Perimenopausal bleeding occurs in the 3-5 years before menopause, with irregular bleeding and intermittent menopausal symptoms. It can cause physical symptoms like hot flashes and night sweats as well as psychological issues like depression and stress. Diagnosis involves medical history, physical exam, laboratory tests, and imaging like ultrasound and hysteroscopy. Treatment options include non-hormonal medications, hormonal therapies, intrauterine devices, and surgery to address structural issues. Managing perimenopausal bleeding requires a comprehensive evaluation and individualized treatment approach.
2. IT IS 3-5 YEARS BEFORE MENOPAUSE WITH INCREASE
FREQUENT IRREGULAR ANOVULATORY BLEEDING
FOLLOWED BY EPISODES OF AMENORRHEA AND
INTERMITTENT MENOPAUSAL SYMPTOMS .
Definition
Symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
2
3. Physical
• hot flashes,
night sweats
• rapid bone loss
• increased risk of
cardiovascular
disease
• vulvovaginal
• atrophy
Menorrhagia and
fibroids
• Up to 14% of
women
Depression and
psychological
stress
• anxiety, irritability
• poor
concentration,
depression
• mood swings,
• and other
changes that may
impair personal
Definition
Symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
3
4. low resource …
basic investigations for abnormal uterine bleeding (AUB) –
bearing in mind issues of effectiveness and cost effectiveness.
4
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
5. Ideally, the evaluation is comprehensive, considering each of
the potential etiological domains as defined by FIGO
PALM-COEIN system for Causes.
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
6. Medications that can be associated with abnormal
uterine bleeding
Anticoagulants
Antidepressants (SSRI and tricyclics)
Hormonal contraceptives
Tamoxifen
Antipsychotics
Corticosteroids
Herbs: ginseng , chasteberry , danshen
6
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
8. Abnormal Uterine Bleeding
New Terminology by FIGO
Term HMB (Heavy mentrual bleeding) has
replaced the term Menorrhagia:
Bleeding that occurs at regular intervals,
loss of ≥ 80 mL blood per
DUB has been replaced by BEO(Bleeding
of Endometrial origin)
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
8
11. DIAGNOSIS OF ABNORMAL UTERINE
BLEEDING :
MEDICAL HISTORY
PHYSICAL EXAMINATION
LABORATORY TESTS
IMAGING TESTS
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
11
12. History
AGE OF ONSET OF MENSES
FREQUENCY/DURATION OF MENSES
QUANTITY OF FLOW, NUMBER OF PADS, PASSAGE
OF CLOTS AND FLOODING
INTERMENSTRUAL BLEEDING
POSTCOITAL BLEEDING
DYSPYERUNIA
USE OF CONTRACEPTIVES/MEDICATION
FAMILY HISTORY OF MENARCHE, MENOPAUSE,
MALIGNANCY
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
12
13. PELVIC PAIN
POSTCOITAL PAIN
VAGINAL DISCHARGE
EXCESSIVE BRUISING/BLEEDING FROM OTHER
SITES
HISTORY OF POST PARTUM HEMORRHAGE
FAMILY HISTORY OF BLEEDING PROBLEMS
URINARY SYMPTOMS
WEIGHT CHANGE ,HEAT OR COLD INTOLERANCE
STRESS
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
13
14. Physical examination
GENERAL EXAMINATION
ABDOMINAL EXAMINATION
VAGINAL / PER SPECULUM AND PELVIC B/M
EXAMINATIONS
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
14
15. Examination
GPE
Assess for obesity, hirsutism, stigmata of thyroid
disease (hypothyroidism associated with
anovulation), signs of hyperprolactinemia (visual
field testing, galactorrhea)
ABDOMINAL EXAM+ INATION
Abdominal masses
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
15
18. Ultrasound
TVUS IS UNDOUBTEDLY THE
PRIMARY IMAGING MODALITY
…AN EXCELLENT TOOL FOR THE
DETERMINATION OF WHETHER FURTHER
INVESTIGATION WITH CURETTAGE OR
SOME FORM OF ENDOMETRIAL BIOPSY IS
NECESSARY
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
18
19. Dilatation and curettage
• alone should not be used as a diagnostic
tool.
