyclooxygenase •  21 RCT decrease blood loss by 20-50 % •  Nsaids •  Mefenemic acid •  Diclofenac •  Flurbiprofen •  Indomethacine •  Naproxen •  Side effect •  GI upset •  Dose •  500 mg q 6 hours for 3 days of period •  C/I renal faliure and peptic ulcer
  32. 32. Progesteron •  It will lead to predictable bleeding but heavy unless the therapy used for several months •  May increase flow by 20 % coulter et al 1995 •  Benefit in anovulatory uterine bleeding as in PCO •  Progestrone ( 5 mg bid on luteal phase northindrone for 7 days led to increase menstrual loss
  33. 33. IUCD caoted progeteron mirena( levonorgesteral) •  Anderson et al 1990 Reduction in MBL after 3 month by 86 % and 97 % after 12 month of use
  34. 34. Combined birth control pills •  Ovul and unovul AUB •  Suppress ovulation, and over time , thin the endometrium lining to an inactive state •  In unovulation it level out the fluctuation in estrogen which often initiate breakthrough bleeding •  C/I •  Side effect
  35. 35. Combined birth control pills •  Excessive bleeding •  Ovral 1 tab tid for 1 week Bid for 2nd weeks and once per week for third week then follow with microgynon 30 for 3 months
  36. 36. Estrogen •  Acute excessive bleeding •  Conjugated equine estrogen (cees) •  Ovu and unovu •  Stop bleeding in 71 % of women compare to placebo •  25 mg IV every 4 hours •  Or 2.5 mg adminstered orally every 4-6 hours for 2-3 weeks •  Once bleeding stop please give progesterone for 7 days
  37. 37. Androgen •  Danazol+ a synthetic derivastive of 17 alpha – ethinyl testosterone •  Ovul AUB •  Danazol resduce blood flow in 50 % -80 % 200-400 mg/d > 100 mg /d for three month •  Side effect
  38. 38. GnRh agonist •  Act by produce unovulation •  Ovul and unovu •  Second week of injection bleeding increase due to gondotrophine flare •  Cost •  Side effect •  With add back therapy can continue therapy beyond 12 months
  39. 39. antiprogesterone •  Mifepristone •  50 mg/day •  Induce ammenorrhae
  40. 40. Cost per cycle •  Nsaid 16$ •  Provera 16 $ •  Ocp 16 $ •  Cyclokopron 60 $ •  Danazol 70 $
  41. 41. ENDOMETRIAL ABLATION: - •  TCRE – Tran Cervical Resection Of Endometrium •  ELA – Endrometrial Laser Ablation •  HTEA – Hydrothermal Endrometrial Ablation v  HYSTEROSCOPIC METHODS: - Surgical Treatment of DUB
  42. 42. •  TBEA – Thermal Balloon Endometrial Ablation ENDOMETRIAL ABLATION: - v NON HYSTREOSCOPIC METHODS: - Surgical Treatment of DUB
  43. 43. •  VAGINAL HYSTERECTOMY •  LPAROSCOPICALLY ASSISTED V H •  Lap Hys.- Total / Subtotal •  Abdominal / MINILAP Hysterectomy- Total / Subtotal HYSTERCTOMY: - Surgical Treatment of DUB
  44. 44. Hysterectomy
  45. 45. •  Hystrectomy is a commonly used and effective treatment for AUB , but it is the most expensive surgical option avaliable and is often medically unnecessary due to the absence of pathological uterine conditions in a large percentage of these women( 40 % )
  46. 46. Summary §  Dysfunctional Uterine Bleeding is a very common disorder at all ages from menarche to menopause. §  Though its pathophysiology is still unclear, Estrogen- Progesterone imbalance is usually the basis of bleeding. §  Available medical treatment modalities are far from satisfactory. The perfect SERM for DUB

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