Dysfunctional uterine bleeding


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Dysfunctional uterine bleeding
Aboubakr Elnashar

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Dysfunctional uterine bleeding

  1. 1. Dysfunctional uterine bleeding Aboubakr Elnashar Benha university, Egypt Aboubakr Elnashar
  2. 2. Define DUB: Any abnormal uterine bleeding in absence of pregnancy, genital tract pathology, or systemic disease Menorrhagia; commonest symptom DUB: 50-60% 15-20% of gynaecological referrals to Hospital Excessive blood loss: >80mL are clinically meaningless If periods are reported as unacceptably heavy. then they are! Aboubakr Elnashar
  3. 3. CLINICAL TYPES Polymenorrhoea: frequent (<21 d) menstruation, at regular intervals Menorrhagia: Excessive & / or prolonged menstruation, at regular intervals Metrorrhagia: Excessive & / 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) Aboubakr Elnashar
  4. 4. Aetiology unknown. Mechanisms 1. Abnormal PG ratios (+ other inflammatory mediators) favoring VD and platelet non- aggregation. 2. Excessive fibrinolysis. 3. Defects in expression/function of matrix metalloproteinases (MMPs), vascular growth factors, and endothelins. 4. Aberrant steroid receptor function. 5. Defects in the endomyometrial junctional zone. Aboubakr Elnashar
  5. 5. Diagnosis Symptoms 1. Heavy and/or prolonged vaginal bleeding (with clots and flooding): 2. Irregular, heavy periods usually occur at the extremes of reproductive life (post-menarche and peri-menopausal). 3. ± dysmenorrhoea. 4. Systemic symptoms of anaemia and disruption of life due to bleeding. 5. A smear history and contraceptive use are vital information. Totally irregular bleeding, IMB. or PCB: prompt a search for cervical or endometrial pathology. Aboubakr Elnashar
  6. 6. Clinical signs 1. Anaemia. 2. Abdomino-pelvic examination: usually normal. If the uterus is significantly enlarged. fibroids are likely. Aboubakr Elnashar
  7. 7. Differential diagnosis 1. Submucous fibroids. 2. Adenomyosis. 3. Endometrial polyps, hyperplasia, or cancer. 4. Very rarely hypothyroidism or coagulation defects. Aboubakr Elnashar
  8. 8. Investigations 1. Pregnancy should always be considered and excluded. 2. CBC (Hb + MCV). 3. Not a routine a. Ferritin, TFT s, and clotting screens: investigations-only consider if clinically indicated. b. Cervical smears: not done opportunistically if smear history normal. c. STI screen including Chlamydia. Aboubakr Elnashar
  9. 9. Testing for coagulation disorders (von Willebrand’s disease) 1. HMB since menarche adolescents 2. Personal or family history suggesting a coagulation disorder. Prothrombin time, Partial thrmoplastin time, Bleeding time, Platelets, Von Willebrand factor with the ristocetin cofactor assay {the single best screening test for the disease. This prevents false-negative results}  Prolactin & TSH: especially in adolescents Aboubakr Elnashar
  10. 10. 4. <45yrs The risk of endometrial pathology is very small: No further investigation: treat and await clinical response. Aboubakr Elnashar
  11. 11. 5. If >45yrs risk factors for endometrial disease, or no clinical response: 1. TVS US  endometrial polyps fibroids measuring endometrial thickness. The risk of endometrial pathology with a normal TVS USS is small, but it may be less accurate during menstruation Aboubakr Elnashar
  12. 12. 2. Pipelle endometrial biopsy Indication: erratic bleeding in women >45yrs To exclude hyperplasia or cancer Aboubakr Elnashar
  13. 13. 3. Hysteroscopy and biopsy • Indication 1. Erratic bleeding in a woman >45yrs if USS reveals focal pathology. e.g. polyp, or is unable to assess the whole endometrium, 2. biopsy is inadequate 3. bleeding is persistent or repeated. Aboubakr Elnashar
  14. 14. Management Regular DUB 1. Mirena IUCD •Releases measured doses of levonorgestrel into the endometrial cavity for 5yrs inducing an atrophic endometrium. •Effects: Blood loss dec by up to 90% 30% will be amenorrhoeic at 12mths. major dec in number of hysterectomies. Provides contraception. •Side effects: insertional issues irregular PV bleeding for first 4-6mths (usually abates) progestagenic side effects: rare {minimal systemic absorption}. Aboubakr Elnashar
