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Abnormal uterine bleeding- Prof.HHY.pptx
- 1. Management of Abnormal uterinebleeding Dr.Hla Hla Yi Central Women’Hospital Mandalay
- 2.
- 3. • Dysfunctional bleeding(DUB) – is a diagnosis made after pathology such as fibroids, polyps, infection and malignancy have been excluded.
- 4. DUB anovulatory Typified by -an irregularcycle -at the extremes of reproductive age 1.Teenagers (perpubertal DUB) Erratic output of gonadotrophin 2. late 30s to late 40s (perimenopausal DUB) Ovary failed to respond gonadotrophins 3. extremely obese women 4. those with PCOS ovulatory aged 35 to 45 years -typified by regular heavy & often painful periods
- 5. DUB is diagnosis of exclusion Anov (20%) -imbalanceof H-P-O axis— 1.adolescents—immature axis and unestablished cycle 2.PCOS—imbalance d/t endogenous oestrogen production 3.perimenopausal– aging axis ov (more common) -Luteal phase dficiency -derangement of local mechanism
- 6.
- 7. endometrial prostaglandin's Vasculature imbalancebetween the vasoconstricting actions of prostaglandin F2α and thromboxane A2 and the vasodilating actions of prostaglandin E2 and prostacyclin on the myometrial and endometrial vasculature
- 8. Adolescents — immature axis and unestablished cycle Nearlyall cases recover spontaneously in few mths reassurance OK
- 9. Anov DUB -continuous unopposed oestrogen Building upof endometrium and erratic bleeding breaks down and is expelled Increased level of plasminogen activator is found in women with HMB Hence antifibrinoly tics is effective
- 10. AUB around Puberty DUB –(ANOVULAR) HAEMOSTSIS (VW,ITP, F-II,V,VII,IX RARE- Preg Ca Contraceptive- Related AUBaround Reproductive age Pregnancy Related Contraceptive related GYNAE PROBLEM PID DUB AUB in Peri-& Post menopausal Atrophic B & M t/m DUB IUCD Ring pessary HRT DUB
- 11. Who not-require contraceptive OR regularcycle ANTIFIBRIN OLYTIC NSAID Who need contraceptive Or Irregular cycle OC PILL PROGESTROGEN LNG-IUS 2ND LINE DRUG SURGERY ENDOMETRIAL RESECTION Myomectomy Hysterectomy
- 12. • The patient’shistory and examination • Detailed history, excluding risk factor for underlying malignancies s/be taken • Key- • to make an accurate assessment of the disorder and estimation of the impact on QOL • General Examination • BMI • S/- of anaemia • Thyroid d/s • Evidence of bleeding disorders • Any medical condition resulting in menstrual disorders
- 13. • Any medicalcondition resulting in menstrual disorders ----Such as – jaundice leading to bleeding diatheses – Alopecia and skin rash ---suggesting autoimmune problem like SLE • Abdominal examination • Any organomaly • Presence of ascites • Abdominal or pelvic mass • (e.g ut is palpable above the s.pubic)
- 14. • Speculum examination –Vg Cx – Cervical smear – Endometrial biopsy – Vaginal swab • Bimanual examination – Reinforced finding
- 15. Confirmatory Investigations • Thepatient’s history and examination • will guide the selection of various tests • Then lead to a diagnosis and management • FBC is an essential investigation • serum or urine beta-hCG (s/b request if any possibility of pregnancy exits) • Hormonal assays • Coagulation screen— • Renal/liver function tests • Blood glucose • TVS (with saline infusion sonohysterography), • TAS • Endometrial sampling
- 16. Endometrial sampling • espin women of >35 years of age • younger women • if there has been a history of chronic anovulation or irregular bleeding direct histological evaluation endometrium = an integral component of evaluating AUB • traditionally-D&C-blind procedure • aspiration techniques • (Pipelle endometrial sampling or Vibra aspirator ) • Hysteroscopy and EB- • it is a gold standard.(as out-pt or as DCS under GA) Methods
- 17. Treatment (acute situation) Arresting ongoing bleeding Oral medoxyprogesterone 10mgdaily for ten days to stop bleeding in acute situation Tranexamic acid injection Correction of anaemia Resuscitation
- 18. Treatment options Medical surgical Expectant Most circumstances mild to moderate levelsof bleeding in an out-patient setting
- 19. Medical therapies • Hormonal treatments –Progestogens – COCP – danazol – GnRHa – HRT – Lng-IUS • Non hormonal –NSAID – Antiprostaglandin (Mefenamic acid) –antifibrinolytics agent (tranexamic acid)
