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abnormal uterine bleeding lecture (2).ppt
- 1.
- 2. AUB.. • Def: anybleeding from the uterus that differs from the usual menstrual cycle in frequency, amount, duration of flow.
- 3. Normal menstrual Cycle •Cycle length 24 to 35 days, normal amount of menstrual blood per cycle 30 to 50ml ,abnormal if > 80ml
- 4. Physiology of normalmenstrual bleeding • Is post ovulatory est- progesterone withdrawal bleeding.
- 5. Physiology…. • Follicular phase Ovarysecret estrogen -endometrial proliferation • Secretory phase after ovulation , C. Luteum secret Pro + estrogen
- 6. Secretory… • Pro limitsendometrial growth & cause it to differentiate • If no pregnancy –C. luteum regresses & hormonal support of the endometrium ceases__ initiates a cascade of events that results in menstrual bleeding.
- 7. Physiology… a. Rhythmic VCof spiral arterioles leads to ischemia, necrosis and sloughing of the surface endometrium b. Lytic enzymes from Ic lysosomes and matrix metalloproteinases .breakdown of endometrial tissue.
- 8. Normal menstrual bleedingis self-limited • It is a universal endometrial event Menstrual changes occur simultaneously in all segment of the endometrium • The endometrial tissue is structurally stable and random break down of tissue due to fragility is avoided -Because it has responded to appropriate sequence of est and progestone
- 9. patterns of AUB •Menorrhagia – hypermenorrhea -heavy or prolonged menstrual flow Causes • submucous myoma • Complications of pregnancy • adenomyosis • Endometrial hyperplasia • malignant trs, • DUB
- 10. Hypomenorrhea – cryptomenorhea -Light menstrual flow Causes. .Hymenal or cervical stenosis .Uterine synechia, ocp Metrorrhagia – intermenstrual bleeding • bleeding occur at any time between menstrual periods Causes:- . end polyps , endometrial and cervical Ca .exogenous est
- 11. Menometrorrhagia • period thatoccurs at irregular intervals .irregular, prolonged and excessive in amount. • Causes .anovulation .est secreting trs
- 12. Polymenorrhea • period thatoccurs too frequently • a menstrual cycle interval of < 21 days causes. Anovulation . shortened luteal phase Oligomenorrhea menstrual periods that occurs more than 35 days apart causes. . An ovulation .est secreting trs
- 13. Patterns.. Contact bleeding- postcoital bleeding • Must be considered a sign of cervical Ca until proved other wise. Other causes cervical polyp cervical or vaginal infection
- 14. Causes of AUB •prepubertal –premenarchal • Vulval lesions –vulval fissure, maceration, condy lomas • F. body • Vulvovaginitis • Precocious puberty • Trauma - abuse, penetration • Vaginal and ovarian trs • Exogenous hormones
- 15. Causes of AUB… Adolescence •anovulation (90%)- hypothalamic immaturity • pregnancy related bleeding • exogenous hormones • Hematologic abnormalities ITP,Vonwillebrand’s disease
- 16. Adolescence AUB… - infections-cervicitis, PID - endocrine or systemic problems . thyroid and hepatic dysfunction .PCOS - Anatomic causes .Mullerian abnormalities Long vaginal septa UX didelphis
- 17. Reproductive age group •pregnancy related bleeding • DUB • Exogenous hormones, endocrine causes • Anatomic causes * Myoma, adenomyosis , endometrial polyps * cervical lesions –polyps, infections, lesions ,condyloma ,HSV ulcer Hematologic causes Coagulation abn – thrombocytopenia, v. will brand’s - Leukemia Neoplasia – Ca (cervical , endometrial ,vaginal) Infectious causes - cervicitis,endometritis
- 18. Dysfunctional uterine bleeding Def-abnormalUx bleeding for which no specific organic cause can be found , after a thorough evaluation and work up of Pt. • Most often occurs in the absence of the cyclic hormonal changes that regulate the menstrual cycle.
