This topic contains detailed description about labour, its definition, date of onset of labour, calculations of date of delivery, causes of onset of labour, physiology of normal labour, and events, clinical course and management of each stages of labour.
Uterine prolapse occurs when weakened or damaged muscles and connective tissues such as ligaments allow the uterus to drop into the vagina. Common causes include pregnancy, childbirth, hormonal changes after menopause, obesity, severe coughing and straining on the toilet.
This topic contains detailed description about labour, its definition, date of onset of labour, calculations of date of delivery, causes of onset of labour, physiology of normal labour, and events, clinical course and management of each stages of labour.
Uterine prolapse occurs when weakened or damaged muscles and connective tissues such as ligaments allow the uterus to drop into the vagina. Common causes include pregnancy, childbirth, hormonal changes after menopause, obesity, severe coughing and straining on the toilet.
Osteoporosis, Hypothyroidism..... Not Just a Woman's Disease By Ms.Prema Kodical
This is part of the HELP Talk series at HELP,Health Education Library for People, the worlds largest free patient education library www.healthlibrary.com
PID and its newer concepts.This presentation is done after grouping information from a variety of textbooks,journals and of course our professors.will definitely enlighten you
Prevalence of Anemia among Jordanian Pregnant Women and the Effect of Early...Runa La-Ela
Iron deficiency anemia is a problem of serious public health affecting more than 700 million in the world.
It is considerably more prevalent in the developing than in the industrialized world.
Iron deficiency anemia is a substantial reduction in proportion of women with hemoglobin level below 10 or 10.5 g/dL.
Very low activities of alkaline phosphatase in first trimester indicated affected fetus.
The term metrorrhagia is often used for irregular menstruation that occurs between the expected menstrual periods. Oligomenorrhea is the medical term for infrequent, often light menstrual periods (intervals exceeding 35 days). Amenorrhea is the absence of a menstrual period in a woman of reproductive age.
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
Telehealth psychology is a digital approach that offers psychological services and mental health care to clients remotely, using technologies like video conferencing, phone calls, text messaging, and mobile apps for communication.
Health Education on prevention of hypertensionRadhika kulvi
Hypertension is a chronic condition of concern due to its role in the causation of coronary heart diseases. Hypertension is a worldwide epidemic and important risk factor for coronary artery disease, stroke and renal diseases. Blood pressure is the force exerted by the blood against the walls of the blood vessels and is sufficient to maintain tissue perfusion during activity and rest. Hypertension is sustained elevation of BP. In adults, HTN exists when systolic blood pressure is equal to or greater than 140mmHg or diastolic BP is equal to or greater than 90mmHg. The
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
Leading the Way in Nephrology: Dr. David Greene's Work with Stem Cells for Ki...Dr. David Greene Arizona
As we watch Dr. Greene's continued efforts and research in Arizona, it's clear that stem cell therapy holds a promising key to unlocking new doors in the treatment of kidney disease. With each study and trial, we step closer to a world where kidney disease is no longer a life sentence but a treatable condition, thanks to pioneers like Dr. David Greene.
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
ICH Guidelines for Pharmacovigilance.pdfNEHA GUPTA
The "ICH Guidelines for Pharmacovigilance" PDF provides a comprehensive overview of the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) guidelines related to pharmacovigilance. These guidelines aim to ensure that drugs are safe and effective for patients by monitoring and assessing adverse effects, ensuring proper reporting systems, and improving risk management practices. The document is essential for professionals in the pharmaceutical industry, regulatory authorities, and healthcare providers, offering detailed procedures and standards for pharmacovigilance activities to enhance drug safety and protect public health.
2. Menorrhagia
MENORRHAGIA {Syn: Hypermenorrhoea)
Definition
• Menorrhagia is defined as cyclic bleeding at
normal intervals; the bleeding is either
excessive in amount (> 80 ml) or duration (> 7
days) or both.
• The term menotaxis is often used to denote
prolonged bleeding.
7. Common causes of menorrhagia
• Dysfunctional uterine bleeding
• Fibroid uterus
• Adenomyosis
• Chronic tubo-ovarian mass
8. DIAGNOSIS :
• Long duration of flow,
• passage of big clots,
• use of increased number of thick sanitary pads,
• pallor and low level of haemoglobin give an
idea about the correct diagnosis and magnitude
of menorrhagia.
10. POLYMENORRHOEA:(Epimenorr
hoea)
Definition
• Polymenorrhoea is defined as cyclic bleeding
where the cycle is reduced to an arbitrary limit
of less than 21 days and remains constant at
that frequency.
• If the frequent cycle is associated with
excessive and or prolonged bleeding, it is
called epimenorrhagia.
11. Causes :
1.Dysfunctional
• It is seen predominantly during adolescence, preceding
menopause and following delivery and abortion.
• Hyperstimulation of the ovary by the pituitary hormones may
be the responsible factor.
2.Ovarian hyperaemia
13. METRORRHAGIA
Definition :
• Metrorrhagia is defined as irregular, acyclic bleeding from
the uterus.
• Amount of bleeding is variable.
• Then again, irregular bleeding in the form of contact
bleeding or intermenstrual bleeding in an otherwise normal
cycle is also included in metrorrhagia.
• In fact, it is mostly related to surface lesion in the uterus .
Menometrorrhagia is the term applied when the bleeding is
so irregular and excessive that the menses (periods)
14. Causes of acyclic bleeding
• DUB — usually during adolescence, following childbirth and
abortion and preceding menopause
• Submucous fibroid
• Uterine polyp
• Carcinoma cervix and endometrial carcinoma
15. Causes of intermenstrual bleeding
• Urethral caruncle
• Ovular bleeding
• Breakthrough bleeding in pill use
• IUCD in utero
• Decubitus ulcer
16. Treatment
• Treatment is directed to the underlying pathology.
• Malignancy is to be excluded prior to any definitive
treatment.
18. Causes
• Age-related
• Weight-related
• Stress and exercise related
• Endocrine disorders
• Androgen producing tumours
• Tubercular endometritis
• Drugs:
o phenothiazines
o Cimetidine
o methyldopa
19. HYPOMENORRHOEA
Definition :
When the menstrual bleeding is unduly scanty
and lasts for less than 2 days, it is called hypo-
menorrhoea.
Causes
• The causes may be local
• endocrinal
• or systemic
20. DYSFUNCTIONAL UTERINE
BLEEDING (DUB)
Definition
• DUB is defined as a state of abnormal uterine
bleeding without any clinically detectable
organic, systemic and iatrogenic cause.
• Heavy menstrual bleeding (HMB) is defined as
a bleeding that interferes with woman's
physical, emotional, social and material quality
of life.
21. Incidence
• incidence of 10 per cent amongst new patients
attending the out-patient seems logical.
• The bleeding may be abnormal in frequency,
amount or duration or combination of any three.
• Currently DUB is defined as a state of abnormal
uterine bleeding following anovulation due to
dysfunction of hypothalamo-pituitary-ovarian axis
(endocrine origin).
22. Pathophysiology
The physiological mechanism of haemostasis in normal
menstruation are :
(1) Platelet adhesion formation.
(2) Formation of platelet plug with fibrin to seal the bleeding
vessels.
(3) Localised vaso constriction.
(4) Regeneration of endometrium.
Biochemical mechanism involved are :
23. In increased endometrial ratio of PGF2α/PGE2.
• PGF2α causes vasoconstriction and reduces bleeding.
• Progesterone increases the level of PGF2α from
arachidonic acid.
• Levels of endothelin which is a powerful vasoconstrictor
is also increased.
• In anovulatory DUB there is decreased synthesis of
PGF2α and the ratio of PGF2α/PGE2 is low.
• Anovulatory cycles are usually not associated with
dysmenorrhoea as the level of PGF2α is low. Women with
menorrhagia have low level of thromboxane in the
endometrium.
24. • The endometrial abnormalities may be primary or secondary to
incoordination in the hypothalamo- pituitary-ovarian axis.
• Emotional influences, worries, anxieties or sexual problems
sometimes are enough to disturb the normal hormonal balance.
25. The abnormal bleeding may be associated with
or without ovulation and accordingly grouped
into :
• Ovular bleeding
• Anovular bleeding
26. Ovular bleeding
a.Polymenorrhoea or polymenorrhagia:
• The condition usually occurs following childbirth and
abortion, during adolescence and premenopausal period and in
pelvic inflammatory disease.
• The follicular development is speeded up with resulting
shortening of the follicular phase.
• This is probably due to hyperstimulation of the follicular
growth by FSH.
• Rarely, the luteal phase may be shortened due to premature
lysis of the corpus luteum. Sometimes, it is related to stress
induced stimulation.
• Endometrial study prior to or within few hours of menstruation
reveals secretory changes.