- 20. Surgical management • Endometrialresection and ablation • Myomectomy • Hysterectomy – TAH – St AH – VH – LAVH • Embolisation
- 21. Patients with regularcycle who do not require contraception • Tranexamic acid (antifibrinolytic) • most effective first line drug • fibrinolytic activity is significantly increased in women with heavy menstrual periods • MOA=inhibiting tissue plasminogen activator (fibrinolytic enzyme) • reduces menstrual blood loss by around 50% • Some ---- 80% reduction • Dose ---1 g TDS or QDS during menstruation • S/E ---mainly GI -/s • CI’--history of thromboembolic disease those who have reduce level of antithrombin III
- 22. • NSAID (suchas mefenamic acid) • effective, well tested, and tolerated • MOA—inhibiting cyclo-oxygenase reducing local Pg levels block myometrial PE2 receptors. (Women with heavy flow have higher levels of PgE2 and F2-ά-Their MOA not clear) • Reduce menstrual blood flow by 25-30% • also a analgesic drugs— therefore often use as a first line treatment for women with dysmenorrhoea and menorrhagia • Dose –500 mg TDS * 5Days during mens • S/E---GI irritation (CI’---PU and GU pts)
- 23. Patients with irregularcycle or who need contraception • COCP – commonly used esp in the younger age gp – it reduces MBL by 50% – helps to regulate periods and – provides contraception – MOA • inhibition of ovulation • production of inactive endometrium • Sequential combined HRT – regulate the cycle – reduce mean blood loss in perimenopausal age group
- 24. • Progestogens – e.g.norethi- sterone 5 mg 8 hourly • from day 12-26 or day 5-26 • the most popular drugs in GP • but minimal or no effect on MBL • can be of value in regulating an irregular cycle • s/e –weight gain, Bloating –androgenic side effect ---- such as acnes • mainly indicated in anovulatory bleeding • to reverse the effect of oestrogen-mediated endometrial proliferation induce endometrial maturation • a minimal role in ovulatory bleeding
- 25. • Depo-provera (contraception) –reduced MBL – amenorrhoea in some women • Levonogestrel-releasing intrauterine contraceptive device (Mirena) – releases 20ug of levonogestral/24 hrs >5 yrs – act locally on the endometrium – MOA— • a reduction in endometrial prostaglandin synthesis • the production of inactive endometrium • a reduction in endometrial fibrinolytic activity • it reduces MBL by 86% after 3 mths (95% by 1 yr) • current devices are active for up to seven yr
- 26. • If aCu IUCD is already in situ – either treat with tranexamic acid or NSAIDs change to Lng-IUS – be warned --irregular bleeding is common during the first 3 months after insertion
- 27. • Second linetreatment • Danazol(100 mg 6-24 hrly) – =a synthetic steroid (derivative of testosterone) – inhibits steroid synthesis – blocks the androgen and progesterone receptors – inhibits pituitary gonadotrophins – combine to inhibit endometrial growth – its use is limited by the androgenic s-ef & high cost (acnes, hirsutism, breast atrophy, and weight gain, voice changes) – it reduces blood loss by 60% • Gestinone • GnRH -a
- 28. Surgical therapies • completedtheir family • failed medical management – Endometrial resection/ ablation – Myomectomy – Hysterectomy
- 30. • Management isdetermined on an individual case-by-case basis according to – age, – reproductive status, – hormonal profile, – family planning intentions, – ultrasound findings, – diagnosis and – ultimately patient choice. • A variety of medical options and recently developed minimally invasive surgical techniques have revolutionized the treatment of menstrual irregularities.
- 31. • A 14-year-oldnulligravid girl • Menarche- 13 yrs; 4/45-50ds cycle • She is not sexually active. • Her physical examination is unremarkable, and her serum pregnancy test is negative. • The next best step in management is: – A. Low-dose birth control pills – B. Reassurance – C. NSAIDs – D. Hysteroscopy and dilation and curettage – E. Coagulation profile
- 32. • The answeris------------------ • B • The pattern of bleeding demonstrated by this patient is – characteristic of the menstrual pattern seen following menarche. • Unless it is prolonged and very heavy (not the case in this patient), – it should evolve into a pattern of regular estrogen-progesterone withdrawal bleeding with time (usually by 2 years from menarche).