- 19. • Is oftena dx of exclusion – organic causes must be excluded • AUB at extremes of reproductive life usually is due to anovulation (DUB) Pathophysiology of DUB • Most common etiology is est. withdrawal or est break through bleeding • In absence of ovulation est stimulates the endometrium without production of progesterone
- 20. Pathophysiology.. • unopposed est leads to excessive glandular proliferation with lack of stromal support unstable, fragile, hetrogenous endometrium prone to superficial breakdown and bleeding. • endometrium slough off in isolated location, the remaining raw surface is restimulated by est and heals as another part of endometrium is slough off
- 21. Etiology of DUB A.Causes of anovulation or oligoovulation • Anovulatory cycles are sms of disruption of the normal regulatory mechanisms that control menstrual cycle. • abnormalities at any site of hypothalmo- pituitary ovarian axis
- 22. 1.Dysfunction of hypothalamicpituitary ovarian axis • Any factor that interferes with the normal pulsatile secretion of GnRH leads to an ovulation Causes – .Hyperprolactinemia – P. adenoma, psychotropic drugs,hypothyroidism • stress and anxiety • rapid weight loss • anorexia nervosa
- 23. 2.Immaturity of hypothalamicpituitary ovarian axis -in post pubertal adolescence shortly after menarche 3. Abnormalities of normal feed back signals Estradiol levels play a critical role in controlling the sequence of events during normal ovulatory cycles • medical conditions – hepatic ds , thyroid abnormalities affect metabolism and clearance of estradiol
- 24. ` 4. other causes Pcos b.causes with ovulation • DUB 2ry to hormonal causes may occur during ovulatory cycles • ovulatory pts with AUB are more likely to have an underlying organic pathology & are not true DUB pts
- 25. Evaluation of AUB A.History • age, parity, marital status, sexual Hx • current pattern of bleeding • menstrual Hx – age at menarche, cycle frequency and duration, presence of molimina sms • contraceptive use & other medications - anticoagulants, psychotropic drugs
- 26. Evaluation … • medicalHx – sms of endocrine & other organic diseases • bleeding tendency & family Hx of bleeding disorder • sms of stress & sms of PID
- 27. Physical examination General P/E •thyroid enlargement, galactorrhea, ecchymosis, purpura • pallor, v/s Gynecologic exam • 2ry sexual x-stics, vaginal trauma, sign of infection, atrophic vaginitis and F.body
- 28. Lab evaluation based onHx physical findings • CBC- Hgb & HCT, WBC, platlet count • Pregnancy test – should be done in all pre menopausal AUB • Test for -STI • Coagulation profile – PT, PTT • TSH, PRL, LFT
- 29. • Androgen profile– Testesterone, DEA, 17 alpha hydoxy progestrone D. Diagnostic procedures 1. ultrasonography & sonohysterography • intra Ux polyps, submucous myoma, ovarian masses • Ux contour, endometrial thickness
- 30. 2 endometrial biopsy -to R/o endometrial ca Indication • those at risk for endometrial hyperplasia or ca • those older than 40 yrs of age • those younger than 40 yrs of age who have chronic unopposed est breakthrough bleeding
- 31. 3. D&C • replacedby endometrial biopsy in the office 4. Hysteroscopy with endometrial sampling Indication • cervical stenosis precluding adequate end ometrial biopsy • pt intolerance of endometrial biopsy • anatomic factors precluding adequate end biopsy
- 32. Hysteroscopy… • presence ofAUB in a pt undergoing another surgical procedure with GA • Direct visualization of endometrial cavity, allow targeted biopsy or excision of the lesion • Gold standard for Dx of AUB
- 33. Management of AUB Dependson the etiology of the bleeding .In identifiable causes the Rx is targeted to wards the cause The Mx of DUB depends on - age of pt -severity of bleeding - desire for future pregnancy - presence of associated pathology Objective of Rx • Control bleeding • Prevent recurrence • Preserve fertility • Correct associated disorders
- 34. Rx… A. Hormonal Rx 1.progestins - Rx of choice for anovulatory DUB - stops endometrial growth, support & stabilize the endometrium an organized sloughing off the endometrium occurs after its withdrawal. - oral medroxy progesterone acetate 10 mg/day for the 1st 12 days each month or day 16 through 25 of each cycle
- 35. Rx… 2 .oral contraceptivetherapy • Convert a fragile, overgrown endometrium into a pseudo decidualized structurally stable lining • Controls bleeding with in 24 hrs
- 36. OCP… • Low dosecombined OCP 2 to 3x a day for 5 to 7 days, then once a day for 3 months. 3. High dose estrogen - promotes rapid endometrial regrowth to cover denuded epithelial surfaces - conjugated equine estrogen 10 mg Po/day qid or 25mg lv Q 2 to 4hrs for 24hrs then oral est 10mg/day for 21 to 25days and medroxy progesterone acetate10mg/day for the last 7-10days. - bleeding usually stops with in 24hrs
- 37. B .Medical therapy 1.non steroidal anti inflammatory agents - inhibit synthesis of PGs - alter the balance b/n thromboxane & prostacycline - effective in ovulatory DUB - eg. Ibuprofen, Naproxen 2. GnRH agonists - down regulate pituitary synthesis of FSH & LH and induce “medical menopause” - last resort when all modalities fail
- 38. 3. Rx ofcoagulation disorder - desmopressine factor VIII - antifibrinolytic agents – E. aminocaproic acid tranexamic acid
- 39. Surgical therapy 1. D&Cwith or without hysteroscopy • Done in pts with bleeding refractory to medical therapy • Can be diagnostic & therapeutic modality • In age above 40 yrs it must be done • Age 20 to 40yrs postponed • Age <20yrs should be deffered
- 40. Surgical … 2 .Hysterectomy •If failed to respond to medical Rx, repeated curettage, endometrial ablation • More definitive -consider age of the pt, her desire for future fertility
- 41. 3 Endometrial ablation •Destruction of the endometrium • For woman who are not candidate for hysterectomy • Using laser, electrocautery, thermal destructive technique
- 42. Post menopausal bleeding •Defn. – bleeding that occurs after 12 months of amenorrhea in a middle aged woman • more likely to be caused by pathological disease • must always be investigated • at least ¼ of PMB woman have neoplasia
- 43. PMB… Etiology - Exogenous hormones-30% HRT – frequency of bleeding depends on the regimen used • atrophic endometritis/ vaginitis -30% • Commonest cause of pmb • due to hypoestrogenism results in a thin surface that is prone to bleed especially after trauma
- 44. - Endometrial ca-15% -endometrial or cervical polyps-10% - endometrial hyperplasia -5% - miscellaneous- cervical ca - uterine sarcoma -10% - ovarian ca - vaginal ca Dx – pelvic examination endometrial sampling – office biopsy - hysteroscopy - D&C Pelvic u/s Mx – cause directed