This document provides guidelines for evaluating and managing abnormal uterine bleeding (AUB) from an Indian perspective. It discusses the need for India-specific guidelines given the high prevalence of AUB in India and variability in clinical practices. The guidelines recommend using the FIGO PALM-COEIN classification system and provide algorithms for the diagnosis and management of AUB. Evaluation involves a thorough history, physical exam, and targeted investigations based on risk factors. Management algorithms are provided for the different structural and non-structural causes of AUB identified in the PALM-COEIN system from an evidence-based perspective in Indian women.
Insight AUB Presentations based on FOGSI AUB GUIDELINES DGFPublicAwareness
DISCLAIMER
Use of these slides is permitted only for the purpose of scientific and educational presentations.
While every reasonable effort has been made to ensure accuracy of content, it is the responsibility of the practitioner, relying on experience and knowledge of the patient, to determine dosages and the best treatment for each individual patient. DGF shall not be responsible or in any way liable for the continued accuracy &/or veracity of the information or for any errors, omissions or inaccuracies or for any injury and/or damage to persons or property arising from relying on the information contained in the presentation or otherwise.
D.G.F. CME CASE STUDY DISCUSSIONAbnormal Uterine BleedingLifecare Centre
D.G.F. CME CASE STUDY DISCUSSIONAbnormal Uterine Bleeding
MODERATOR : Dr. Ila Gupta
Dr. Sharda Jain
PANELIST : Dr. Jyoti Agarwal
Dr. Raj Bokaria
Dr. Dipti Nabh
Dr. Vandana Gupta
Ovulation Stimulation Protocols for IUI - Dr Dhorepatil BharatiBharati Dhorepatil
What are important factors to be considered important
Ovarian reserve
Previous ovarian response
Basic hormone profile
Role of LH
Trigger
Luteal phase support
Pregnancy rate/cycle
Uterine Fibroids: Symptoms, Causes, Risk Factors & Treatment uterine fibroids aren't associated with an increased risk of uterine cancer and almost never develop into cancer
Insight AUB Presentations based on FOGSI AUB GUIDELINES DGFPublicAwareness
DISCLAIMER
Use of these slides is permitted only for the purpose of scientific and educational presentations.
While every reasonable effort has been made to ensure accuracy of content, it is the responsibility of the practitioner, relying on experience and knowledge of the patient, to determine dosages and the best treatment for each individual patient. DGF shall not be responsible or in any way liable for the continued accuracy &/or veracity of the information or for any errors, omissions or inaccuracies or for any injury and/or damage to persons or property arising from relying on the information contained in the presentation or otherwise.
D.G.F. CME CASE STUDY DISCUSSIONAbnormal Uterine BleedingLifecare Centre
D.G.F. CME CASE STUDY DISCUSSIONAbnormal Uterine Bleeding
MODERATOR : Dr. Ila Gupta
Dr. Sharda Jain
PANELIST : Dr. Jyoti Agarwal
Dr. Raj Bokaria
Dr. Dipti Nabh
Dr. Vandana Gupta
Ovulation Stimulation Protocols for IUI - Dr Dhorepatil BharatiBharati Dhorepatil
What are important factors to be considered important
Ovarian reserve
Previous ovarian response
Basic hormone profile
Role of LH
Trigger
Luteal phase support
Pregnancy rate/cycle
Uterine Fibroids: Symptoms, Causes, Risk Factors & Treatment uterine fibroids aren't associated with an increased risk of uterine cancer and almost never develop into cancer
PANEL DISCUSSION ON ENDOMETRIOSIS RELATED INFERTILITY (EVIDENCE BASED)Lifecare Centre
PANEL DISCUSSION ON ENDOMETRIOSIS RELATED INFERTILITY (EVIDENCE BASED)
MODERATOR
DR SHARDA JAIN
DR JYOTI AGARWAL
DR ILA GUPTA
UMA RAI
RAJ BOKARIA
JYOTI AGARWAL
JYOTI BHASKER
RENU CHAWLA
DIPTI NABH
VANDANA GUPTA
Dr Sujoy Dasgupta moderated a Panel Discussion on "Difficult cases in IUI" in the Annual Conference of ISAR (Indian Society of Assisted Reproduction), Bengal held in December, 2022
Endometriosis an overview by dr. sharda Jain, Dr. Jyoti Agarwal , Dr. Jy...Lifecare Centre
Endometriosis :An Overview
Presented in Endometriosis update in Delhi June (2016) Hotel Leela
EB Guidelines
RCOG: Evidence-based Clinical, 1999
Endometriosis and infertility. ASRM, 2004.
ACOG. Endometriosis in adolescents, 2005.
ESHRE guideline for the diagnosis and treatment of endometriosis, 2005.
Endometriosis and infertility. ASRM, 2006.
Endometriosis: diagnosis and management.
Fertility: Assessment and Treatment for People with Fertility Problems. NICE, 2013.
ESHRE guideline: management of women with endometriosis,2014.
Recurrent pregnancy loss is a significant redroductive medical problem, influencing 2%–5% of couples. ... Throughout the years, proof based medications, for example, surgical correction of uterine abnormalities or asprin and heparin for antiphospholipid syndrome have improved the results for couples with repetitive pregnancy loss.
there is a change in attitude for monofollicular ovulation induction to treat infertility: previously clomiphene citrate was the standard drug to start with : Now it is different
PANEL DISCUSSION ON ENDOMETRIOSIS RELATED INFERTILITY (EVIDENCE BASED)Lifecare Centre
PANEL DISCUSSION ON ENDOMETRIOSIS RELATED INFERTILITY (EVIDENCE BASED)
MODERATOR
DR SHARDA JAIN
DR JYOTI AGARWAL
DR ILA GUPTA
UMA RAI
RAJ BOKARIA
JYOTI AGARWAL
JYOTI BHASKER
RENU CHAWLA
DIPTI NABH
VANDANA GUPTA
Dr Sujoy Dasgupta moderated a Panel Discussion on "Difficult cases in IUI" in the Annual Conference of ISAR (Indian Society of Assisted Reproduction), Bengal held in December, 2022
Endometriosis an overview by dr. sharda Jain, Dr. Jyoti Agarwal , Dr. Jy...Lifecare Centre
Endometriosis :An Overview
Presented in Endometriosis update in Delhi June (2016) Hotel Leela
EB Guidelines
RCOG: Evidence-based Clinical, 1999
Endometriosis and infertility. ASRM, 2004.
