Puberty menorrhagia refers to heavy menstrual bleeding lasting longer than 7 days or exceeding 80 ml of blood loss during puberty. Common causes include dysfunctional uterine bleeding due to immature hypothalamic-pituitary-ovarian axis, bleeding disorders, polycystic ovary syndrome, and complications of pregnancy. Evaluation involves detailed history, physical exam, ultrasound, blood counts, pregnancy test, and tests for underlying causes as needed. Treatment is usually medical, focusing on controlling bleeding through hemostatic agents like tranexamic acid or desmopressin, correcting anemia, and treating any underlying disorders found. Surgery is rarely needed.
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.
In cases of Nulliparous prolapse or even patients deserving child bearing uterus preserving surgeries are done.
Recently even for prolapse if women want to preserve uterus for variety of reasons ,with newer minimally invasive methods it is now gaining popularity.Larger studies and longer followup is required.
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.
In cases of Nulliparous prolapse or even patients deserving child bearing uterus preserving surgeries are done.
Recently even for prolapse if women want to preserve uterus for variety of reasons ,with newer minimally invasive methods it is now gaining popularity.Larger studies and longer followup is required.
Fetal growth restriction (FGR), formerly called intrauterine growth restriction (IUGR), refers to a condition in which an unborn baby is smaller than it should be because it is not growing at a normal rate inside the womb.
Mild FGR usually doesn't cause long-term problems. In fact, most babies who have it catch up in height and weight by age 2. But severe FGR can seriously harm a baby before and after birth. The extent of the problems depends on the cause and how severe the growth restriction is. It also depends on what point in the pregnancy it starts.
Presentation on the description of normal and abnormal uterine bleeding, menstrual cycle, FIGO classification with PALM-COEIN, common differentials of AUB, assessment, diagnosis, and management.
Fetal growth restriction (FGR), formerly called intrauterine growth restriction (IUGR), refers to a condition in which an unborn baby is smaller than it should be because it is not growing at a normal rate inside the womb.
Mild FGR usually doesn't cause long-term problems. In fact, most babies who have it catch up in height and weight by age 2. But severe FGR can seriously harm a baby before and after birth. The extent of the problems depends on the cause and how severe the growth restriction is. It also depends on what point in the pregnancy it starts.
Presentation on the description of normal and abnormal uterine bleeding, menstrual cycle, FIGO classification with PALM-COEIN, common differentials of AUB, assessment, diagnosis, and management.
It is considerable cycle variability in the adolescent years. Regular ovulatory menstrual cycles occur every 21 to 35 days and last up to 7 days, with an average blood loss of 25 to 69 mL. Many patients complain of menstrual problems that actually fall within normal variations. In the first year after menarche, 50% of cycles are anovulatory, but 80% still fall in the normal range for duration. By the third year of menarche, 95% of menstrual cycles fall into this range. Charting the menstrual flow on a calendar can be helpful to clarify normal versus abnormal cycles. Cycles that fall outside of the norm should be evaluated for underlying pathology. There are multiple causes for abnormal uterine bleeding in adolescents, the most likely cause is dysfunctional uterine bleeding (DUB) due to an immature hypothalamic-pituitary-ovarian (HPO) axis, causing an ovulatory cycles and irregular bleeding
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
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
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.
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.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
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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7. MENSTRUAL PATTERN IN PUBERTY
MENORRHAGIA
• Soaking through pads / tampons in 1 h for 203 h in a row ?
• Passing blood clots ≥ 1 inch in diameter (“about the size of a
quarter”)?
• Using “double protection” (pad plus tampon or 2 pads
together) ?
• Flooding or gushing sensation?
• Frequent “accidents” or leaking through protection ?
• Ever diagnose with anemia?