- 33. • The chancethat an anatomic lesion such as a polyp or a fibroid would be the cause of her bleeding – is unlikely • given her age and pattern of bleeding. – Therefore, hysteroscopy with dilation and curettage would not help. • Oral contraception and NSAIDs are not indicated at this point unless she desires contraception. • Coagulopathy is an unlikely cause of her bleeding because the timing, not the volume, is problematic for this patient
- 35. • A 32-year-oldwoman, para 2+0, • c/o - bleeding between her periods and lengthening of the time between her periods to more than 40 days • Systems Review • 70-lb weight gain since her pregnancy (2 years ago) • No medical problems. • She is 5’ 4’’ tall and weighs 230 lb. • Her physical examination is otherwise unremarkable.
- 36. • The mostlikely explanation for her bleeding is: – A. Increased endogenous progesterone – B. Increased exogenous progesterone – C. Increased endogenous estrogen – D. Increased exogenous estrogen – E. Increased prolactin • The answer is • C
- 37. • This patientis obese – therefore likely has increased endogenous production of estrogen from adipose tissue – which can lead to suppression of FSH and anovulation • leading to menstrual irregularity. • With estrogen production unopposed by progesterone, – the endometrium experiences excessive glandular proliferation without stromal support. – As a result, the endometrium sloughs in isolated locations, leading to unpredictable and prolonged bleeding.
- 38. • There isno history of exogenous hormone intake. • Progesterone is not being produced. • High prolactin typically results in amenorrhea and galactorrhea.
- 40. • An 18-year-oldnulligravid girl • Arrived to the A&E by ambulance – because she passed out on the floor of her house and is covered in blood. – She is now conscious. – She has been bleeding off and on for the past 5 months. Her BP = 98/48, P = 120, RR = 16, and T = 96.2. • VE – Speculum examination reveals blood trickling from the cervical os. There are no lesions in the vagina or cervix. – The bimanual examination is unremarkable.
- 41. – Pelvic ultrasoundis also unremarkable. – Serum human chorionic gonadotropin (hCG) is negative, and – her hemoglobin is 7 g/dL. • The next best step in management of this patient is: – A. Depot-medroxyprogesterone acetate – B. Oral conjugated estrogen – C. Intravenous estrogen – D. Low-dose combination oral contraceptive pills – E. GnRH agonist therapy
- 42. • The answeris • -------------------D – A low-dose oral contraceptive given as three pills a day with taper over 3 to 4 days is an effective way to stop dysfunctional bleeding fairly quickly. – Intravenous estrogen is indicated when the bleeding is profuse and the patient unstable. Estrogen (25 mg) is administered i.vly every 4 hours until the bleeding lessens.
- 43. – This patientdoes not have profuse bleeding, and therefore does not warrant using intravenous estrogen, but she has been bleeding for a long time and is anemic, so a quick method to stop the bleeding would be appropriate. – Since this patient has been bleeding for 5 months and is young, she is probably anovulatory.(normal peripubertal anovulation ) – Causes other than normal peripubertal anovulation should be looked for (thyroid disease, bleeding disorder). – Just giving estrogen would not help because she is already bleeding due to unopposed estrogen.
- 44. – Depomedroxyprogesterone acetateand a GnRH agonist can both be used to treat anovulation, but they both take a while to work so would not be ideal.
- 46. • A 38-year-old •c/o -heavy menst: flow 9/32 days x 2 yrs – with occasional episodes of soaking her clothes and bedsheets with menstrual blood. – no bleeding between menses. – history of hypertension controlled with a diuretic. • The next step in evaluation would be: – A. Obtain a coagulation profile – B. Obtain a pregnancy test – C. Perform an endometrial biopsy – D. Obtain a pelvic ultrasound – E. Obtain a TSH level
- 47. • The answeris • ------------------- D • This woman has a history of regular cyclic menstrual flow, but with men-orrhagia. – regular pattern ------so, she does not have an ovulation disorder – that the bleeding is most likely from a structural problem. – The next best step would be to obtain a pelvic ultrasound to look for the presence of fibroids, endometrial polyps, or adenomyosis. – ? Endometrial biopsy
- 48. • An endometrialbiopsy – to look for endometrial hyperplasia or cancer – is not warranted • bleeding is regular and cyclic • no bleeding between menses, making this diagnosis unlikely. • A coagulation profile – unlikely to be abnormal since this problem is relatively new. • A pregnancy test is also not indicated. • ?TFT
- 49. • ?TFT – Itis unlikely that hypothyroid abnormalities would cause this regular but heavy menstrual flow. – Extreme hypo-or hyperthyroidism can cause irregular menses and anovulation, but not menorrhagia.