ACOG. Endometriosis in adolescents, 2005.
ESHRE guideline for the diagnosis and treatment of endometriosis, 2005.
Endometriosis and infertility. ASRM, 2006.
Endometriosis: diagnosis and management.
Fertility: Assessment and Treatment for People with Fertility Problems. NICE, 2013.
ESHRE guideline: management of women with endometriosis,2014.
Recurrent pregnancy loss is a significant redroductive medical problem, influencing 2%–5% of couples. ... Throughout the years, proof based medications, for example, surgical correction of uterine abnormalities or asprin and heparin for antiphospholipid syndrome have improved the results for couples with repetitive pregnancy loss.
there is a change in attitude for monofollicular ovulation induction to treat infertility: previously clomiphene citrate was the standard drug to start with : Now it is different
This MIRENA LAWSUIT updates provides context to growing number of Mirena Lawsuits by Attorney Gabriel F Zambrano one of the lawyers speaking out about the dangers of the Mirena IUD since July 2010.
A COMPARATIVE ANALYSIS OF HEMATOLOGICAL INDICES IN PREGNANT WOMEN AND NON PR...FidelityP
Red blood cell (RBC) indices are individual components of a routine blood test called the complete blood count (CBC). The CBC is used to measure the quantity and physical characteristics of different types of cells found in your blood. Blood consists of RBCs, white blood cells (WBCs), and platelets that are suspended in your plasma. Platelets are cells that enable clot formation. RBCs contain hemoglobin, which carries oxygen throughout your body to all of your tissues and organs. An RBC is pale red and gets its color from hemoglobin. It’s shaped like a doughnut, but it has a thinner area in the middle instead of a hole. Your RBCs are normally all the same color, size, and shape. However, certain conditions can cause variations that impair their ability to function properly. The RBC indices measure the size, shape, and physical characteristics of the RBCs. Your doctor can use RBC indices to help diagnose the cause of anemia. Anemia is a common blood disorder in which you have too few, misshapen, or poorly functional RBCs123
The Impact of Chinese Herbal Medicine on In Vitro Fertilization Outcomes A Sy...keith644288
Many are familiar with acupuncture and its possible benefits for infertility patients. Numerous studies on IVF and acupuncture have been conducted over the last twenty-five years. In the United States fewer are aware that historically in China the specialty of women’s health in Chinese medicine is almost exclusively herbal. In Vitro Fertilization has now been in use for 40 years, originally developed to help women conceive who had blocked fallopian tubes. Recent advances in freezing embryos and preimplantation genetic testing for aneuploidies (PGT-a) have helped physicians gradually increase their IVF rates of success. Pregnancy rates at some of the nation’s top fertility clinics hover at approximately 65%. Physicians and patients alike continue to seek novel methods to further optimize their IVF cycles. This work seeks to explore mechanisms of action and the impact of one of the world’s most ancient medical systems, Chinese medicine’s Chinese herbal medicine (CHM) on the outcomes of IVF.
How evidence affects clinical practice in egyptWafaa Benjamin
Evidence based medicine is the gold standard for clinical care.
It implies the integration of best research evidence with clinical expertise and patient values.
There is still a wide gap between availability of evidence and its incorporation into routine practice in our country.
Barriers to implementation could be personal, social, institutional, financial and legal barriers.
True practice of evidence based care can only occur where evidence based decisions coincide with patients’ beliefs and clinicians’ preferences.
Continuing medical education programs should be set with integrating evidence based medicine teaching and learning within clinical training.
The importance of presence of local national guidelines which need to take into account variation in expertise, resources and patient preferences across our geographical and cultural contexts .
Customisation of a guideline to meet the local needs of a target patient population is critical to successful implementation.
Recurrent pregnancy loss (RPL), also referred to as recurrent miscarriage or habitual abortion, is historically defined as 3 consecutive pregnancy losses prior to 20 weeks from the last menstrual period.
This Presentation is made by Dr.Laxmi Shrikhande
Fertility Management: Synergy between Endoscopists and Fertility SpecialistsSujoy Dasgupta
Dr Sujoy Dasgupta was invited to moderate a panel discussion on "Fertility Management: Synergy between Endoscopists and Fertility Specialists " in a CME by Torrent held on 27 May 2023.
PATIENT-GENERATED SUBJECTIVE GLOBAL ASSESSMENT (PG-SGA): A REVIEW Neeleshkumar Maurya
The present investigation, Subjective Global Assessment (SGA) and its different variants are being widely used as a nutritional status or risk assessment tool in clinical and hospital practice for myriads of disease including life-threatening one such as cancer, chronic kidney diseases. SGA is based on measurement and observation of several parameters such as weight change, dietary intake change, gastrointestinal symptoms, functional capacity, co morbidities related to nutritional condition and physical examination. However, the tool is not devoid of limitation and is being constantly improved for the optimization of its use in various other diseases. Therefore, clinicians need an easy to use and interpret, low cost, reliable tool to assess nutritional status. The PG-SGA is a more sensitive tool than other versions of SGA and is successfully being used as a screening tool in diseases like cancer, tuberculosis, HIV and chronic kidney disease (CKD) etc. According to the theory of “reverse epidemiology”, a patient with better nutritional status is supposed to have increased scope of survival. Therefore, it is increasingly being used patients who are at the pre-dialysis stage or being treated with dialysis. The review will summarize the basics of the nutritional assessment tool, its indications, and limitation of use in clinical practice etc. Moreover, the review will summarize the recommendations for use of PG-SGA in CKD and a brief review of existing literature to understand the scope of use and future perspective of the application of this tool for using in CKD patient population. Key Words: SGA, PG-SGA, Chronic kidney disease, Dialysis, nutrition
Week 2 The Clinical Question77 unread replies.2525 replies..docxcockekeshia
Week 2: The Clinical Question
77 unread replies.2525 replies.
