Menses Abnormal uterine Bleeding Differential diagnoses Leiomyoma, its medical and surgical management

1. Powerpoint Templates
Page 1
Powerpoint Templates
Abnormal Uterine Bleeding:
Leiomyoma
Case Discussion

2. Powerpoint Templates
Page 2
Objectives
• Review normal menstruation
• Discuss the differential diagnoses of
abnormal uterine bleeding in a
reproductive age woman
• Discuss the diagnosis of leiomyoma and
its management

3. Powerpoint Templates
Page 3
Normal Menses
• Menses is a suspension of blood- and
tissue-derived solids within a mixture of
serum and cervico-vaginal fluid.
• Generally conform to a cycle length of 21
to 35 days, with a duration of fewer than 7
days of menstrual flow
• Average blood loss per cycle is 35mL
Berek and Novak’s 14th
ed

4. Powerpoint Templates
Page 4

5. Powerpoint Templates
Page 5

6. Powerpoint Templates
Page 6
Endometrium
throughout menstrual cycle

7. Powerpoint Templates
Page 7
Normal Menstruation
• Factors that come into play for
hemostasis:
1. A higher thromboxane level (PGF2) in
relation to prostacyclin (PGE2)
2 .Fibrin clot formation
3. Stabilization of the hemostatic platelet plug
The absence of any, or all of these factors may
result in heavier menstruation.

8. Powerpoint Templates
Page 8
Abnormal Uterine Bleeding
• Encompasses any significant deviation from
normal frequency, regularity, heaviness (volume
or amount) and duration of menstrual bleeding
• It is used to describe all abnormal menstrual
signs and symptoms arising from the uterine
corpus.
POGS CPG 2009

9. Powerpoint Templates
Page 9
Terms used to describe AUB
• Menorrhagia: prolonged or heavy
(>80ml/cycle)
• Metrorrhagia: intermenstrual
• Breakthrough bleeding: associated
with hormone therapy
• Menometrorrhagia
William’s Gyne 2nd
ed

10. Powerpoint Templates
Page 10
• Hypomenorrhea: diminished or
shortening of menses
• Oligomenorrhea: cycle with intervals
>35days
• Withdrawal bleeding: predictable
bleeding that results from an abrupt
decline in progesterone levels
Terms used to describe AUB

11. Powerpoint Templates
Page 11

12. Powerpoint Templates
Page 12

13. Powerpoint Templates
Page 13

14. Powerpoint Templates
Page 14
Pregnancy is the first consideration in
women of reproductive age who
present with AUB

15. Powerpoint Templates
Page 15
Non-pregnancy related genital causes:

16. Powerpoint Templates
Page 16
Acute v. Chronic AUB
• Acute: characterized by significant blood
loss that results in hypovolemia or shock.
• Chronic: bleeding from the uterine corpus
that is abnormal in duration, volume,
regularity and/or frequency and has been
present for the majority of the last 6
months.

17. Powerpoint Templates
Page 17
Diagnosis of AUB
• 1. History
• 2. Physical Examination
• 3. Blood Tests
• 4. Imaging Procedures

18. Powerpoint Templates
Page 18
LEIOMYOMA

19. Powerpoint Templates
Page 19
Leiomyoma
• Uterine myoma (i.e. fibroids) are benignbenign
monoclonal tumors arising from the
smooth muscle cells of the myometrium.
• Myomas may contain a large amount of
extracellular matrix (collagen,
proteoglycan, fibronectin) surrounded by a
thin pseudocapsular of areolar tissue and
compressed muscle fibers

20. Powerpoint Templates
Page 20
Epidemiology
• Growth parallels the ontogeny and life
cycle changes of the reproductive
hormones estrogen and progesterone
• Although the growth of myoma is
responsive to gonadal steroids, these
hormones are not necessarily responsible
for the genesis of the tumors.

21. Powerpoint Templates
Page 21
Risk Factors
• Age:
– 30s and 40s through menopause
– After menopause, myoma usually shrink
• Geography/Race/Ethnic origin
– African-American has the highest incidence,
while Hispanic and Asian women have a
lower incidence similar rates as to the whites

22. Powerpoint Templates
Page 22
Risk Factors
• Weight / BMI/ Obesity
• Genetic factor
• Gravidity and Parity
– Pregnancy decreases risk
• Use of OCPs
– OCP decreases risk

23. Powerpoint Templates
Page 23
Risk Factors
• Smoking
– Smoking decreases risk
• Menarche
– Early menarche increases risk
• Diet
– High fat and eating large amounts of red
meats increase the risk

24. Powerpoint Templates
Page 24
Clinical Features
• majority asymptomatic (60%), often
discovered as incidental finding on pelvic
exam or U/S
• abnormal uterine bleeding (30%):
dysmenorrhea, menorrhagia

25. Powerpoint Templates
Page 25
Clinical Features
• pressure/bulk symptoms (20-50%)
– pelvic pressure/heaviness
– increased abdominal girth
– urinary frequency and urgency
– acute urinary retention (extremely rare but
surgical emergency!)
– constipation, bloating (rare)

26. Powerpoint Templates
Page 26
Clinical Features
• acute pelvic pain
– fibroid degeneration
– fibroid torsion (pedunculated subserosal)
• infertility, recurrent pregnancy loss
• pregnancy complications (potential
enlargement and increased pain,
obstructed labor, difficult C-section)

27. Powerpoint Templates
Page 27
Types

28. Powerpoint Templates
Page 28
Diagnosis
• Bimanual exam:
– uterus asymmetrically enlarged, usually
mobile
• CBC:
– anemia
• U/S:
– to confirm diagnosis and assess location of
fibroids

29. Powerpoint Templates
Page 29
Diagnosis
• sonohysterogram:
– useful for differentiating endometrial polyps
from submucosal fibroids, or if intracavitary
growth
• endometrial biopsy:
– to rule out uterine cancer for abnormal
uterine bleeding (especially if age >40 yr)
• occasionally MRI is used for pre-operative
planning (e.g. before myomectomy)

30. Powerpoint Templates
Page 30
Treatment
• The majority of myoma is asymptomatic
and will not require therapy (POGS CPG 2010)

31. Powerpoint Templates
Page 31
Factors influencing Treatment
• Size
– In asymptomatic women with a uterine
myoma > 20wks, hysterectomy or
myomectomy is an option (POGS CPG 2010)

32. Powerpoint Templates
Page 32
Factors influencing Treatment
• Bleeding
– In women who present with acute hemorrhage
related to uterine myoma, conservative
management consisting of hysteroscopy, or
D&C may be considered but hysterectomy
may become necessary in some cases (POGS
CPG 2010)

33. Powerpoint Templates
Page 33
Factors influencing Treatment
• Age
– Hormone replacement therapy may cause
myoma growth in postmenopausal women but
it does not appear to cause clinical symptoms.
– Postmenopausal bleeding and pain in women
with myoma should be investigated in the
same way as in women without myoma. (POGS
CPG 2010)

34. Powerpoint Templates
Page 34
Factors influencing Treatment
• Degeneration
– There is currently no evidence to substantiate
performing a hysterectomy for an
asymptomatic myoma for the sole purpose of
alleviating the concern that it may be
malignant. (POGS CPG 2010)

35. Powerpoint Templates
Page 35
Medical Management
• Medical management of myoma should be
tailored to the needs of the patient and
should be geared towards alleviating her
symptoms.
• Cost and side effects may limit their long-
term use.

36. Powerpoint Templates
Page 36
Progestins
• When contraceptive steroid therapy is
initiated, close monitoring of both myoma
and uterine size is recommended

37. Powerpoint Templates
Page 37
GnRH agonist
• Available in nasal spray, subcutaneous inj,
slow release inj.
• In general, myoma are expected to shrink
by up to 50% of their initial volume within 3
months of therapy.
• Admin. Of GnRH analogues for 2-4months
prior to surgery for uterine myoma is
recommended for women with a large
uterus (>18wks size) or with preoperative
anemia

38. Powerpoint Templates
Page 38
Danazol
• Danazol is a synthetic isoxazole derivative
chemically related to 17-ethinyl testosterone
which creates a high androgen and low estrogen
environment resulting in the wasting of
endometrium and shrinkage of myoma.
• S/Es include acne, hirsutism, weight gain,
irritability, musculoskeletal pain, hot flushes and
breast atrophy

39. Powerpoint Templates
Page 39
Surgical management
• Hysterectomy
– Indicated only in asymptomatic women when
rapidly enlarging or after menopause.
– In women who do not wish to preserve fertility
and who have been counseled regarding the
alternatives and risks, hysterectomy may be
offered as the definitive treatment for
symptomatic uterine myoma and is
associated with a high level of satisfaction.

40. Powerpoint Templates
Page 40
Surgical management
• Myomectomy
– Option for women who wish to preserve their
uterus, but women should be counseled
regarding the risk of requiring further
intervention.
– Studies show a higher risk for blood loss and
greater operative time

41. Powerpoint Templates
Page 41
Surgical management
• Selective uterine artery occlusion
– interventional radiology approach
– shrinks fibroids by 50% at 6 mo;
– improves menorrhagia in 90% of patients
within 1-2 mo; not an option in women
considering childbearing

42. Powerpoint Templates
Page 42
Mnemonic