  15. 15. 2. Antifibrinolytics: tranexamic acid •1g tds days 1-4 •40% dec in loss •Safe, non-hormonal, non-contraceptive •Side effects leg cramps minor GI upset •Caution in cardiac disease. The majority of women will respond to medical therapy, especially tranexamic ± mefenamic add. Aboubakr Elnashar
  16. 16. 3. NSAIDS: mefenamic acid •500mg tds days 1-5 •20-30% dec in loss •significant dec in dysmenorrhoea •Safe, non-hormonal contraceptive. •Side effects GI upset including ulceration. renal impairment •Caution: Asthmatic CV disease renal impairment peptic ulcer. Aboubakr Elnashar
  17. 17. 4. COCP: •20-30% dec loss •improvement in dysmenorrhoea •provides contraception •Side effects BTB Headache Wt gain Aboubakr Elnashar
  18. 18. •Contraindications 1. Breast cancer 2. Breast feeding, postpartum less than 1 month 3. Cirrhosis Severe 4. DVT/PE 5. DM: nephropathy, retinopathy, 6. GB disease 7. Headache: Migraine with aura 8. Hypertension 9. Liver tumors: adenoma, malignancy 10.Multiple risk factors for arterial vas Dis 11.Smoking +above 35 y 12.SLE 13.Viral hepatitis: acute 14.Drug interaction: Anticonvulsant, Rifampicin,Aboubakr Elnashar
  19. 19. 5. Oral progestagens: no benefit in regular menorrhagia other than-short term continuous treatment to stop bleeding. Aboubakr Elnashar
  20. 20. Irregular DUB 1. Mirena IUCD: as above. 2. Tranexamic 3. mefenamic acid useful to dec loss during periods. 4. COCP regulate an irregular cycle safe up to the menopause if no other cardiovascular risk factors. Aboubakr Elnashar
  21. 21. 4. Progestagen •Cyclical (days 5-26) •Norethisterone 5mg tds or medroxyprogesterone acetate 5-10 mg tds •Regulates cycle. but little evidence to suggest dec in loss •Side effects Bloating headache. Aboubakr Elnashar
  22. 22. 5. further medical treatment Indications 1. First-line therapy has failed 2. Very anaemic women, bleeding continuously. having their life disrupted 3. Cautions or contraindications to surgery. a. GnRH analogues •Achieve amenorrhoea quickly by inducing a medical menopausal state •Side effects vasomotor symptoms •use limited to 6-12mths maximum {bone loss}. Aboubakr Elnashar
  23. 23. b. High-dose progestagens: •medroxyprogesterone acetate 10mg tds continuously •induce amenorrhoea. •may be time-limited due to side effects. Danazol and ethamsylate: no longer indicated. Aboubakr Elnashar
  24. 24. Surgical management Indications 1. Failure to respond to medical management 2. Women have completed her family Aboubakr Elnashar
  25. 25. 1. Endometrial ablation  Destruction of the endometrium down to the basalis layer Effective for most women Methods: 1. Hysteroscopic resection, or rollerball ablation now used much less often {operative complications} 2. New A. Microwave (MEA). B. Thermal balloon (Thermachoice). C. Novasure (electrical impedance). Aboubakr Elnashar
  26. 26. Therma Choice: Heating element within the balloon (Neuwirth et al 1994) Aboubakr Elnashar
  27. 27. Nova sure: The bipolar radio frequency wire mesh over a triangular frame (Cooper et al 2002) Aboubakr Elnashar
  28. 28. Microwave endometrial ablation (Bain et al., 2002) MEA Aboubakr Elnashar
  29. 29. Results •less effective if the endometrial cavity is >10cm. •in normal size cavities: 80-90%: significantly improved. 30%: amenorrhoeic. 20%: need a second procedure by 5yrs. Risk: Small bleeding, infection, uterine perforation, and failed procedure. very safe and straight­forward Carried out under GA but may occasionally be done under cervical block. Aboubakr Elnashar
  30. 30. 2. Hysterectomy The only guaranteed cure for DUB Compared to ablation higher morbidity longer recovery financial costs Complications Haemorrhage Infection bladder, ureteric, or bowel injury «1%). Death is extremely rare. Long-term satisfaction rates very high and regardless of method most women report improved sexual function Aboubakr Elnashar
  31. 31. Aboubakr Elnashar
  32. 32. Aboubakr Elnashar Thank you