Your capstone change project begins this week when you identify a practice issue that you believe needs to change. The practice issue must pertain to a systematic review that you must choose from a List of Approved Systematic Reviews (Links to an external site.)Links to an external site. for the capstone project.
· Choose a systematic review from the list of approved reviews based on your interests or your practice situation.
· Formulate a significant clinical question related to the topic of the systematic review that will be the basis for your capstone change project.
· Relate how you developed the question.
· Describe the importance of this question to your clinical practice previously, currently, or in the future.
· Describe what a research-practice gap is.
· Collapse Subdiscussion
Julie White
Julie White
SundayOct 29 at 9:39am
Manage Discussion Entry
Opening Post_Julie
On a daily basis, healthcare providers are faced with an array of clinical decisions to be made in an efficient and timely manner. Translating evidence into best practices is one way to achieve this. Without current best evidence, practice is rapidly outdated, often to the detriment of the patient. Evidence based practice is the conscientious use of current best practice in making decisions about patient care (Sackett, Richardson, Rosenberg, & Hayes, 2000). It is important for health care professionals to ask questions about their current clinical practice. In this week’s threaded discussion you will ask that burning question that you ask in your daily care of your patients.
You’ll need to focus on asking the right questions, narrowing the questions to one that is nurse driven and the need for change is evident. The question that you formulate will be the question for your Capstone Project.
The process of reviewing scholarly articles for a change in practice is an important part of the development of any type of research project that can lead to a change in practice. As you are appraising the systematic review and other scholarly articles for your change project, think about areas of the article such as sample size, the population, type of study, discussion and limitations. Critiquing a research article will allow you to evaluate the scientific merit of the study and decide how the results may be useful in practice.
ReplyReply to Comment
·
Collapse Subdiscussion
Adele Allen
Adele Allen
SundayOct 29 at 12:58pm
Manage Discussion Entry
Hello Professor and Classmates,
Nurses are called to rely on current research to guide evidence-based practice. The research on a topic can be vast and contradictory. Traditional reviews of the evidence are no longer appropriate. The information sifting called for with the wealth of information available is too great a task. The reviewer needs guidelines to ensure bias is minimized and th.
The Newer Concepts In Endometriosis Management : Dr Sharda JainLifecare Centre
The Newer Concepts In
Endometriosis Management
ENDOMETRIOSIS IS ENIGMA
DIAGNOSTIC DELEMMA
DEBILITATING DISEASE QOL
PROGRESSIVE DISEASE
RECURRENCE IS BIG PROBLEM
NO FINAL VERDICT ON CAUSE
NO PERMANENT CURE
The exact prevalence of endometriosis is unknown, but estimates 10% in the general female population in India but up to 50% in infertile women
The Newer Concepts forReduced Surgery to preserve fertility in Endometrios...Lifecare Centre
The Newer Concepts forReduced Surgery to preserve fertility in Endometriosis
ENDOMETRIOSIS IS ENIGMA
DIAGNOSTIC DILEMMA
DEBILITATING DISEASE QOL
PROGRESSIVE DISEASE
RECURRENCE IS BIG PROBLEM
NO FINAL VERDICT ON CAUSE
NO PERMANENT CURE
The exact prevalence of endometriosis is unknown, but estimates 10% in the general female population in India but up to 50% in infertile women
Anemia Free India Gynaecologist to focuss on *12gm Haemoglobin at Delivery I...Lifecare Centre
Important Highlights
Prophylactic Iron and Folic Acid Supplementation in all six target age groups.
Intensified year-round Behaviour Change Communication (BCC) Campaign for:(a) improving compliance to IFA and deworming, (b) enhancing appropriate infant and young child feeding practices, (c) encouraging increase in intake of iron-rich food through diet and/or fortified foods (d) ensuring delayed cord clamping .
Testing and treatment of anaemia, using digital methods and point of care treatment, with special focus on pregnant women and school-going adolescents.
Addressing non-nutritional causes of anaemia
in endemic pockets with special focus on malaria, hemoglobinopathies and fluorosis
Strategies for Improving Success Rates in ART PARTLifecare Centre
Strategies for Improving Success Rates in ART
Part - 2
Strategies for Improving Success Rates in ART
Tailoring Controlled Ovarian Stimulation
Strategies for Luteal Phase in ART cycles
Endometrial Receptivity Array
How to optimize success rates in ART? : Dr Sharda JainLifecare Centre
How to optimize success rates in ART? : Dr Sharda Jain
How to improve success rates in ART?
The big debate कार्य में आनंद
Evolution of In-vitro Fertilization (IVF)
Factors Influencing IVF Success Ist Part
Strategies for Improving Success Rates in ART Second Part
Innovations & Breakthroughs in IVF Part Three
OPEN DEBATE
SOCIALEGG FREEZING : Dr Poorva Bhargav and Dr Sharda JainLifecare Centre
SOCIALEGG FREEZING : Dr Poorva Bhargav and Dr Sharda Jain
Introduction
Social egg freezing (oocyte cryopreservation for non-medical reasons) has evolved as a proactive option for women looking to extend their reproductive possibilities past their peak childbearing years
It is the process of saving or protecting eggs, or reproductive tissues so that a person can use them to have biological children in future
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
2. DISCLAIMER
• Use of these slides is permitted only for the purpose of
scientific and educational presentations.
• While every reasonable effort has been made to ensure
accuracy of content, it is the responsibility of the
practitioner, relying on experience and knowledge of
the patient, to determine dosages and the best
treatment for each individual patient. DGF shall not be
responsible or in any way liable for the continued
accuracy &/or veracity of the information or for any
errors, omissions or inaccuracies or for any injury
and/or damage to persons or property arising from
relying on the information contained in the
presentation or otherwise.
3.