• suggested that D&C does not give
additional
diagnostic information over and above
a hysteroscopy with endometrial biopsy
it is
not therapeutic in cases of heavy menstrual
bleeding
19
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
20. D&C should no longer be used as the first-line method of investigating
PMB in most cases.
20
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
21. it is limited in its ability to access the tubal cornua of
the uterus.
Hysteroscopy with biopsy provides more information
than
dilatation and curettage alone and rivals the
combination of
saline-infusion sonohysterography and endometrial
biopsy in
its ability to diagnose polyps, submucous fibroids, and
other sources of abnormal uterine bleeding.
21
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
22. Hysteroscopy with directed biopsy is more sensitive in
disclosing all types of uterine lesions than dilatation and
curettage.
Curettage done after hysteroscopy and directed biopsy does
not improve the detection of endometrial cancer
22
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
23. We support hysteroscopy as a routine alternative to
dilatation and curettage in the diagnosis of
postmenopausal bleeding
23
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
24. Endometrial Biopsy
SAFE, SIMPLE OFFICE PROCEDURE
INEFFECTIVE AT DIAGNOSING FOCAL LESIONS.
POLYPS (AUB-P) ARE FREQUENTLY MISSED (UP TO 50%)
BY BLIND TECHNIQUES, WHICH MAY INCLUDE CASES
OF FOCAL ATYPICAL HYPERPLASIA AND CARCINOMA
ESPECIALLY IN PREMENOPAUSAL CASES.
24
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
26. Saline infusion sonohysterography
CAN DISTINGUISH FOCAL LESIONS FROM DIFFUSE
ENDOMETRIAL THICKENING. POLYPS ARE FOCAL LESIONS,
WHICH PROJECT INTO THE LUMEN OF THE ENDOMETRIAL
CAVITY.
Endome-trial
polyp
Multiple
polyps
Endometrial
hyperplasia
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
26
27. SIS
Performed during proliferative phase
Not later than 10 days
Post menopuasal bleeding – any time
Women on HRT time it during withdrawal or during progesterone
phase
Bleeding not a contraindication but clot can make interpretation
difficult. But
Doppler can differentiate cavitory lesions.
27
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
28. SIS
If a focal lesion is identified on SIS, that lesion can be treated with
hysteroscopy.
Those patients who do not have a focal lesion can be spared hysteroscopy
in many cases.
28
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
29. In postmenopausal women, polyps are found to be the cause
of bleeding in approximately 30% of cases.
Most of these polyps are benign.
malignancy in polyps ranges from 0.5% to 1.5%.
29
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
30. Transvaginal sonography cannot distinguish endometrial
hyperplasia from benign polyps
both conditions can cause thickening of the endometrium, are
hyperechoic, and can contain cystic spaces.
30
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
31. Clinical impact
SIS added certainty to the
diagnosis in 88% of the patients studied.
SIS results changed the patients’ treatment in 80% of cases.
Increased diagnostic confidence by 86%.
31
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
32. hysteroscopy
IN THE PRESENCE OF AN ABNORMALLY THICK ENDOMETRIUM,
WHEN MYOMAS EXIST SUSPICIOUSLY CLOSE TO THE EEC OR
WHEN ABNORMAL BLEEDING OCCURS OR PERSISTS DESPITE A
NORMAL TVUS, HYSTEROSCOPY IS INDICATED.
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
32
33. Endometrial carcinoma and endometrial hyperplasia (AUB-M),
especially
those arising as a field defect, may not always be clearly
recognizable by
hysteroscope alone, which should be performed in conjunction
with
endometrial biopsy.
Definition
Symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
33
34. SIS v/s Hysteroscopy
SIS is comparable to hysteroscopy in its sensitivity
for
the diagnosis of intracavitary polyps and
submucosal
myomas
In SIS- limited evaluation of the endocervical canal
and
the inability to concurrently remove selected lesions
34
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
35. Medical treatment
NON HORMONAL ……
NSAID
REDUCED MENSTRUAL BLOOD LOSS BY 33% TO 55% WHEN COMPARED
WITH PLACEBO, WITHOUT A SIGNIFICANT DIFFERENCE IN ADVERSE
EFFECTS.
ADDED BENEFIT OF IMPROVING DYSMENORRHEA FOR UP TO 70% OF
PATIENTS.
START BEFORE THE DAY OF MENSES AND CONTINUE FOR 3-5 DAYS.