- 51. • A 50-year-old,G3, P2+1(spontaneous abortions 1), • c/o - abnormal vaginal bleeding. • Cycles –usually regular 3-4/30 ds – She now has periods 6-7ds/every 15 to 22 ds • no past medical or surgical history. • Systems review-negative • No light -headedness. • VE – speculum examination is unremarkable. – BE- slightly enlarged, regular contour, AV ut • nontender to palpation. • The next best step in management is:
- 52. • The nextbest step in management is: – A. Low-dose oral contraceptive pills – B. Endometrial biopsy – C. Dilation and curettage – D. Endometrial ablation – E. Levonorgestrel IUD • The answer is • ----------------------------B
- 53. • The riskof endometrial carcinoma – increases with age and – should be ruled out in patients with abnormal bleeding who are over age 40 years. – In addition, endometrial hyperplasia often develops in women with a history of chronic anovulation and unopposed estrogen stimulation of the endometrium (most likely in this perimenopausal patient). • If histology revealed---endometrial hyperplasia with atypia – she has an increased risk for endometrial ca.
- 54. • Simple EndometrialHyperplasia without atypia – can be treated with progestin therapy. • A perimenopausal women – have erratic bleeding • because of the transition from regular ovarian folliculogenesis and hormone production to relative ovarian quiescence. – An office endometrial biopsy is the must. – Birth control pills will regulate her bleeding but will not tell you about the endometrium.
- 55. – Dilation andcurettage is the next step • after an endometrial biopsy if the results are not satisfactory (e.g., cervical stenosis and inability to obtain biopsy in the office or no tissue obtained on biopsy) or if the patient is refractory to agents aimed at stopping the bleeding. – ? Endometrial ablation • Endometrial ablation should not be done until you know the endometrium is completely normal. – Levonorgestrel IUD is a good treatment option after biopsy of the endometrium.
- 57. • A 24-year-oldwomen with P1+0 (aged 5) – planning another pregnancy next 6-12 mths. – She is in a 2-year stable relationship using the OCP. • c/o intermenstrual bleeding, usually at mid-cycle, for 6 months. – She has Normal menstruation–3-7/21-35ds • (IMB) – refers to vaginal bleeding (other than post- coital) at any time during the menstrual cycle other than during normal menstruation.
- 58. • IMB canbe predictable – (e.g. always premenstrual or mid-cycle), or • unpredictable – (i.e. occurs any time of the cycle). • Predictable IMB is – usually endometrial in origin secondary to hormonal changes. – Mid-cycle (ovulatory) blding lasts for 12-72 h – thought to be caused by sudden fluctuations in oestr: levels destabilizing the endometrium. • Unpredictable IMB – arise from anywhere in the genital tract.
- 59. • Premenstrual bleedingis – blding for up to 10 days prior to menstrution. – This occurs when the endometrium is shed early due to lack of progesterone support. – This is often termed luteal phase deficiency.
- 60. • Aetiology ofintermenstrual bleeding • 1 Pregnancy related e.g. gestational trophoblastic disease • 2 Physiological: 1-2% spotting at time of ovulation • 3 Iatrogenic – COCP - either in too low dose on in combination with an enzyme inducing drug – Progesterone-only pill (30% risk of IMB or irregular bleeds) – Contraceptive depot injections (Depo Provera) or implants – (Implanon): 30% risk of IMB – Mirena IUS – Emergency contraception – Tamoxifen – Following smear or treatment to cervix – Drugs altering clotting parameters e.g. anticoagulant, SSRIs, – corticosteroids – Alternative remedies e.g. ginseng, ginkgo, soy supplements, – St Johns Wort • 4 Vaginal causes – Infection e.g. Chlamydia – Tumours e.g. polyps, carcinoma
- 61. • 5 Cervicalcauses – HPV infection – Cancer (however, bleeding most often post-coital, can have irregular bleeds þ/ foul discharge – Polyps – Ectropion – Cervicitis – Condylomata accuminata of the cervix • 6 Uterine causes – Polyps – Adenocarcinoma/adenosarcoma – Leiomyosarcoma – Adenomyosis (usually only symptomatic in later reproductive life) – Fibroids
- 62. • Management – Inthe presence of pathology removal of the cause is likely to be curative. • Foreign bodies, cervical or endometrial polyps should be removed, • infection eradicated with appropriate antibiotics • neoplastic lesions treated according to site, type, grade and stage. • In the absence of physical pathology – cyclical menstrual control can be achieved using the COCP or cyclical progestogen. – In this case, breakthrough blding on COCP • can be treated by changing the current COCP to another with a different progestogen or alteration of the progestogen/oestrogen ratio.