8. ADOLECENT AUB -30 TO 40 % (2 IN 5)
PUBERTY MENORRHAGIA 20 % (1 IN 5)
PREVALENCE
9. PREVALENCE
A College of DU (college of Applied sciences ) & VATSALYA Vocational Training
centre--quiz based study of 1006 adolescents done by DELHI GYNAECOLOGIST
FORUM: 2010
Incidence of AUB was 40 %
Out of those who have AUB
20% had Puberty Menorrhagia.
20% had delayed periods bcz of PCOD (35 to 90 days)
Survey done during ADOLESCENT WORKSHOPS of
DGF
10. CAUSES OF PUBERTY MENORRHAGIA
Endocrinogic
• Dysfunctional uterine bleeding (immaturity of the HPO
axis)
• Polycystic ovary syndrome
• Thyroid disturbance
Hematologic
• Von Willebrand disease
• Platelet function disorder
• Connective tissue disorder (eg Ehlers – Danlos Syndrome )
Thrombocytopenia
• Hemophilia Carriage
• Cloting factor deficiencu
14. PREGNANCY
• Should always be considered ,particularly in
adolescents who may be reluctant to reveal
their sexual history.
• It is important to emphasize that the most
common cause of sudden departure from a well
established pattern of regular & predictable
menses is a complication of pregnancy—
threatened or spontaneous abortion & ectopic
pregnancy .
15. Birth 10 20
Estrogen Withdrawal
Anovulation
Coagulopathies
Infections
Complications of
pregnancy
Foreibdy
Trama ifctn ovarian tumr
sarcoma botroids
CAUSES :According to Age of
presentation to Doctors
ADOLESCENCE :10 to 19 years
Anovulation
Coagulopathies
Infections
Complications of
pregnancy
10
16. “ LACK OF CORRELATION BETWEEN
PERCEPTION & ACTUAL BLOOD LOSS
SO OBJECTIVE EVALUATION OF BLOOD
LOSS IS MUST
Several Studies
17. Objective Evaluation of HMB From
Menstrual History is Must
Qualitative Quantitative
Menses lasting more than 7
days
Changing pad or tampon
more than hourly
>80 ml blood loss
Clots greater than 1 inch in
diameter
Soaking through clothes
PBAC Score > 100
22. History
• Detailed Menstrual Bleeding pattern-spend time with
patient.
• Amenorrhoea followed by prolonged HMB-as seen in
PCOS.
• Sexual history
• Medications( harmones ,I.PILL ,Antiseizure
.Antidepressants etc )
• Underlying systemic illness (Renal disease, Liver disease
,Thyroid etc )
• Personal /Family H/O bleeding disorder
23. Detail menstrual history-tells the
Diagnosis
• Age at menarche
• Onset of abnormal menses ( sudden ,gradual )
• Timing, duration, and quantity of her uterine bleeding
• Inter menstrual interval.
• Cramping and/or clots
-------------------------------------------------------------------
weight changes, eating pattern / exercises schedule
S trickland J, Gibson EJ, Levine SB. Dysfunctional uterine bleeding in adolescents.
J Pediatr Adolesc Gynecol. 2006; 19(1):49-51.
24. Evaluation of H/O
BLEEDING DISORDERS
ONE OR MORE
Epistaxis-> 10 min requiring medical attention
Spontaneous bruising > 2 cm / minor wound bleeding > 5 min
Bleeding from oral cavity/ GIT without obvious lesion
Prolonged / excessive bleeding after surgery
Hemorrhage requiring BT
• Family H/O bleeding disorders
Significant bleeding complication not yet investigated
25. PCOS as a cause of PM
• PCOS can present as Puberty Menrrhagia.
• Possible risks of endometrial hyperplasia and
early development of endometrial carcinoma
in later Life require consideration &
counselling.
27. REGULAR MONTHLY HEAVY PERIODS
TO ANATOMICAL LESION OR BLEEDING
DISORDER THAN TO ANOVULATION .