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
35
36. Tranexemic acid
OVERALL REDUCTION IN MENSTRUAL BLOOD LOSS BETWEEN 40% AND 59%
FROM BASELINE.
1 GRAM OF TRANEXAMIC ACID TAKEN ORALLY EVERY 6 HOURS DURING
MENSTRUATION, BUT A SINGLE DAILY DOSE OF 4 GRAMS HAS ALSO BEEN
FOUND TO BE EFFECTIVE
INTRAVENOUS TRANEXAMIC ACID IS AVAILABLE FOR MORE ACUTE
SCENARIOS, WITH A DOSE OF 10 MG/KG EVERY 6 HOURS.
SUPERIORITY OF TRANEXAMIC ACID TO LUTEAL-PHASE PROGESTINS AND
NSAID
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
36
37. Hormonal…
CYCLIC LUTEAL-PHASE PROGESTIN THERAPY IS SIGNIFICANTLY LESS
EFFECTIVE IN TREATING “MENORRHAGIA” THAN NSAIDS, TRANEXAMIC
ACID, OR DANAZOL
IN CONTRAST, LONG-CYCLE, HIGH-DOSE ORAL PROGESTINS HAVE BEEN
SHOWN TO REDUCE MENSTRUAL LOSSES FOR WOMEN WITH HEAVY
MENSTRUAL BLEEDING.
DANAZOL AND GONADOTROPIN-RELEASING HORMONE AGONISTS WILL
EFFECTIVELY REDUCE MENSTRUAL BLEEDING, AND MAY BE USED FOR
SCENARIOS IN WHICH OTHER MEDICAL OR SURGICAL TREATMENTS HAVE
FAILED OR ARE CONTRAINDICATED.
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
37
40. Composition
• Composed of estradiol-17 valerate and cyproterone
acetate
• Presented in calendar packs of 21 tablets each
• First 11 tablets contain estrogen only; the other 10
contain both hormones
ClimenDefinition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
40
41. Contraindications of HRT
PREVIOUS THROMBOEMBOLIC DISEASE
IMPAIRED LFT/ LIVER DISEASE
CARCINOMA BREAST
CARCINOMA ENDOMETRIUM
FIBROIDS &ENDOMETRIOSIS(relative)
HYPERTENTION,DIABETES,CARDIO-VASCULAR
DISEASE ARE NOT C/I
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
41
42. Oral Progestogens
Norethisterone acetate (Primolute N)
Dose is 5-10mg three times a day from day 6 to
26 of the cycle
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
42
43. Mirena®
Indications:
Contraception
Treatment of heavy menstrual bleeding (idiopathic
menorrhagia)
Protection from endometrial hyperplasia during
oestrogen replacement therapy
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
43
44. LNG-IUS
Maximal Benefits Outweigh Minimal Risks.
A reduction in menstrual blood loss of 86% at 3 months and 97% at 12
months was demonstrated in a single-arm study on the use of the LNG-
IUS in women with menorrhagia,
20-80% become amenorrhic by 12 months.
44
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
45. Endometrial effects with Mirena®
Before Mirena®
Endometrial changes
Ovulation
Menstruation
Reduced
menstruation
After Mirena®
Ovulation
45
46. Surgical management
indications-
-failure to respond to medical therapy,
-inability to utilize medical therapies (i.e. side effects, contraindications),
-significant anemia,
-impact on quality of life, and
concomitant uterine pathology (large uterine fibroids, endometrial
hyperplasia).
46
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
47. Surgical ….
DIAGNOSTIC HYSTEROSCOPY / DILATATION &
CURRETTAGE
FOR THE ACTIVELY BLEEDING WOMAN WITH SEVERE MENORRHAGIA
AND SECONDARY HYPOVOLEMIA, A D&C SHOULD BE CONSIDERED,
PARTICULARLY IF HORMONAL TREATMENT THE D&C IS DIAGNOSTIC BUT
RARELY CURATIVE IN THE CHRONIC MENORRHAGIA PATIENT, BECAUSE WHILE
THE SUPERFICIAL HYPERPLASTIC ENDOMETRIUM IS REMOVED, THE
UNDERLYING LESION PERSISTS.