4. Evidence-based Guidance for Clinical
Decision Making and Approach to
Diagnosis of abnormal uterine bleeding
“An Indian Perspective”
L.IN.MA.WH.02.2016.0746
5. AUB-Spectrum of problem
11
Total women in
reproductive age group
Women
affected
with AUB
at any
given
point
17.9
Total women in
reproductive age group
Women
affected
with AUB
Women
not
affected
In world In India
Prevalence increases with age, reaching 24 percent in women aged 36 to 40. 1
1. Harlow SD, Campbell OM. BJOG. 2004;111:6– 16; 2. Omidvar S, Begum K. J Nat Sci Biol Med.
2011;2:174–9. 3. Chattopdhyay B, Nigam A, Goswami S. Eur Rev Medi Pharmacol Sci. 2011;15:764–768
6. Burden of HMB in India
Excessive bleeding has been reported in about 8-9%
women from India and neighboring countries.1
42-53% of women aged < 21 years and those > 21 years
complained of excessive bleeding.2
15% of all gynecology OPD visits and 25% of all
gynaecological surgeries3
1. Harlow SD, Campbell OM. BJOG. 2004;111:6– 16; 2. Omidvar S, Begum K. J Nat Sci Biol Med. 2011;2:174–9.
3. Chattopdhyay B, Nigam A, Goswami S. Eur Rev Medi Pharmacol Sci. 2011;15:764–768
8–9%
42–53%
15%
7. AUB impacts up to 30% of women at some time in their
lives
Behavior and Attitude of patients
• HMB isn’t clearly understood, it’s mostly associated to menopause &
Hormonal imbalance
• Several myths are associated to the same – kachra blood, spicy foods, a
sign of feminity.
• Heavy bleeding is sometimes viewed wrongly as ‘return to womanhood’
• Fear and anxiety is present to visit the doctor and several women function
in the zone of denial, hence delaying visitation or consistent follow-up,
check-up
• Treatment is a psychological block in itself to undertake as it will be
prolonged, painful, extended and result in hysterectomy
*Source: Independent market research funded by Bayer Zydus Pharma Pvt. India.
L.IN.MA.WH.02.2016.0746
8. Impact of AUB on Quality of life (QoL)
Major impact on a woman’s
quality of life
Over 60% of women
diagnosed with HMB ended
up having a hysterectomy
within 5 years from the
diagnosis4
About 1/3rd of
hysterectomies for HMB
result in removal of
anatomically normal
uterus5
Impact of HMB
Anxiety
Decreases
work
productivity2
Iron
deficiency
anaemia 1
Discomfort
1
Negative
impact on
relationship
with
partners3
Decreased
QOL1
1. Ghazizadeh S. Int J Women’s Health. 2011;3: 207–21. 2. Magon N. J Midlife Health. 2013;4(1):8–15; 3. Bitzer J.Open Access J Contracep.
2013; 21–28; 4. NICE 2007; can be accessed at: https://www.nice.org.uk/guidance/cg44 5.Roy SN, Bhattacharya S. Drug safety 2004
10. Abnormal Uterine Bleeding
1. ACOG: Obstet Gynecol. 2013;121(4):891-6. 2. NICE Guidance 2007
ACOG1 NICE2
Bleeding from uterine
corpus that is abnormal in
a) regularity,
b) volume,
c) frequency, or
d) duration and
e) occurs in the absence of
pregnancy
When a woman experiences a
change in
a) her menstrual loss, or
b) the degree of loss or
c) vaginal bleeding pattern
differs from that
experienced by the age-
matched general female
population
11. Acute and Chronic AUB
• Acute uterine bleeding unrelated to pregnancy was
defined in as “that which is sufficient in volume as to, in
the opinion of the treating clinician, require urgent or
emergent intervention.” (FIGO definition)
• Chronic: AUB present for most of the previous 6 months
1. ACOG: Obstet Gynecol. 2013;121(4):891-6.
2. Munro et al. Am J Obstet Gynecol. 2012 Oct;207(4):259-65.
12. Role of FIGO Nomenclature
L.IN.MA.WH.02.2016.0746
13. Limitations of the current nomenclature
• Terms associated with AUB
– inconsistently defined in literature12
a) sub-optimal diagnosis of patients
b) Impact the comprehensive management of
the condition
– It also make it difficult to plan and conduct
studies and compare results of different
studies2
– Towards rectifying inconsistent terminologies,
FIGO developed a consistent and universally
accepted nomenclature a classification
system for clinicians, investigators, and patients
to facilitate communication, clinical care, and
research
1. Woolcock et al. Fertil Steril 2008;90:2269-80.
2. Munro et al. Am J Obstet Gynecol. 2012 Oct;207(4):259-65.
14. FIGO System of Nomenclature
for the etiologies of AUB
Polyps (P)
Adenomyosis (A)
Leiomyoma (L)
Malignancy & Hyperplasia
(M)
Coagulopathy (C)
Ovulatory dysfunction (O)
Endometrial (E)
Iatrogenic (I)
Not defined (N)
Submucosal
Other
Structural causes
a) discrete in nature,
b) can be measured visually
with imaging techniques
and/or histopathology
Non- Structural causes
entities that are not defined
by imaging or histopathology
Munro et al. Am J Obstet Gynecol. 2012 Oct;207(4):259-65.
15. International guidelines on Management of AUB
Faculty of Family Planning and Reproductive Health Care (FFPRHC) Guidance
2004
National Institute for Health and Care Excellence (NICE) 2007
Clinical Practice Guideline: Management of Abnormal Uterine Bleeding
(France)
Finnish Society of Obstetrics and Gynecology, 2006
Cochrane Review:-Progesterone or Progestogen releasing Intra Uterine
systems for Heavy Menstrual Bleeding; 2005
Clinical Practice Guideline: Management of Menorrhagia (Ministry of Health –
Malaysia); 2004
ACOG Guidelines- Management of Acute Abnormal Uterine Bleeding in Non-
pregnant Reproductive-Aged Women, 2013 reaffirmed in 2015
SOGC Canadian Clinical Practice Guideline: Management of AUB in Pre-
Menopausal Women; 2013
16. Why India specific guidelines for
AUB??
Need
for AUB
GCPR
Inconsistency
in day to day
management
of AUB
Unavailability of
clear diagnostic
and therapeutic
criteria impact
overall standard
of health care
High prevalence
of AUB among
women in India
Diverse clinical
practices
Lack of good
clinical practice
guidelines
specific to
Indian context
1. The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB. Available
at http://www.fogsi.org/wp-content/uploads/2016/02/gcpr-on-aub.pdf Last accessed at 24 February, 2016
2. Rahnn et al. J Clin Epidemiol. 2011;64(3):293-300
17. Level of evidences
Strength of recommendation (adapted from AACE Task Force)
A Strongly recommended
B Intermediate
C Weak
D Not-Evidence based, Panel recommended
Scale of scientific support
1 Meta-analysis of randomized controlled trials and randomized controlled trials
2
Meta-analysis of non-randomized prospective or case-controlled trials, non-randomized
controlled trials, prospective cohort study, and retrospective case-control studies
3
Cross-sectional studies, surveillance studies (registries, surveys, epidemiologic studies,
retrospective chart reviews, mathematical modelling of database), consecutive case series,
single case reports
4 Opinion/consensus by experts or preclinical study
1. Handelsman et al. Endocr Pract. 2013;19:675-93
18. Methodology
Review of literature: Best evidence
Evidence reviewed by experts group
Variability in Indian context identified: cultural,
racial, socioeconomic background
Need identified to formulate GCPR in Indian
context
Draft recommendations framed : April 2014
Expert Panel meeting, 26.9.2015: Draft discussed
Where evidence was limited, the panel relied on
experience/ clinical judgement
Final version framed → Graded
19. Methodology
Current consensus guidelines in accordance with
AACE protocol
Recommendations organized etiology-wise
(PALM-COEIN)
Based on :
Clinical importance and graded- A, B, C, and D
Coupled with four intuitive levels of evidence-
1, 2, 3, 4 (quality of supporting evidence)
21. Recommendations: History /
Examination
Use PALM-COEIN , Abandon old terminology
(Grade A; Level 4)
Thorough history, physical examination to direct
need for investigations/ Tt
(Grade A; Level 4)
22. Diagnosis and Evaluation
Thorough History
(Grade A; Level 4)
Preliminary
assessment (Grade A;
Level 4)
Investigations
(Grade A; Level 4)
Menstrual
Pattern
a) Duration,
b) amount,
c) cycle length,
d) regularity,
e) intermenstrual
bleed
Pain a) Dysmenorrhea,-
spasmodic or
congestive,
b) intermenstrual,
chronic pain,
c) dyspareunia
Concomitant
Medications
(Grade B;
Level 4)
a) Anticoagulants,
b) Tamoxifen
c) Hormonal
contraceptives
d) Anti depressants
and anti psycotics
e) Corticosteroids
History suggestive of bleeding
diathesis, PCOS or thyroid disorder
1) Laboratory
testing
2) Imaging
3) Specialized
tests
4) Endometrial
histopathology
Assess pallor, weight, features
suggestive of PCOS, thyroid
disorders
Abdominal
examination
Palpable
uterus
Per speculum
examination
cervical
lesions,
discharge
Per vaginum
examination
uterine size,
contour,
consistency,
tenderness,
adnexal mass
or tenderness
The Federation of Obstetric and Gynecological Societies of India. Good clinical practice
recommendations for AUB. Available at http://www.fogsi.org/wp-content/uploads/2016/02/gcpr-on-
aub.pdf Last accessed at 24 February, 2016 L.IN.MA.WH.02.2016.0746
23. Recommendations: History /
Examination
Criteria - Positive screen for coagulopathies :
H/o heavy bleeding starting at menarche
One of following:
At least two of following:
Examination: Weight, BMI, pallor, thyroid, breasts, acne,
FG scoring (if hirsutism),
P/A, P/S, P/V examination (Grade A; Level 4)
PPH
Bld with dental work
Surgery-related bld
Bruising : ≥ 1 episode / mth
Epistaxis: ≥ 1 episode / mth
Frequent gum bleeding
F/H bleeding symptoms
(Grade B; Level 4)
24. Recommendations: Lab testing
CBC: Hb, platelets
UPT if s/o pregnancy
Bleeding time
Platelet count
Prothrombin time
Partial thromboplastin time
TSH test : when clinically indicated
Coagulopathy screen +
Adolescents
Hematologist Cx &
Further testing :
Von Willebrand antigen
vWB- Ristocetin cofactor
activity
Factor VIII activity
25. Imaging
Ultrasound
Imaging - Mandatory
Magnetic Resonance
Imaging - Optional
Hysteroscopy
Doppler
sonography
Suspected AV malformation,
malignancy cases and to
differentiate between fibroid
and adenomyomas (Grade B;
Level 3)
3D USG For evaluating intra
myometrial lesion in selected
patients for fibroid mapping
(Grade B; Level 4)
SIS If intracavitary lesion is
suspected and hysteroscopy
is not available (Grade A;
Level 1)
USG should be done in AUB to evaluate uterus,
adnexa and endometrial thickness (Grade A; Level 1)
a) Map exact location of
fibroids before planning
conservative surgery and
prior to therapeutic
embolization for fibroids
b) To differentiate
between fibroids and
adenomyomas
a) Direct visualization
of intracavitary lesion
(Grade A; Level 1)
b) Facilitates directed
biopsy
The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB. Available at
http://www.fogsi.org/wp-content/uploads/2016/02/gcpr-on-aub.pdf Last accessed at 24 February, 2016
Not indicated
for ALL AUB
26. GCPR- Endometrial Assessment and Biopsy
recommended in all
women with AUB
Older than 40
years of age
(Grade A; Level 2)
Less than 40 years
who are at risk of
endometrial cancer
(Grade A; Level 2)
Risk factors of endometrial cancer
• Irregular bleeding
• Obesity associated with hypertension
• Endometrial thickness > 12 mm
• Polycystic Ovarian syndrome (PCOS)
• Diabetes Mellitus
• History of malignancy of ovary/breast/
endometrium/colon
• Use of Tamoxifen for HRT or breast cancer
• AUB-unresponsive to medical management
• HNPCC syndrome (hereditary nonpolyposis
colorectal cancer or Lynch Syndrome)
Endometrial assessment (EA)
Endometrial histopathology Dilatation and curettage Hysteroscopy
Performed if
endometrium is
thick on imaging
but HPE is
inadequate, to
rule out polyps
(Grade A; Level 2)
Not be a procedure of choice
for EA (Grade A; Level 3)
Endometrial aspiration should be the
preferred procedure for obtaining
endometrial sample for histopathology.