27. b. Oligomenorrhoea:
• Primary ovular oligomenorrhoea is rare.
• It may be met in adolescence and preceding
menopause.
• The disturbance may be due to ovarian
unresponsiveness to FSH or secondary to pituitary
dysfunction.
• There is undue prolongation of the proliferative
phase with normal secretory phase.
• Endometrial study prior to or within few hours of
menstruation reveals secretory changes.
29. Irregular shedding of the endometrium
• The abnormality is usually met in extremes of
reproductive period.
• Normally, regeneration of the endometrium is
completed by the end of third day of
menstruation.
• In irregular shedding, desquamation is continued
for a variable period with simultaneous failure of
regeneration of the endometrium.
30. The possible explanations are:
• Incomplete withdrawal of LH even on 26th day of
cycle incomplete atrophy of the corpus luteum
persistent secretion of progesterone.
• Persistent LH -» inhibition of FSH -» suppresses
ripening of the follicle in the next cycle -> less
oestrogen -» less regeneration.
• Endometrial sampling performed after 5th or 6th
day of the onset of menstruation reveals a mixture
of secretory and proliferative endometrium. There
is total absence of any surface epithelium.
31. Irregular ripening of the endometrium
• There is poor formation and inadequate function of the
corpus luteum.
• Secretion of both oestrogen and progesterone is inadequate
to support the endometrial growth.
• As such, slight bleeding occurs and continues prior to the
start of proper flow.
• The endocrine profile in the luteal phase shows persistent
low level of urinary pregnanediol level of less than 3 mg or
plasma progesterone level less than 5 ng/ml.
• Endometrial study prior to or soon after spotting reveals
patchy area of secretory changes amidst proliferative
endometrium.
32. Anovular bleeding
a.Menorrhagia
• Anovular bleeding is usually excessive.
• In the absence of growth limiting progesterone due to
anovulation, the endometrial growth is under the
influence of oestrogen throughout the cycle.
• There is inadequate structural stromal support and the
endometrium remains fragile.
• Thus, with the withdrawal of oestrogen due to negative
feedback action of FSH, the endometrial shedding
continues for a longer period in asynchronous
sequences because of lack of compactness.
33. b.Cystic glandular hyperplasia
(Syn:Metropathiahaetnorrhagica,Schroeder's
disease)
• This type of abnormal bleeding is usually met in
premenopausal women.
• The basic fault may lie in the ovaries or may be
due to disturbance of the rhythmic secretion of the
gonadotrophins.
• There is slow increase in secretion of oestrogen
but no negative feedback inhibition of FSH.
• The net effect is gradual rise in the level of
oestrogen with concomittant phase of
amenorrhoea for about 6-8 weeks.
34. • As there is no ovulation, the endometrium is under the
influence of oestrogen without being opposed by growth
limiting progesterone for a prolonged period.
• After a variable period, however, the oestrogen level falls
resulting in endometrial shedding with heavy bleeding.
• Bleeding also occurs when the endometrial growth have
outgrown their blood supply.
• Due to increased endometrial thickness, tissue breakdown
continues for a long time.
• Bleeding is heavy as there is no vasoconstrictor effect of
PGF2α.
• Bleeding is prolonged until the endometrium and blood
vessels regenerate to control it.
35. Changes in the uterus :
• There is variable degree of myohyperplasia with symmetrical
enlargement of the uterus to a size of about 8-10 weeks due to
simultaneous hypertrophy of muscles .
• The endometrial changes are classical.
• On naked eye examination, the endometrium looks thick,
congested and often polypoidal (multiple polyposis).
36. Microscopically
• There is marked hyperplasia of all the endometrial
components.
• There is however, intense cystic glandular hypertrophy
rather than hyperplasia with marked disparity in sizes.
• Some of the glands are small, others are large giving the
appearance of "Swiss cheese" pattern (small and large holes
of Swiss cheese made in Switzerland).
• The glands are empty and lined by columnar epithelium.
• Absence of secretory changes.
• Areas of necrosis in the superficial layers with small
haemorrhages and leucocytic infiltration .
37. Changes in the ovary :
• Cystic changes maybe observed involving one
or both the ovaries.
• The cyst may be single or multiple and the
fluid contains oestrogen.
• The cyst is of follicular type. There is no
evidence of corpus luteum.
38. Atrophy of the endometrium:
• This type of abnormality is commonly met in
postmenopausal women but may occur in
reproductive period as final involutionary state of
a previous metropathia.
