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AUB for 4th year med.students
- 1. Associate Clinical Prof.Dr Aisha EL-Bareg, MD, PhD Senior Consultant in (Obs & Gyn/Reproductive Medicine) Faculty of Medicine, Misurata University, LIBYA
- 2. Abnormal uterine bleeding(AUB) Any deviation from normal frequency, duration or amount of menstruation in women of Reproductive age. NORMAL MENSES •Frequency: 21-35 d •Duration: 3-7 d •Volume: 30-80 ml
- 3. AUB- Clinical types •Polymenorrhoea:frequent (<21 d) menstruation, at regular intervals •Menorrhagia: Excessive (>80 ml) & / or prolonged menstruation, at regular intervals •Metrorrhagia: Mensturation at irregular intervals.
- 4. AUB- Clinical types •Menometrorrhagia:both. •Intermenstual bleeding: episodes of uterine bleeding between regular menstruations. •Hypomenorrhoea: scanty menstruation. •Oligomenorrhea: infrequent menstruation (>35 d)
- 5.
- 6. Organic cause 1. Pregnancycomplications: •Miscarriages •Ectopic pregnancy •Trophoblastic disease AUB- Causes
- 7. 2. Genital disease .Tumors: Benign: - Fibroid, cervical & endometrial polyp. Malignant: - Cervical, endometrial Ca. - Ovarian (estrogen secreting) tumor. . Infection: - PID . Endometriosis, Adenomyosis . IUCD . Marked uterovaginal prolapse AUB- Causes
- 8. Systemic cause: . Endocrine:- Hypo & hyperthyroidism, DM - Adrenal gland disease - Hyperprolactinemia . Coagulopathy: •Idiopathic thrombocytopenic purpura, •Von-Willebrand disease, Liver failure AUB- Causes
- 9. • Chronic systemicdisease: anemia, heart failure, liver failure • Iatrogenic - Hormonal contraception, HRT, anticoagulants, antipsychotic drugs. • Emotional • Under & over weight AUB- Causes
- 10. •Definition: Abnormal uterine bleedingin absence of obvious pelvic organ disease or a systemic disorder •Incidence: • 60 % of AUB Dysfunctional uterine bleeding (DUB)
- 13. Mechanism of hemostasisduring menstruation 2. Hemostatic plug formation in the functional endometrium 1. Vasoconstriction in the basal layer Vascular occlusion is not complete, for short time Until endometrial regeneration is completed
- 14. DUB- Pathophysiology 1. Anovulatory- 90 % Endocrine abnormality • Insufficient follicles • Persistent follicle Endometrial changes • Inadequate proliferative or atrophic (↓ E). • Proliferative or hyperplastic (↑ E).
- 15. • Estrogen withdrawalbleeding – Frequently occurs in peri-menopause. – Short proliferative phase because of abnormal follicular developments. – E levels will vary with the quality and state of follicular recruitment and growth. – Bleeding might be light or heavy depending on the individual response. DUB- Pathophysiology
- 16. • Estrogen breakthroughbleeding – Anovularoty cycles have no CL formation – Progesterone is not produced – The endometrial continues to proliferate under the influence of unopposed E. – Out-of-phase endometrium is shed in an irregular manner that might be prolonged and heavy. – Occur in absence of E decline. DUB- Pathophysiology
- 17. Endocrine abnormality Insufficient C.luteum leading to short luteal phase Persistent C luteum leading to long luteal phase Endometrial changes Irregular or deficient Secretory changes Irregular shedding A. Hormonal disturbances DUB- Pathophysiology
- 18. B. Local endometrialdefect – Increase PGE2/PGF2α- VD – Decreased Thromboxane A2/Prostacyclin ratio – Increased activity of the fibrinolytic system locally in the uterus Why these changes occur and their exact causal relation with menorrhagia have not yet been determined.
- 19. AUB- Complications • Irondeficiency anemia • Endometrial adenocarcinoma: 1-2% of women with anovulatory bleeding might develop Ca. • Infertility: as with chronic anovulation, with or without androgen production : PCOS, obesity, chr HTN, DM are at risk. • Complications of the etiology if present .
- 20. Aim: 1. Nature &severity of bleeding 2. Exclusion of organic causes 3. Ovulatory or anovulatory Diagnosis
- 21. I. History 1. Personal:Age 2. Present H: onset of the problem, amount of bleeding, duration, frequency, relation to sexual intercourse, associated symptoms (pain, abdominal mass). 3. Menstrual H. 4. Sexual activity: infection. Diagnosis
- 22. 5. Obstetric andgynecological H 6. Contraceptive H. 7. Past medical & surgical H. 8. Family history 9. Current medication Diagnosis I. History
- 23. II. Examination: 1. Generalexamination Obesity (BMI) Signs of androgen excess (hirsutism, acne) Signs of hypo or hyperthyroidism Galactorrhea Visual field defect (pituitary lesion) Ecchymosis, purpura Signs of anemia Diagnosis
- 24. 2. Abdominal examination –liver, spleen, pelvi-abdominal mass 3. Local examination • External genital lesions • Speculum ex: assess the bleeding, vaginal discharge, vaginal & cervix lesions • Bimanual ex: uterine size, shape, countour, adnexa for ovarian mass. Diagnosis
- 25. III.Investigations Systemic 1. CBC, peripheralblood smear, Iron studies . 2. B.HCG 3. Hormonal assay: LH, FSH, androgens, prolactin, TFT 4. LFT, RFT 5. PT, APTT, BT, platelets, Von Willebrand factor Diagnosis
- 26. III.Investigations Local 1. Pap smear,cervical swap for infection 2. USS, saline-infusion-sonography 3. Endometrial biopsy, D & C biopsy 4. Fractional curettage 5. Hysteroscopy Diagnosis
- 27. 1. TAS: canexclude pelvic masses, pregnancy complications. 2. TVS: • More informative than TAS. • Measurement of the endometrial thickness. • Endometrial carcinoma in postmenopausal is suspected if endometrial thickness > 3.5 mm. Ultrasonography
- 28. 3. Saline infusionsonography: Infusion of saline into the uterine cavity. Ultrasonography
- 29. TVS is recommended 1.Weight >90 Kg 2. Age > 40 3. Other risk factors for endometrial hyperplasia or carcinoma e.g. infertility, nulliparity, family history of colon or endometrial cancer, exposure to unopposed estrogen. Ultrasonography
- 30. Indications: • Between 20& 40 yrs. • If endometrial thickness on TVS is >10mm, endometrial sample should be taken to exclude endometrial hyperplasia. Aim • Diagnosis of the type of the bleeding • Exclude local pathology Endometrial biopsy
- 31. Methods: •As an outpatientprocedure. 1.Pipelle curette 2.Sharman curette 3.Accrette 4.vabra aspirator Advantages: An adequate & acceptable screening procedure in females under 40 yrs Endometrial biopsy
- 32. Indications 1. Mandatory after4o yrs. 2. Persistent or recurrent bleeding after medical tt in patient between 20 & 40 yrs. Aim 1. Diagnosis of organic disease e.g. endometritis, polyp, carcinoma, TB. 2. Diagnosis of the type of the endometrium, hyperplastic, proliferative, secretory, atrophic. Dilatation & Curettage (D & C)
- 33. 3. Arrest ofthe bleeding, if the bleeding is severe or persistent, particularly hyperplastic endometrium. Curettage is essentially a diagnostic & not a therapeutic procedure. Disadvantages 1.Small lesions can be missed. 2.The sensitivity of detecting intrauterine pathology is only 65% . Dilatation & Curettage (D & C)
- 34. Indication: >40 yrs Method:3 samples: endocervical, lower segment & upper segment Fractional curettage
- 35. • It isan endoscopic visualization of endometrial cavity. Hysteroscopy •Using a telescope, camera and light source. • Use distensile media CO2, normal saline, Glycin 1.5%
- 36. Hysteroscopy 1) To locatesubmucous myoma. 2) To diagnose uterine septum. 3) To locate & remove lost I.U.C.D. 4) To locate Endometrial polyp. 5) To locate uterine synechae. 6) To detect endometrial cancer. • Indications
- 37.
- 38. • Aim 1. