case presentations of dub what should be treatment protocol and treatment modalities

1. UJJAIN CME
DR. KAWITA BAPAT
September 20, 2014 ONE DAY HYSTERECTOMY

2. Case 1
32-year-Amita presented with a 6-month history of
increasingly heavy periods.
er menstrual cycle was regular, every 28 days,
with bleeding lasting for 6 days.
The loss was very heavy for 3 days with the
passage of large blood clots and it gradually settled over the final 3
days.
September 20, 2014 ONE DAY HYSTERECTOMY
he experienced some lower abdominal discomfort when the bleeding
was heavy, although she did not need to take analgesics.

3. Case 1
o mid-cycle or post-coital bleeding
recent negative smear.
wo children, both delivered normally,
sed a condom for contraception.
Abdominal examination was unremarkable
September 20, 2014 ONE DAY HYSTERECTOMY

4. Q I: Which of the following would be appropriate management
options?
: Hysterectomy.
: Administration of mefenamic acid.
: Administration of danazol.
: Diagnostic curettage.
September 20, 2014 ONE DAY HYSTERECTOMY
: Administration of tranexamic acid.

5. Case 1
he haemoglobin concentration was 11.0 g
fter discussing the management options, the patient was advised to
take tranexamic acid 1 g four times per day during her menstrual
periods
She was to be reviewed in3 months' time.
t the next visit, her symptoms were unchanged. She was keen not to
take any more medication.
September 20, 2014 ONE DAY HYSTERECTOMY

6. Q2: How would you counsel her regarding further management?
•She considered that a hysterectomy was too radical at her age even
though she did not wish to have any more children.
•She decided that she would undergo an endometrial resection.
• A date for surgery was arranged for 2 months later
•she was advised to take Danazol 200 mg three times
per day for 4 weeks before surgery.
• An ultrasound scan showed a normal uterine cavity.
September 20, 2014 ONE DAY HYSTERECTOMY

7. Q3: Which of the following are side effects of Danazol?
: Visual disturbance.
: Tinnitus.
: Irreversible deepening of the voice.
D: Hirsutism.
: Leucopenia.
September 20, 2014 ONE DAY HYSTERECTOMY

8. Case 1
fter taking the danazol for 1 week
The woman was unable to tolerate the side-effects.
he reported to the outpatient clinic,
here she was given a subcutaneous injection of GNRH AGONIST (3.6
mg).
September 20, 2014 ONE DAY HYSTERECTOMY

9. Q4: What are the immediate complications of endometrial resection
and what precautions would you take to avoid them?
Inform the patient that further pregnancy
•risks of abnormal implantation and fetal malformation
•amount of systemic absorption of the irrigating fluid overload leads to haemolysis and
hyponatraemia
• The immediate complications
•excessive and uncontrollable bleeding
•which may necessitate hysterectomy on rare occasions
•Uterine perforation
•catastrophic consequences with damage to bladder, bowel and major vessels
•Longer term
•Not effective
•Gradual regeneration
•Intra uterine adhesions
•Ashermans September 20, 2014 syndrome may causeON Ep DaAYin HY STERECTOMY

10. Case 1
he underwent a laparoscopic sterilization and transcervical
endometrial resection 3 weeks later
he uterine cornua and the fundus was treated with the diathermy
rollerball,
with the remaining endometrium was removed with the diathermy
loop to the level of the internal cervical os.
September 20, 2014 ONE DAY HYSTERECTOMY

11. Case 1
he patient went home the following day and was given an outpatient appointment
for 3 months later.
fter the operation she bled for 4 weeks,
although the flow was not heavy, and it became more of a brown discharge after the
first 2 weeks.
She had no further bleeding before the
outpatient attendance.
ix months later, she was referred back with severe cyclical pain for 2 days every 4
weeks.
September 20, 2014 ONE DAY HYSTERECTOMY
t was suprapubic and she described it as a cramp.