The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB.
Available at http://www.fogsi.org/wp-content/uploads/2016/02/gcpr-on-aub.pdf Last accessed at 24 February, 2016
27. Algorithm for the Diagnosis of AUB
The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB. Available at http://www.fogsi.org/wp-content/uploads/2016/02/gcpr-on-aub.pdf Last accessed at
24 February, 2016
29. Agenda • Management Algorithms for PALM COEIN causes of
AUB
• Current treatment options for AUB
a) Management of AUB-PALM
Clinical evidences
India specific clinical recommendations-treatment
algorithms
b) Management of AUB-COEIN
Clinical evidences
India specific clinical recommendations-treatment
algorithms
L.IN.MA.WH.02.2016.0746
32. Current Treatment Options
• Pharmacological
– Levonorgesterol -
Intrauterine System
(LNG-IUS)
– Antifibrinolytics
– NSAIDS
– GnRH analogues
– Oral contraceptives
– Cyclic progestins
Surgical
Endometrial ablation (EMA)
Considered appropriate only for patients
who have completed their family.
It is also not suitable for women with a
large uterus
Hysterectomy
Remains the definitive treatment for
HMB
Should not be used as first-line
treatment in cases with primary HMB
unless all other treatments are
contraindicated or refused by the
patient.
Uterine fibroid embolization
New and still experimental
The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB. Available at
http://www.fogsi.org/wp-content/uploads/2016/02/gcpr-on-aub.pdf Last accessed at 24 February, 2016
34. Treatment Algorithm: AUB-P
In women with AUB
diagnosed with
Single endometrial
polyp
Multiple endometrial polyps and
women is not desirous of
continued fertility
Suggested to perform
hysteroscopic
polypectomy for younger
women.(Grade A; Level 1)
Suggested to perform
hysteroscopic polypectomy
(Grade A; Level 1)
LNG IUS insertion (Grade A;
Level 1)
Histopathology examination
If benign
lesion on
HPE
If HPE suggest
malignancy
Further management
should as AUB-M.
The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB. Available
at http://www.fogsi.org/wp-content/uploads/2016/02/gcpr-on-aub.pdf Last accessed at 24 February, 2016
35. Recommendations for AUB-A
For managing AUB-A: Individualize
Age
Symptoms (AUB, pain and infertility)
Associated leiomyomas, polyps,
endometriosis
Fertility desire
36. Treatment Algorithm: AUB-A
LNG IUS is
recommended
as 1st line
therapy (Grade
A; Level 1)
In women with AUB due to
Adenomyosis
Women desirous of fertility
Unwilling for
immediate
conception
Resistant or
unwilling to use
LNG IUS
Gonadotropin releasing
hormone (GnRH) agonists
with add back therapy is
recommended as 2ndline
therapy (Grade A; Level 1)
GnRH agonists cannot be
indicated for symptomatic relief
Combined oral contraceptives,
Danazol, NSAIDS and progestogens
are recommended (Grade B; Level 4)
Women not desirous of fertility
Vaginal or laparoscopic
hysterectomy / Trans-
cervical resection of
endometrium is
recommended (Grade A;
Level 3)
long-term GnRH agonists and add-
back therapy can be initiated/ LNG
USG
Medical management
Failure or refusal for medical
management
L.IN.MA.WH.02.2016.0746
The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB. Available at http://www.fogsi.org/wp-content/uploads/2016/02/gcpr-on-aub.pdf Last accessed at
24 February, 2016
Adenomyomectomy conservative surgery that may be offered in selected cases
presenting with infertility or with strong desire to retain uterus. (Grade B; Level 2).
38. Recommendations: AUB-L
Individualized : Age, parity, symptoms, fertility desire
Type 0-1
Hysteroscopic myomectomy (<4 cm)
Abdominal myomectomy (>4 cm) (Grade B; Level 4)
First generation ablation (TCRE / REA)- in selected cases
undergoing hysteroscopic myomectomy in pts not desiring
pregnancy
39. <4 cm
diameter
Hysteroscopic
myomectomy
(Grade B;
Level 4)
In women with AUB due to
Leiomyoma
Sub-mucosal
(Type 0-1)
Depending
on size
Women desirous of
preserving
fertility/uterus
If treatment fails, or if
myoma is causing infertility
Tranexamic acid or COCs
or NSAIDS – 2nd line
(Grade A; Level 1)
Women >40 years and
not desirous of fertility
Hysterectomy is
definitive
treatment or
medical
management / LNG-
IUS before resorting
to Sx
(Grade B; Level 3)
Treatment Algorithm: AUB-L
Site
Intramural/Sub-serous
(symptomatic)
(type II-VI)
>4 cm
diameter
Abdominal
myomectomy
(Grade B;
Level 4)
LNG-IUS
(Grade A; Level 1)
Abdominal (open or laparoscopic)/ Hysteroscopic
myomectomy is recommended (Grade A; Level 3)
The Federation of Obstetricand Gynecological
Societies of India. Good clinicalpractice
recommendations for AUB. Availableat
http://www.fogsi.org/wp-
content/uploads/2016/02/gcpr-on-aub.pdf Last
accessed at 24 February, 2016
Immediate
conception desired
and LNG IUS failure
Conception
not desired for
at least 1 year
40. Treatment Algorithm: AUB-L contd.
In women with AUB due to
Leiomyoma – not desirous of
fertility
Improving
general
condition,
anaemia
Long term managementShort term management (up to 6 months):
In all AUB-L (III-VI)
except (AUB-L type 0 &
1) and selected cases of
AUB –(LII)
LNG-IUS is
recommended
(Grade A; Level 1)
The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB. Available at
http://www.fogsi.org/wp-content/uploads/2016/02/gcpr-on-aub.pdf Last accessed at 24 February, 2016
In selected
patients
prior to
myomectomy
In selected
perimenopausal
women so that
they can tide over
menopause
GnRH agonists with add back
therapy is recommended
(Grade A; Level 1)
In younger
patients to
delay/avoid
early surgical
intervention
41. Newer promising options :
PRMs: Ulipristal acetate (5 mg/D) (Grade A; Level 1)
Mifepristone (5-10 mg/D), low doses
N/A (Grade A; Level 1)
Endometrial ablation:
- HMB with small uterine fibroids (< 3 cm), uterus <10
wks
- 2nd gen. ablation techniques should be used (TBEA,
MEA)
Recommendations: AUB-L
42. Revised classification of
Endometrial hyperplasia WHO 2014
New Term Coexistent Invasive
Endometrial Cancer
Progression To
Invasive
Cancer
Hyperplasia without
Atypia
<1% RR:1.01-1.03
Atypical
Hyperplasia
25-33% RR:14-45
43. Standard protocol for
management of malignancy to
be followed (Grade B; Level 4)
Endometrial hyperplasia
(AUB-M)
AUB-M
If LNG IUS is contraindicated or
patient unwilling to use LNG IUS
Hysterectomy-
definitive
treatment
(Grade B; Level 2)
Hyperplasia without
atypia
LNG IUS is recommended
as 1st line therapy
(Grade A; Level 1)
Treatment Algorithmfor AUB-M
Endometrial
malignancy
Oral Progesterones
can be used(Grade A;
Level 1)
Atypical endometrial
hyperplasia
The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB.
Available at http://www.fogsi.org/wp-content/uploads/2016/02/gcpr-on-aub.pdf Last accessed at 24 February, 2016
Conservative treatment with high-dose
progestins and close histological
monitoring should only be considered in
exceptional cases
Preventive hysterectomy should
only be considered in
exceptional cases (e.g., extreme
obesity without any prospect of
weight loss).
44. Recommendations for AUB-M
Endometrial Hyperplasia with Atypia
• EA to be repeated 6 monthly for close monitoring
• Endometrial ablation not recommended-
complete destruction not ensured, histological
follow up difficult
45. Management of AUB-PALM
The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB. Available at
http://www.fogsi.org/wp-content/uploads/2016/02/gcpr-on-aub.pdf Last accessed at 24 February, 2016
Key recommendations for Treatment of AUB-PALM
AUB-P Single Polyps: Hysteroscopic polypectomy
Multiple Polyps: Hysteroscopic polypectomy followed by LNG IUS placement
if benign lesion on HPE.
AUB-A Women desirous of fertility: and immediate conception not desired: LNG
IUS 1st line of treatment
Women not desirous of fertility: Long term GnRH agonists with add back
therapy
AUB-L Submucosal: Hysteroscopic/abdominal resection depending on size
Intramural/subserosal: Immediate conception not desired LNG IUS 1st line
of treatment and immediate conception desired Tranexmic acid
Women >40 years and fertility not desired: Hysterectomy
Women >40 years and fertility desired
a) Long term management of AUB-L(III-VI) LNG IUS 1st line of treatment
b) Short term management GnRH agonists with add back therapy
AUB-M Atypical Hyperplasia fertility not desired: hysterectomy
Hyperplasia without atypia LNG IUS is 1st line of treatment. If contraindicated
then progesterone receptor modulators
47. After consultation with haematologists
Tranexamic acid 1g
QID (Grade A; Level 2)
In women with AUB due to
coagulopathy (AUB-C)
Hormonal treatment-
secondary option
COCs/LNG IUS is
recommended (Grade A;
Level 2)
Treatment Algorithm: AUB-C
Following considerations have to be taken care of:
• In refractory cases von-willebrand disease with uncontrolled uterine bleeding with above
medical management, specific factor replacement where possible or desmopressin to be given
in consultation with haematologist.
• When surgical interventions are indicated, for appropriate pre-, intra- and post-operative
management of bleeding – Factor replacement /desmopressin
Non hormonal treatment-
primary options
L.IN.MA.WH.02.2016.0746
The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB. Available at http://www.fogsi.org/wp-
content/uploads/2016/02/gcpr-on-aub.pdf Last accessed at 24 February, 2016
48. Treatment Guidelines: AUB-O
• In women not desiring conception presently, COCs can be
used as first-line therapy for 6-12 months (Grade A; Level
1).
• Cyclic luteal-phase progestins (for 10-14 days) can not be used
as a specific treatment in women with AUB-O (Grade A; Level 1)
• Norethisterone cyclically (for 21 days) is given as initial
therapy in acute episodes of bleeding for short-term
management of 3 months (Grade B; Level 4).
The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB.
Available at http://www.fogsi.org/wp-content/uploads/2016/02/gcpr-on-aub.pdf Last accessed at 24 February, 2016
49. Treatment Guidelines: AUB-O
• It is suggested to assess response after 1 year of medical
management and judge to continue/discontinue existing
therapy (Grade B; Level 4).
• Surgical intervention is not recommended unless, there is
evidence of persistent AUB or failure of medical
management to alleviate the condition (Grade A; Level 4).
• If COCs are contraindicated or patient is unwilling for COCs,
LNG-IUS is recommended if she wishes to use it for at least 1
year (Grade A; Level 1).
• In adolescents with AUB-O, both hormonal and non-
hormonal therapies can be prescribed. (Grade A; Level 4).
50. Endometrial (AUB-E)
1. Management of AUB-E can be similar to the management
of AUB-O (Grade A; Level 4).
AUB that occurs due to a primary disorder of the
endometrium and secondary to endometrial
inflammation or infection, abnormalities in the local
inflammatory response or endometrial vasculogenesis, in
the context of predictable and cyclic menstrual bleeding
with no other definable causes
The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB. Available at
http://www.fogsi.org/wp-content/uploads/2016/02/gcpr-on-aub.pdf Last accessed at 24 February, 2016
51. Iatrogenic (AUB-I), Definition
and recommendations
• Patients with unscheduled endometrial bleeding due to:
– Using gonadal steroid (eg, estrogens, progestogens, androgens) or
– gonadal steroid-related therapy (eg, GnRH agonists, aromatase
inhibitors, selective estrogen receptor modulators, or progesterone
receptor modulators, heparins and anti-coagulants)
Treatment Algorithm: AUB-I
• Whenever feasible, medications causing AUB should be changed to other
alternatives, if no alternatives are available
• LNG-IUS is recommended for treatment (Grade A; Level 1).