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
47
48. SURGICAL HYSTEROSCOPY
ON OCCASIONS, A LESION PREVIOUSLY NOT ACCESSIBLE TO
ENDOSCOPIC THERAPY, AFTER TWO TO THREE MONTHS
MEDICAL
PRE-TREATMENT WITH GNRH AGONISTS OR DANAZOL TO
SHRINK
THE FIBROID, MAY BE REDUCED TO A SIZE WHICH IS
TREATABLE
BY HYSTEROSCOPIC RESECTION.
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
48
49. ENDOMETRIAL ABLATION
IN THE PRESENCE OF GENERALIZED ENDOMETRIAL DISEASE,
E.G. EXTENSIVE SUBMUCOSAL FIBROIDS, OR WHEN MEDICAL THERAPY
FAILS TO CONTROL THE MENORRHAGIA, A DECISION NEEDS TO
BE MADE AS TO WHETHER HYSTEROSCOPIC ENDOMETRIAL ABLATION
OR HYSTERECTOMY IS THE PREFERRED TREATMENT.
Definition
symptoms
FIGO
Classification
Differential
diagnosis
diagnosis
Treatment
49
If the fibroid projects into the lumen
by more than 50% of its surface, then it can be resected by hysteroscopy, obviating an abdominal surgical procedure
Saline infusion sonohysterography is a simple technique that yields additional information over TVS in evaluation of endometrial and subendometrial conditions
SIS added certainty to the
diagnosis in 88% of the patients studied.
SIS results changed the patients’ treatment in 80% of cases.
increased diagnostic confidence by 86%.
In the presence of an abnormally thick endometrium, when myomas exist suspiciously close to the EEC or when abnormal bleeding occurs or persists despite a normal TVUS, hysteroscopy is indicated.
Androgenic steroids The effect is dose related. At higher
doses (600-800 mg daily),
Gonadotrophin releasing hormone agonists are
extremely effective for cycle suppression and quickly
bring about complete amenorrhoea
Continuous progestin therapyfor two months and then
14 days per month thereafter, can be expected to induce
endometrial atrophy.
There are three indications for Mirena®:
Contraception
Treatment of heavy menstrual bleeding (idiopathic menorrhagia)
Endometrial protection during oestrogen replacement therapy.
This presentation will focus on the use of Mirena® for the treatment of
heavy menstrual bleeding.
Currently, Mirena® is marketed in 113 countries and has market authorisation in a further 15 countries. As of December 2012, there have been 28.4 million cumulative Mirena® placements since launch, corresponding to 83.4 million cumulative women-years of experience.
This figure shows the endometrial changes that occur with Mirena use, compared with the ‘normal’ cyclical changes observed without Mirena® use.
Mirena® induces profound morphological and biochemical changes in the endometrium, mainly as a result of the high endometrial levonorgestrel concentration. This downregulates endometrial oestrogen and progesterone receptors, making the endometrium insensitive to circulating oestradiol (thereby suppressing endometrial growth).
After only a couple of months of Mirena® use, the glands of the endometrium atrophy, the stroma becomes swollen and decidual, the mucosa thins and the epithelium becomes inactive. Vascular changes include a thickening of arterial walls, suppression of the spiral arterioles and capillary thrombosis.3 An inflammatory reaction characterised by an increase in neutrophils, lymphocytes,
plasma cells and macrophages is described3,4 and focal stromal necrosis may also occur.2,4
The endometrium becomes uniformly atrophic and suppressed within 3 menstrual cycles after Mirena® placement,3 and persists in this thin, inactive state with no further histological development taking place over the long-term.2
The initial changes in the endometrium caused by Mirena® may be associated with irregular bleeding or spotting, particularly in the first few months of treatment. With Mirena® use, once the endometrial effects are established, bleeding becomes less in quantity than usual, or may cease altogether.
Following Mirena® removal, the morphological changes in the endometrium revert to ‘normal’, and menstruation has been reported from as early as the first month afterwards.5
References
Pakarinen PI, et al. Hum Reprod 1998; 13: 1846–53.
Silverberg SG, et al. Int J Gynecol Pathol 1986; 5: 235–41.
Zhu PD, et al. Contraception 1989; 40: 425–38.
Phillips V, et al. J Clin Pathol 2003; 56: 305–7.
Nilsson CG & Lahteenmaki P. Contraception 1977; 15: 389–400.