ANATOMICAL LESION
28. Physical exam-D/D guided
• Haemo dynamic status-pallor,tachycardia,BP
• acute / chronic HMB( > 6 months history )
• Degree of anaemia
• Features of bleeding disorder-
Ecchymosis,purpura
• Features of PCOS / BMI
• Features of Thyroid enlargement or other
Endocrinopathies
• P/S & P/V if sexually active
29. DETAILED EXAM & ULRASOUND +CBC + UPT
are logical first 4 steps.
It is cost effective & require little technical skill
33. Is USG needed in initial evaluation ??
In a Retrospective chart review of 230 patients <18 years old
presenting with PUBERTY MENORRHAGIA to the Gynecology clinic
• The most common diagnosis in both the ultrasound group and
non- ultrasound group with Puberty Menorrhagia was immature
HPO axis.
• Of the patients who received an ultrasound, 72% had normal
findings, incidental findings were identified in 18% and PCOS
morphology in 6%.
• Structural causes of AUB were found in only 2 (1.3%) of the
adolescents imaged.
• No patient had a change in her AUB management plan due to
ultrasound findings.
Pelvic ultrasound is not required in the initial investigation of
AUB in the adolescent population
J Pediatr Adolesc Gynecol. 2016 Oct 6. pii: S1083-3188(16)30206-6
34. ≥ 8 years after menarche
Ultrasound should
not
be used for the
diagnosis of PCOS
< 8 years after menarche
8MHz Probe,
The threshold for PCOM
should be on either ovary, a
follicle number per ovary of >
20 and/or an ovarian volume
≥ 10ml
New Guidelines 2018
35. We as group do feel ULTRASOUND
need to be done in evaluation of
Puberty Menorrhagia
37. Initial Laboratory Evaluation
for Bleeding Disorders
Initial
Evaluation
Complete Blood
Count
Prothrombin
Partial Thrombo
Plastin time
(aPTT)
Fibrinobin Time
(TT)
Von Willebrand
assay
Complete
Blood Count
Complete
Blood Count
38. EVALUATION of
Puberty Menorrhagia
BEFORE LABELLING AS ANOVULATION RULE OUT OTHER CAUSES
PCOS
THYROID
DISTURBANCES
PREGNANCY
STI
BLEEDING
DISORDERS
MEDICATIONS
SYSTEMIC
ILLNESS
TRAUMA
STRUCTURAL
CAUSES
39. EVALUATION – MAIN POINTS
INITIAL TRIAGE
HAEMODYNAMICALLY
STABILITY
PREGNANCY STATUS
UNSTABLE
HOSPITALISE
STABLE
NEGATIVEPOSITIVE
BETA HCG
TVS
Blood Group AND
CrossMatching
TESTS FOR BLEEDING
DISORDERS
MISCARRIAGE
ECTOPIC
MOLAR
OTHER CAUSES
40. Goals of Management
Determining factors for treatment-
• Clinical classification of Puberty Menorrhagia
• Underlying cause
• Control of Bleeding
• Prevent further episodes of Bleeding
• Treat Anaemia
41. Goals of Management
Determining factors for treatment- contd..
• Contraception need of patient if needed
• Prevention of long-term consequences of
anovulation
Anaemia,
Infertility
Endometrial hyperplasia
Endometrial cancer
42. CLINICAL CLASSIFICATION Of
PUBERTY MENORRHAGIA--must
DURATION FLOW HAEMOGLOBIN
MILD > 7 OR < 24
FOR 2 MONTHS
MILD TO
MODERATE
10 -12
MODERATE > 7 DAYS MODERATE
TO HEAVY
> 10
SEVERE DISRUPTIVE HEAVY < 10
45. Treatment Outline of
Puberty Menorrhagia Made Simple By
WHO criteria of Anemia
10 - 12
10 - 8
< 8
< 5 - 6
KEEP HEAMATOLOGIST IN LOOP IF HAS BLEEDING DISODERS
46. Multiple MEDICAL modalities
Used in Puberty Menorrhagia
• HAEMANITICS for ANAEMIA
• NSAIDS
• ANTIFIBRINOLYTICS
• HORMONAL
• REPLACEMENT OF MISSING COAGULATION
FACTOR
47. CORRECTION OF ANAEMIA
• For girls with mild or moderate AUB and mild
asymptomatic anemia ( Hb 10 - 12 g/dL), initiate
iron supplementation with 60 mg elemental iron
per day.