12. Q5: What is the problem and how would you deal with it?
ysteroscopic examination of the uterine cavity revealed synechiae
between the anterior and posterior walls.
t was possible to divide these with the hysteroscope and at the end of
the procedure a multiload copper 250 coil was left in the uterus.
he coil was removed 3 months later, but unfortunately the pain
returned within 3 months although she continued to be
amenorrhoeic.
September 20, 2014 ONE DAY HYSTERECTOMY

13. Q6: Which of the following treatment options would you recommend?
: Repeat endometrial resection.
: Administration of the oral contraceptive pill.
: Administration of mefenamic acid.
: Hysterectomy.
he patient elected to undergo hysterectomy. At the time of the
endometrial resection, there was no significant uterine prolapse and
September 20, 2014 ONE DAY HYSTERECTOMY

14. Q7 Which of the following are complications of hysterectomy?
: Lymphocyst formation.
B: Premature menopause.
: Internal iliac artery aneurysm.
D: Uterovaginal fistula.
: Irritable bowel syndrome.
September 20, 2014 ONE DAY HYSTERECTOMY

15. Case 1
The operation was uncomplicated
he patient made a good recovery
When she was seen 2 months later, the pain had completely resolved.
he was happy
September 20, 2014 ONE DAY HYSTERECTOMY

16. Q2: Explain the differences between menorrhagia, heavy periods and
dysfunctional uterine bleeding (DUB).
enorrhagia is an 'excessive' regular menstrual blood loss.
Excessive' is objectively defined as menstrual blood loss greater than 80 ml.
owever, estimation of blood loss is not feasible in current routine
clinical practice.
eavy periods is a subjective symptom;
approximately 30% of women who seek medical treatment do not actually have loss
greater than average
You are obliged to ascertain from the history,
the degree of blood loss and its effect on the quality of life
Indirect objective evidence should be sought to support the symptomatology
This includes anemia and iron deficiency anemia
September 20, 2014 ONE DAY HYSTERECTOMY

17. Medical option
Combined oral contraceptive pills
ontraception by inhibiting ovulation
auses a 50% reduction in menstrual blood loss by
regular shedding of a thinner endometrium Cheap
Effective
dditional benefit of contraception
September 20, 2014 ONE DAY HYSTERECTOMY
isadvantage

18. Medical option
Non Steroidal Anti-Inflammatory Drugs
ndometrial prostaglandins are elevated with excessive menstruation
on- steroidal anti-inflammatory drugs (NSAIDs) reduce prostaglandin
levels through the inhibition of the cyclo-oxygenase enzyme
ith reduction in menstrual blood loss of 25- 35%
September 20, 2014 ONE DAY HYSTERECTOMY

19. Medical option
Anti-fibrinolytic agents
ranexamic acid, a synthetic derivative of the amino acid lysine
exerts an anti- fibrinolytic effect through reversible blockade on
plasminogen
roducing a 50% reduction in menstrual loss
ot associated with an increase in side effects
September 20, 2014 ONE DAY HYSTERECTOMY

20. Medical option
Progestogens only
rogestogens administered from the fifteenth day or from 19th - 26th
day of the menstrual cycle were significantly
less effective in reducing menstrual blood loss when compared to
other medical therapies
lthough most commonly prescribed
cheap
side effects
September 20, 2014 ONE DAY HYSTERECTOMY

21. Medical option
Anti estrogens Danazol
ynthetic steroid that suppresses estrogen and progesterone
eceptors in the endometrium, leading to endometrial atrophy
(thinning of the lining of the uterus)
educe menstrual loss.
t is an effective treatment for heavy menstrual bleeding
September 20, 2014 ONE DAY HYSTERECTOMY
owever, its side-effect profile,its lack of acceptability to women

22. Medical option
GnRH agonists
onadatrophin-releasing hormone (GnRH) agonists induce a reversible
hypoestrogenic state,
Reducing total uterine volume.
hey are highly effective,
ut their side-effects make them suitable only for short-term use
September 20, 2014 ONE DAY HYSTERECTOMY
nRH agonists may obviate emergency surgery in patients with high

23. The levonorgestrel intrauterine system (LNG IUS)
ntrauterine device
eleasing a steady amount of levonorgestrel (20μg /24 hours) from a
steroid reservoir around the vertical stem of the device.
t reduces menstrual blood loss by 80%,
ore effective than cyclical norethisterone,
atients being more satisfied
illing to continue with treatment.
ide effects such as
nter-menstrual bleeding and
September 20, 2014 ONE DAY HYSTERECTOMY

24. Surgical options
aser /thermal/cold/diathermic ablation
rans-cervical resection of endometrium
Balloon
Microwave
ysterectomy September 20, 2014 ONE DAY HYSTERECTOMY

25. Q10: What are the advantages and disadvantages of endometrial resection or ablation over hysterectomy
for women with heavy periods?
ndometrial resection or ablation
horter operating time
ower postoperative complication rate than hysterectomy.
Women require a shorter period in hospital
esume normal activities earlier
ost benefits but these must be offset against the need to
Perform a hysterectomy in 23% of cases within 2 years.
September 20, 2014 ONE DAY HYSTERECTOMY
he long-term effects remain unknown.