The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB. Available
at http://www.fogsi.org/wp-content/uploads/2016/02/gcpr-on-aub.pdf Last accessed at 24 February, 2016
52. In women with AUB (not
yet defined-N)
Medical management
If fails or
contraindicated
If LNG IUS is
contraindicated
Women desires contraception
For AUB that is mainly cyclic or
has predictable
Treatment Algorithm: AUB-N
LNG IUS is
recommended as
1st line therapy
(Grade A; Level 1)
COCs are
recommended as 2nd
line therapy
(Grade A; Level 1)
GnRH agonists
along with add-
back hormone
therapy are
recommended
(Grade B; Level 4).
Surgical treatment
(such as ablation) – if
fails or is
contraindicated
Non hormonal options such NSAIDS and
Tranexamic acid are recommended
(Grade A; Level 1)
The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB.
Available at http://www.fogsi.org/wp-content/uploads/2016/02/gcpr-on-aub.pdf Last accessed at 24 February, 2016
1) Uterine Artery
embolization is
recommended.
2) Hysterectomy is the
last resort (Grade
B; Level 4).
In women with AUB
(not yet defined-N)-
AV Malformation
53. Management of AUB-COEIN
Key recommendations for Treatment of AUB-COEIN
AUB-C Nor-hormonal is primary treatment: Tranexmic acid
Hormonal treatment: secondary treatment LNG IUS/COCs
AUB-O Women not desirous of fertility: COCs for 1st 6 months. If COCs are
contraindicated then LNG IUS is preferred as 1st line treatment
Surgical treatment not a choice of treatment unless failure of medical
management.
AUB-E Similar to AUB-O
AUB-I LNG IUS is preferred choice of treatment
AUB-N Women not desirous of contraception: LNG IUS is 1st line of treatment
If medical and surgical treatment fails: or is contraindicated :GnRH
agonists are preferred
The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB. Available at
http://www.fogsi.org/wp-content/uploads/2016/02/gcpr-on-aub.pdf Last accessed at 24 February, 2016
54. Endometrial Ablation in AUB
Benign lesions (All except AUB-M)
As primary Tt if intolerant/ no response to
medical Tt
Medical Tt fails, & poor surgical candidates for
hysterectomy
Pt preference
(Grade A, Level 1)
SOGC Clinical practice Guidelines 2015Initial cost of ablation- significantly lower than hysterectomy
Since re-treatment is often necessary, the cost difference
narrows over time
Cochrane 2010
55. Uterine artery embolization
Indications
AV Malformations (Grade A, Level 1)
Symptomatic fibroid with significant symptoms
No desire for fertility but want to preserve uterus
Poor surgical risks
Severely anemic & require immediate intervention
RESULTS
Symptomatic improvement : 84% at 6 mths
83% at 24 mths
Reduction in fibroid volume: 40–70%
Reintervention:15-28%(Hysterectomy, Myomectomy, Rpt. UAE)
NICE GUIDELINES for UAE, 2010
(Grade A, Level 1)
56. MRI- Guided High intensity Focused
Ultrasound (HIFU)
Mechanism:
High intensity USG waves → specific target point
→ temp rise (55-90oC) → Coagulative Necrosis
Concurrent MRI - Accurate tissue mapping &
- Real time temperature feedback
Adv:
Noninvasive
OPD based Tt
No radiation
Kim YS, Am J Roentgenol, 2014
57. MRI- Guided High intensity Focused
Ultrasound (HIFU)..
Limitations
Too large (upto 10 cm), too deep and multiple myoma
Presence of scar tissue, bowel loops in sonication path
Excessive thick subcutaneous layer of ant abd wall
Vascular myoma
Inability to withstand stationary position
Not recommended for women wishing to preserve fertility
Cost
Kim YS, Am J Roentgenol, 2014
Response: 71% at 6 mth, 51% at 12 months (Zhao WP, Eur Radiol, 2014)
Re intervention > 12 months: 35% (Stewart, Fertil Steril, 2006)
58. MRI- Guided High intensity Focused
Ultrasound (HIFU)..
FDA approved in 2004
NICE 2011 : Use only in research and audit
settings
Ongoing FIRSTT trial comparing UAE v/s
HIFU
(Ending in Aug 2016)
59. Summary-Clinical recommendations
Key recommendations for Diagnosis of AUB
1) For proper Evaluation
a) Thorough history of bleeding patter, pain and concomitant
medication
b) Preliminary assessment- Abdomen, vaginal and cervical
examinations for any structural distortions
c) Investigations
Laboratory testing: for coagulopathies, pregnancy and thyroid
disorder
Imaging: TVUS for endometrial thickness, doppler USG for
AVM, 3D USG for myometrial lesions and SIS for intracavitary
lesions
MRI: to map exact location of fibroids and differentiate
between fibroids and adenomyomas.
Hysteroscopy: diagnosis of uterine abnormalities.
2) Endometrial Assessment and Biopsy
Endometrial histopathology: performed in all women >40
years and <40 years at risk of endometrial carcinoma.
Endometrial aspiration is preferred method for EA.
Hysteroscopy: performed if endometrium is thick but
inadequate to rule out polyps.
Key recommendations for
Management of AUB
1) LNG IUS is recommended as 1st
line of treatment for:
a) AUB due to multiple polyps after
hysteroscopic polypectomy if benign
lesion on HPE
b) AUB-A women desirous of fertility
but not immediate conception
c) Intramural/subserosal leiomyoma
d) Type III-VI leiomyoma in peri-
menopausal women
e) Hyperplasia without atypia
f) In women with ovulatory
dysfunction and COCs are
contraindicated
g) AUB due to iatrogenic causes
h) AUB-N, when women are not
desirous of fertility.
The Federation of Obstetric and Gynecological Societies of India. Good clinical practice recommendations for AUB. Available at http://www.fogsi.org/wp-
content/uploads/2016/02/gcpr-on-aub.pdf Last accessed at 24 February, 2016
60. Take home message
AUB is a common problem from menarche to
menopause
PALM-COIEN system- simplified the clinical
classification and provided an organized approach for
diagnosis and evaluation of AUB.
Individualized / Cafeteria approach
Newer drugs are promising but need to be evaluated
carefully
Evidence based management can avoid number of
unnecessary hysterectomies
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