• For girls with severe AUB , initiate iron
supplementation as soon as the patient is stable
and able to take pills by mouth. Depending upon
the severity of iron deficiency, use 60 mg of
elemental iron once or twice per day. IV Iron
therapy in moderate to severe Anaemia.
50. TRANEXAMIC ACID TREATMENT—is
drug of choice
• Tranexamic acid is administered orally:
1000 mg three times per day for up to
five days with each menses
Or
• 1 gm loading dose & 500 mg 3 times a
day
• Mefenamic acid 500mg 3 times a day
51. DESMOPRESSIN TREATMENT-is
favorite of few
• Desmopressin is administered IV as follows:
Desmopressin 0.3 mcg/kg IV over 15 to 30
minutes; the dose may be repeated in 48
hours if there is no response
Or
In Puberty Menorrhagia Dose is
900 mg daily, until the normalization of
menstrual cycle
52. DIOSMIN in Puberty Menorrhagia
Summary of Clinical Trials
• 100% Pure micronized diosmin is a potent , gentle, non-
hormonal treatment in cases of menorrhagia , with or
without hormonal therapy.
Summary of Clinical trials
I. Pure Diosmin reduces amount of bleeding upto 50%
II. Reduces duration of bleeding by 2.5 days
III. Relieves dysmenorrhea score by 50%
IV. Normalizes menstrual cycle by 80%.
V. Effective in Functional gynaecological bleeding in 88-98%
patients.
VI. Safe and well tolerated
: Int J Gynaecol Obstet. 2005 May;89(2):156-7,
Gobet A.: Med. Prat. 1978; (1-2): 713-14
53. AMINOCAPROIC ACID- TREATMENT-is
another choice
• AMINOCAPROIC ACID may be administered
orally or IV as follows:
Aminocaproic acid 4 to 5 g IV during the first hour
of treatment, followed by a continuous infusion at
a rate of 1 g per hour; treatment is continued for
approximately eight hours or until the bleeding
has been controlled.
55. RATIONALE OF HORMONE THERAPY
I
Administration of exogenous estrogen permits
additional endometrial proliferation, which heals
the sites of endometrial bleeding, and provides
hemostasis
Administration of progestin stabilizes the
endometrial lining
56. CONCERN of GYNAECOLOGISTS
• High doses of estrogen may cause premature
closure of the growth plates, reducing
ultimate adult height.
• However, by the time of menarche, most
female adolescents have already undergone
their growth spurt and achieved
approximately ≥95 percent of adult height.
57. PATIENT/ PARENTS EDUCATION
• In majority of patients , medical management cures the
problem
• Common side effects of high – dose oestrogens are : nausea ,
vomiting , headache , depression & fluid retention
contraindicated in liver disease, history of thromboembolic
disorder, cardiovascular disease & oestrogen – dependant
neoplasm
• Common side effects of Progestogens are depression , fluid
retention ,fatigue, insomnia , dizziness, nausea & breast
tenderness.
• Common side effects are acne , weight gain fluid retention ,
hoarseness of voice
58. PATIENT /PARENTS EDUCATION
• Emphasise on maintaining menstrual calendar
• Emphasise on correction of anaemia & good healthy
diet
• Explain about optimising Weight
• Evaluation , counselling & management of
breakthrough bleeding
• Explain risk of endometrial cancer in endometrial
hyperplasia in PCOD
59. MILD AUB
HAEMOGLOBIN CONTRACEPTION TREATMENT HORMONE
NORMAL
(12GM +)
NO OBERVATION AND
REASSURANCE
NO
10-12 GM% YES / NO IRON THERAPY YES
KEEP A MENSTRUAL CALENDAR
FOLLOW UP IN 2 - 3 MONTHS – UNLESS SEVERE BLEED
RPT CBC
60. Mild Puberty Menorrhagia-
Hemodynamically stable
• Hb > 10 gm %
• Decide about COCP / Progestogen
• May need to increase dose of COCP to BD and then
taper
• Follow up with iron supplementation + COCP if
started.
61. SAMPLE PRESCRIPTION
PM with HB 12 GM or MORE
• Tab Tranexamic acid 1 gm loading dose
followed by 500 mg 3 times a day.OR
• Tab Mefenamic acid 500 mg 3 times a day.
• Good Diet
• Iron+ folic acid 60 mg once a week.
62. SAMPLE PRESCRIPTION
HB <12 gm but > 10 gm
• Tab Tranexamic acid 1 gm loading dose followed by 500
mg 3 times a day. Treatment of choice OR
• Tab Mefenamic acid 500 mg 3 times a day.
+
• Cyclic oral contraceptive pill ( OCP )
OR
• If OCP contraindicated ,Medroxy-progesterone acetate
(MPA ) 10 mg from 16 -26 day OR
• Norethisterone 5 to 10 mg BD from 16 to 26 day
• +Iron tab daily
63. HARMONE—TO GIVE PROGESTOGEN OR COCP ?
• Although cyclic progestin Therapy generally works
well in girls who are completely Anovulatory & not
sexuall active,
• Treatment with an oestrogen-progestin contraceptive
is better choice for those who are likely still ovulate (
infrequent ) or want to avoid pregnancy.
• Experts feel standard cyclic PROGESTIN Therapy does
not reliably suppress the HPO axis.,so they will not
prevent random ovulation & are NOT contraceptive.
64. Combined hormonal contraceptive
(OCP ) in INDIA—is choice
• COCP-cyclic IS MOST PRESCIBED-with
Anovulatory bleeding, & who may be
sexually active.
• Acute prolonged episodes of HMB also can
be effectively managed with High dose
COCP provided the endometrium is normal
or increased thickness .
65. COCP – to be given for 3 to 6 months
Monophasic OCP containing 30 µg - 35 µg ethinyl
estradiol (preferred for most adolescent )
Progestogen in OCP can be any of the following :
• Norgestrel 0.3 mg/ ethiny estradiol 30 µg
• Levonorgestrel 0.15 mg / ethiny estradiol 30 µg
• Norgestimate 0.25 mg/ ethiny estradiol 35 µg
Regular daily use with monthy withdrawal bleeds
or extended cycle (elimination placebo pills)
66. PROGESTOGEN ONLY THERAPY
It is indicated for adolescent in whom oestrogen is
contraindicated or poorly tolerated.
• Medroxyprogesterone 10 mg po daily continously or
for 10-12 d/month
• Norethindrone acetate 5-10 mg po OD or BD daily
Treat for at least 6 months
then reassess for need for therapy if desired
67. COUNSELLING with M P A
• Instruct patients to take oral MPA 10 mg every night for the first
12 days of each calendar month as this regimen seems the easiest
for teenagers to follow.
• It is not a method of contraception.
• Oral micronised progesterone are not effective.
• If they become sexually active and desire contraception they will
need COC.
• If they have unprotected sexual intercourse while using progestin-
only therapy, emergency contraception may be warranted.
68. Various Hormonal Therapy as
practiced by Gynaecologists in INDIA
• COCP-cyclic IS MOST PRESCIBED
• OCP continuous- adolescents In western
world prefer extended cycles (84/ 7)
• Transdermal patch (not given in INDIA )
• Vaginal ring (not given by Gynaecologists )
70. Treatment of Puberty menorrhagia
10 - 12
10 - 8
< 8
< 5 - 6
KEEP HEAMATOLOGIST IN LOOP IF HAS BLEEDING DISODERS
71. Moderate HB <10GM %
• Mostly outpatient Treatment
• The treatment typically involves Hormonal Therapy to stabilize
endometrial proliferation and shedding.