26. Case 2
28-year-old single nulligravida
awyer
ivorced
eferred to the gynaecology clinic
ith a 3-year history of increasingly heavy periods
September 20, 2014 ONE DAY HYSTERECTOMY

27. QI: Which of the following statements about norethisterone are correct?
A: it is a 19-carbon atom containing synthetic progestogen derived from
testosterone.
•B: It is a 2I-carbon atom containing naturally occurring progesterone.
•C: 40% of women receiving medical treatment for menorrhagia
are prescribed norethisterone.
•D: Norethisterone has been found to be no more effective than placebo in
the short-term treatment of menorrhagia.
E. Norethisterone should no longer be prescribed for the medical treatment
of menorrhagia
September 20, 2014 ONE DAY HYSTERECTOMY

28. Case 2
•Her menarche had been at the age of 14 years
•periods had always been regular, lasting 3-4 days every 26-28 days.
•recent normal cervical smear
•No complain of any inter-menstrual bleeding.
•o obvious history of previous pelvic infection.
•Over the preceding 2 years she had noticed increasing dysmenorrhoea lasting for 2 days.
September 20, 2014 ONE DAY HYSTERECTOMY

29. Case 2
•The heaviness of her menstrual flow meant that she regularly missed 1 or 2 days of
work most months
• she soiled her bedclothes despite wearing double protection.
•To her knowledge she had not been anaemic
• had not suffered any other medical or surgical illnesses.
•She had never practiced any form of contraception.
• She had no gastrointestinal symptoms.
September 20, 2014 ONE DAY HYSTERECTOMY

30. Case 2
On examination
he patient looked slightly pale but otherwise well.
here was no goitre
er breasts were normal
bdominal palpation was normal with no masses found.
Pelvic examination revealed a normal-looking
vagina and cervix.
he uterus was anteverted, mobile, tender and uniformly enlarged,
approximately equal to an 8-week gravid uterus.
September 20, 2014 ONE DAY HYSTERECTOMY

31. Q2: Which of the following conditions can cause uterine tenderness?
: Endometrial hyperplasia with severe architectural and cytological atypia.
B: Endometritis.
: Salpingitis isthmica nodosa.
: Adenomyosis uteri.
: Fibromas.
September 20, 2014 ONE DAY HYSTERECTOMY

32. Case 2
full blood count revealed
a haemoglobin concentration of 9.9 g
MCV) normal
MCH) normal.
Thyroid function was normal
September 20, 2014 ONE DAY HYSTERECTOMY

33. Q3: How would you describe the scan and what is the differential
diagnosis?
pelvic ultrasound scan
arge ill-defined echogenic region
djacent to endometrial cavity
September 20, 2014 ONE DAY HYSTERECTOMY

34. Q9: Which of the following statements concerning adenomyosis are
true
: Adenomyosis is the presence of endometrial glandular structures within
the myometrium.
: Concomitant endometriosis is found in 10-20% of cases of adenomyosis
at hysterectomy.
: Adenomyosis has a strong positive correlation with parity and is very
rare in nulliparous women.
: All cases of adenomyosis are symptomatic.
: Imaging techniques have a sensitivity and specificity of around 80% in
the diagnosis of adenomyosis.
September 20, 2014 ONE DAY HYSTERECTOMY

35. Q6: What medical treatment options are available?
Antifibrinolytic drugs,
Non-steroidal anti-inflammatory agents
n intrauterine progestogen delivery system
should be considered if uterine causes have been excluded
September 20, 2014 ONE DAY HYSTERECTOMY

36. Q7: What are the surgical options available for this woman?
YSTERECTOMY
ounseling
fertility
myomectomy
ndometrial resectionis preferred option in flits-Situation as the patient's dysmenorrhoea will not be
treated
ollowing detailed discussions she decided to have an abdominal
hysterectomy with ovarian conservation.
his was performed without complication and there was no evidence of peritoneal or ovarian
endometriosis or previous pelvic inflammatory disease.
September 20, 2014 ONE DAY HYSTERECTOMY

37. September 20, 2014 ONE DAY HYSTERECTOMY