• The bleeding occurs from the rupture of the
dilated capillaries beneath the atrophic surface
epithelium.
• The cause of endometrial atrophy may be due to
total absence of oestrogen or failure of uterine
receptors to become responsive to oestrogen.
39. Endometrial pattern in DUB
• In majority (60 %), the endometrium is
normal secretory in every aspect.
• In about 30 per cent, the endometrium is
hyperplastic and in the remaining, there are
evidences of irregular shedding, irregular
ripening or atrophic pattern.
40. • Investigations
The investigation aims at .
• To confirm the menstrual abnormality as stated
by the patient.
• To exclude the systemic, iatrogenic and
'organic' pelvic pathology.
• To identify the possible aetiology of DUB.
• To work out the definite therapy protocol
41. History .
• Confirmed that the bleeding is through the vagina
and not from the urethra or rectum.
• statement of excessive bleeding is assessed by
number of pads used, passage of clots (size and
number) and duration of bleeding.
• If ambiguity is found from the estimated
haemoglobin percentage, it is better to assess the
blood loss by admitting the patient during period.
• Among the patients presenting with menorrhagia,
only about 50 per cent have got excess blood loss
(> 80 ml).
42. • Nature of menstrual abnormality is then to be enquired —
cyclic or acyclic, its relation to puberty, pregnancy events
and last normal cycle.
• Any emotional upset or psychosexual problem should be
elicited tactfully.
• Use of steroidal contraceptives or IUCD insertion should be
enquired.
• History of abnormal bleeding from the injury site, epistaxis,
gum bleeding or that suggestive of PID should be enquired.
• Estimation of menstrual blood loss either directly by
alkaline haematin or indirectly by pictorial chart is not
routinely done.
43. Internal examination :
• Bimanual examination including speculum
examination should be done in all cases except
in virgins where rectal examination is to be
done to exclude palpable pelvic pathology.
• If vaginal examination is required in virgins, it
should be done under general anaesthesia and
along with endometrial curettage.
44. Special investigations
Blood values
• Haemoglobin estimation is done in every case.
• Serum feritin test is not done as a routine.
• In pubertal menorrhagia not responding to
usual therapy, platelet count, prothrombin
time, bleeding time, partial thromboplastin
time are to be estimated.
• In suspected cases of thyroid dysfunction,
serum TSH, T3, T4 estimation is to be done.
45. • Ultrasound and Colour Doppler findings of
endometrial hyperplasia are :
(i) Endometrial thickness >12 mm.
(ii) Hyperechoic and regular outline,
(iii)Angiogenesis and neovascular signal study.
• Transvaginalsonography (TVS) is also very sensitive
to detect any anatomical abnormality (fibroid,
adenomyosis) of the uterus, endometrium md adnexae.
• Saline Infusion Sonography (SIS) is found very
helpful to diagnose endometrial polyps, submucous
fibroids and uterine abnormality (septate/subseptate
uterus).
46. Hysteroscopy
• is done for better evaluation of endometrial
lesion and to take biopsy from the offending
site under direct vision.
• The frequent findings of polyp and submucous
fibroid are often missed by blind curettage.
• Hysteroscopy and directed biopsy (H and B)
can be performed on an outpatient basis. H and
B has replaced conventional D and C .
47. Endometrial sampling can be done as an outpatient
basis.
• Pipelle sampler is easy to use.
• As it is a blind procedure, intrauterine pathology
(polyps, submucous fibroids) can not be detected.
Laparoscopy — to exclude unsuspected pelvic
pathology such as endometriosis, PID or ovarian
tumour (granulosa cell tumour). The indication is
urgent, if associated with pelvic pain.
48. Diagnostic uterine curettage (D & C)
Diagnostic uterine curettage is indicated in DUB —
(1) To exclude the organic lesions in the endometrium
(incomplete abortion, endometrial polyp, tubercular
endometritis or endometrial carcinoma).
(2) To determine the functional state of the endometrium.
(3) To have incidental therapeutic benefit.
• In adolescent DUB, it is rarely needed only if bleeding
fails to stop or is severe in nature .
• During childbearing period (20-40 years), it should be
done, if the bleeding is acyclic. Risk of endometrial
carcinoma in this age group is verylow.
• During premenopausal period, diagnostic curettage is
mandatory prior to any therapy to exclude endometrial
malignancy.
49.
50. During postmenopausal period, it is
mandatory
to exclude endometrial malignancy.
Thin plastic endometrial tissue samplers
(pipellae) are available .
It helps to obtain adequate endometrial sample
for histological examination.
It is done as an OPD procedure without any
anaesthetic.
51. MANAGEMENT
management protocols have been grouped
accordingly.
• Pubertal and adolescent menorrhagia < 20
years .
• Reproductive period (20-40 years).
• Premenopausal (> 40 years).
• Postmenopausal .
53. a. GENERAL -.
Rest.
Assurance and sympathetic handling
diet, haematinics and blood transfusion.
Clinically evident systemic or endocrinal
abnormalities should be investigated and
treated accordingly.
54. b.MEDICAL MANAGEMENT OF DUB
• Hormones
• Progestins:
The common preparations used are
norethisterone acetate and medroxyprogesterone
acetate .
55. The preparations are used:
• Cyclic therapy
• Continuous therapy
To stop bleeding and regulate the cycle:
• Norethisterone preparations (5 mg tab) are
used thrice daily till bleeding stops which it
usually does by 3-7 days.
57. 5th to 25th day course :
• In ovular bleeding — Any low dose combined oral pills
are effective when given from 5th to 25th day of cycle for 3
consecutive cycles.
• It causes endometrial atrophy.
• It is more effctive as compared to progesterone therapy as
it suppress the hypothalamopituitary axis more effectively.
• Normal menstruation is expected to resume with restoration
of normally functioning pituitary-ovarian-endometrial axis.
• It reduces menstrual blood loss by 50 per cent. It serves as a
contraceptive as well.
58. In anovular bleeding
• Cyclic progestogen preparation of
medroxyprogesterone acetate (MPA) 10 mg or
norethisterone 5 mg is used from 5th to 25th
day of cycle for 3 cycles.
59. 15th to 25th day course
• In ovular bleeding, where the patient wants
pregnancy or in cases of irregular shedding or
irregular ripening of the endometrium,
dydrogesterone 1 tab (10 mg) daily or twice a
day from 15th to 25th day may cure the state.
• This regimen is less effective than 5th to 25th
day course. However, it does not suppress
ovulation.
60. Continuous progestins:
• Progestins also inhibit pituitary gonadotropin secretion
and ovarian hormone production.
• Medroxyprogesterone acetate 10 mg thrice daily is
given and treatment is usually continued for at least for
90 days.
• Various continuous preparations may be used. Oral ,
long-acting intramuscular injections, DMPA implants
Progestogen only pill are effective to reduce menstrual
blood loss. They may also result in oligomenorrhoea or
amenorrhoea.
• Progesterone treatment helps organised endometrial
shedding upto the basal layer and increases the
endometrial ratio of PGF20C/PGE2 and thromboxane .
61. Oestrogen:
• In situations where the bleeding is acute and severe,
conjugated oestrogen 25 mg is given IV.
• It helps with rapid growth of the denuded endometrium
and promotes platelet adhesiveness.
• It controls bleeding by process of healing.
• It may be repeated every four hours till the bleeding is
controlled, when oral therapy is started.
• Once the bleeding stops, progestin (MPA 10 mg a day)
is to be added.
• COC is used for long term treatment.
• Proliferation of endometrium, increase in the level of
fibrinogen, factors - V, X and platelet aggregation are
the other mechanisms of action for oestrogen therapy.
• If bleeding continues further, D and C is indicated.
62. Intrauterine progestogen
• Levonorgestrel intrauterine system (LNGIUS) induces
endometrial glandular atrophy, stromal decidualisation and
endometrial cell inactivation .
• It is effective for 5 years. It has minimal systemic
absorption.
• Reduction of blood loss is upto 97 per cent.
• It is considered as medical hysterectomy.
• In addition to its many other health benefits it is an effective
contraceptive measure .
• LNG-IUS is recommended as a first line therapy for a
woman with HMB in the absence of any structural or
histological abnormality.
63. Danazol
• Danazol is suitable in cases with recurrent symptoms
and in patients waiting for hysterectomy.
• The dose varies from 200-400 mg daily in 4 divided
doses continuously for 3 months.
• A smaller dose tends to minimise the blood loss and a
higher dose produces amenorrhoea .
• It reduces blood loss by 60 per cent. However, danazol
should not be used as a routine.
64. Mifepristone (RU 486):
• It is an anti-progesterone (19 nor steroid).
• It inhibits ovulation and induces amenorrhoea
and reduces myoma size .
65. GnRH agonists :
• The subtherapeutic doses reduce the blood loss
whereas in therapeutic doses produce
amenorrhoea.
• It is valuable as short-term use in severe DUB,
particularly if the woman is infertile and wants
pregnancy.
• The drugs are used subcutaneously or intranasally.
• It improves anaemia, and is helpful when used
before endometrial ablation
66. NON HORMONAL
MANAGEMENT
Anti-fibrinolytic agents (Tranexamic acid)
• It reduces menstrual blood loss by 50 per cent.
• It counteracts the endometrial fibrinolytic
system.
• It is particularly helpful in IUCD induced
menorrhagia.
• Gastrointestinal side effects are common.
67. Prostaglandin synthetase inhibitors:
Mefenamic acid is much effective in women aged more than
35 years and in cases of ovulatory DUB.
The dose is 150-600 mg orally in divided doses during the
bleeding phase.
The fenamates inhibit the synthesis of prostaglandins and
interfere with the binding of PGE2 to its receptor.
NSAIDS can reduce menstrual blood loss by 25-40 per cent.
Improvement of dysmenorrhoeaheadache, or nausea are the
added benefits.
Side effects are often mild. NSAIDS may be used as second
line medical treatment
68. • Desmopressin — is a synthetic analogue of
arginine — vasopressin.
• It is especially indicated in cases with von
Willebrand's disease and factor VIII
deficiency.
• It is given IV (0.3 pg/kg) or intranasally.
70. A.Uterine curettage
• It is done predominantly as a diagnostic tool for elderly
women
• it has got haemostatic and therapeutic effect by removing
the necrosed and unhealthy endometrium.
• It should be done following ultrasonography for detection of
endometrial pathology.
• The indication is an urgent one, if the bleeding is acyclic
and where endometrial pathology is suspected.
• Ideally hysteroscopy and directed biopsy should be
considered both for the purpose of diagnosis and therapy.
• Presently, dilatation and curettage should be used neither as
a diagnostic tool nor for the purpose of therapy.
71. B.Endometrial ablation/resectson
• Indications are :
• (a) Failed medical treatment
• (b) women do not wish to preserve menstrual or
reproductive function
• (c) uterus — normal size or no bigger than 10 weeks
pregnancy size
• (d), small
• uterine fibroids, (< 3 cm)
• (e) women , who want to avoid longer surgery
• (f) women prefers to preserve her uterus.
72. • Laser ablation of the endometrium using the Nd:
YAG laser through hysteroscope is an alternative
to hysterectomy.
• It is employed as an elective alternative to
hysterectomy or when hysterectomy has been
medically contraindicated.
• Tissue destruction (coagulation, vaporisation and
carbonisation) to a depth of 4-5 mm produces a
therapeutic Asherman's syndrome and
amenorrhoea.
73. • Uterine thermal balloon for destruction of
endometrium
• Endometrium is destroyed using a thermal
balloon with hot normal saline (87°C) for 8-10
minutes.
• No dilatation of the cervical canal is needed.
This procedure is suitable for women who are
not suitable for general anaesthetic or long
duration surgery.
74. • Microwave endometrial ablation is simple
and carried out as an outpatient procedure.
• Microwave electromagnetic heat energy causes
ablation of the endometrium.
• Endometrial tissue upto a depth of 6 mm is
ablated.
• Temperature in the region is 75-80°C.
• Treatment time (2-3 minutes) .
75. • Novasure: Endometrial ablation is done using a bipolar
radio frequency mounted on an expandable frame.
• This creates a confluent lesion on the entire
endometrial surface.
• Radio frequency energy vaporises or coagulates the
endometrium upto the myometrium.
• The procedure is quick, simple and safe. Women with
uterine cavity < 4 cm, PID, caesarean delivery are
contraindicated.
• Pretreatment with danazol or GnRH agonists for 3
weeks prior to endometrial ablation is helpful to make
the endometrium atrophic.
76. Uterine artery embolisation is commonly done
in women with large uterine fibroid (> 3 cm)
with heavy bleeding.
Particles are injected to block uterine artery
under local anaesthesia.
This shrinks fibroids. The procedure is safe and
effective.
77. • Hysterectomy is not recommended as a first line
therapy for heavy menstrual bleeding (HMB) or
DUB.
• Presence of endometrial hyperplasia and atypia on
endometrial histology, is an indication for
hysterectomy.
• The decision can be made easily as the patient is
approaching 40.
• Healthy ovaries may be preserved at the time of
hysterectomy especially those under 45 years of
age.