• The choice of agent(s) depends, to some extent, upon how
heavily& actively the patient is bleeding.
• Girls with moderate PM should be provided with iron
supplementation +IRON /Protein rich diet
• COC pills be taken 2 to 3 times per day until the bleeding ceases
(usually within 48 hours), then tapered to twice daily for 5 days,
and then decreased to once daily to complete 21 days of hormone
therapy.
R imsza ME. Dysfunctional uterine bleeding. Pediatr Rev. 2002;23(7):227-233.
72. COC
• Oral contraceptive pills taper protocol
using monophasic pills can also be given,
• 4 pills evenly spaced per day for 4 days,
• 3 pills per day for 3 days,
• 2 pills per day for 2 days and
• 1 pill /per day for 2 months without taking the
placebo pill.
Linda M, Szymanski, Kimberly B Abnormal uterine bleeding,
The John Hopkins manual of Gynecology and obstetrics Third
edition page 417-428 Lippincote Williams and wilkins
73. • Heavy bleeding can also be treated with oral
PROGESTERONE Medroxyprogesterone 10 mg three times
/day for 14 days.
• Medroxyprogesterone acetate injection (Depo Provera) 150
mg intramuscularly every 12 weeks.
• Progesterone can also be used for medical curettage, in the
form of Norethisterone Acetate 20-30 mg daily for 3 days to
arrest haemorrhage.
• It may then be continued at a lower dose for up to 21 days.
Withdrawal bleeding will occur on stopping the treatment
that ceases in 4-5 days
MPA - as alternative TREATMENT
74. Norethisterone acetate (NETA)
– another favourite
• Different dosing regimens are in practice
• NETA 5-10 mg, generally administered in luteal phase from day 15/19 to
day 26 in anovulatory cycles
• Recently an increase in the duration and dosage has been investigated in
patients with ovulatory dysfunctional uterine bleeding
• Administration of oral progestogens from day 5 to day 26 of the cycle
produced a significant reduction in bleeding
• Acute anovulatory bleeding:
• High dose NETA 15 mg & treatment should continued for 3 weeks,
tapering the dose after 7-10 days Lethaby et al.
In studies, Norethisterone progestogens were more effective in the
treatment of Abnormal uterine bleeding than dydrogesterone.
(Am. Med. J. 1 (1): 23-26, 2010)
75. Norethisterone acetate controls bleeding and
normalizes menstrual cycle by the following actions:
• Effects on Uterus:
• Binds to progesterone receptors in the endometrium and brings
synchronous secretory changes in oestrogen primed endometrium
• Promotes regrowth of the endometrium over irregularly denuded
surfaces due to its weak estrogenic action
• Styptic effect on uterine hemorrhage:
• Checks bleeding by constriction of uterine blood vessels (like a
hemostatic agent).
•
• Used for the management of acute bleeding as well as for the
prevention of recurrence. Beneficial in both ovulatory and
anovulatory DUB.
76. Side effects of PROGESTERONE only therapy
• Break Through Bleeding
• Need for long-term oral medication and the possibility of unwanted
`pre- menstrual symptoms’
• Androgenic effects (depending on the progestogen used), such as
acne and hirsutism; irregular breakthrough bleeding and a change in
carbohydrate tolerance and lipid balance.
• Depo-Provera will induce amenorrhoea in 50% of users at 1 year and
break through bleeding in 15±20%---not used in Puberty Menorrhagia
very often..
.
77. • Use Monophasic COCP with a minimum of 30
mcg EE to ensure a sufficient amount of
Oestrogen to prevent breakthrough bleeding
• One pill every eight hours until the bleeding stops
(usually takes 48 hours )
• One pill every 12 hours for 5 days, then
• One pill once per day for a total of at least 21 days
• Close follow-up (in person or by phone) is essential while the pills
are being taken two or three times per day.
HOW TO PREVENT B.T.B.
79. RULE OF Treatment
ACTIVE BLEEDING
• Combined oestrogen-progestin oral
contraceptives rather than progestin-only
hormone therapy
BECAUSE ESTROGEN PROVIDES HAEMOSTASIS
80. HORMONE THERAPY
(commonly used in Heavy Bleeding)
Use OCP with doses of oestrogen (eg, 30 or 35 mcg ethinyl
estradiol)
●One pill every six hours until the bleeding subsides (usually within
24 hours)
●One pill every eight hours for three days, then
●One pill every 12 hours for up to two weeks
Antiemetic therapy --PromethazinPe 12.5 to 25 mg orally or
ondansetron 4 to 8 mg orally) may be required for girls who are
taking more than one pill per day.
81. PARENTERAL ESTROGEN
Reserved for patients with
Severe anovulatory uterine bleeding who are
unstable and cannot take oral medications
If bleeding is not controlled after 24 hours of
combination hormonal therapy.
82. Treatment of SEVERE BLEEDING
Hemodynamically unstable Patient
-needs HOSPITALISATION
• Hb < 8 gm %
• Fluid and blood Transfusion
• Inj Conjugated equine oestrogen
• Inj Tranexamic acid 1gm loding dose followed
by500mg IV 8 hourly for 5 days
• Simultaneous with IV Conjugated oestrogen---
start COCP containing 30-35 Ug EE orally every 4-
6 hrs till bleeding stops and taper to or BD over
10-14 days
83. PRACTICAL TIPS with I/V CE
• The dose of IV CONJUGATED ESTROGEN is 25 mg
every four to six hours until the bleeding stops.
• No more than six doses should be administered
• Thromboembolism is a potential complication
• Administration of antiemetics one hour before
each dose of IV estrogen may alleviate the side
effects of nausea and vomiting
84.
85.
86. Role of SURGERY
Role of surgery – endometrial curettage
• Acute bleeding in Heamodynamically unstable
patient to quickly control the bleeding.
• In acute episode , if bleeding does not decrees
significantly in 12-24 hours with medical treatment ,
than re-evaluation is mandatory & surgical
curettage should be done
88. HOSPITALISATION – INDICATIONS
• Hemodynamic instability
• Hemoglobin concentration <8 g/dL
• or <10 g/dL with active heavy bleeding
• Home management with daily monitoring may be possible for
patients with hemoglobin between 8 and 10 g/dL if the patient is
hemodynamically stable and the patient and family are reliable
and can maintain close telephone contact.
• Symptomatic anaemia (eg, fatigue, lethargy)
• Need for intravenous conjugated estrogen (eg, cannot take oral
medications, continued heavy bleeding after 24 hours of
oestrogen-progestin combination therapy) or surgical intervention
• Need for surgical intervention
89. PRACTICAL TIPS of FOLLOW-UP AND
LONG-TERM CARE
• After treatment is initiated, patients should be seen
at regular intervals whatever is grading of puberty
menorrhagia.
• Long-term management depends on the anaemia
and the desire for contraception.
• Most experts recommend continuing hormonal
therapy for at least 6 months.
• After therapy is discontinued, the patient should
still be followed to ensure regulation of
menstruation.
90. Dr Sharda Jain
MD, (PGIMER), MAMS , FICOG, FIMSA, DHM, QM & AHO PGDMLS (SYMBIOSIS)
Regd. No 11076/ DMC No 2734
ACADEMICIAN & SURGEON PAR EXELLENCE
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M.D (Gynae & OBST –LHMC ,DU )
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92. USP of Delhi Gynaecologist forum
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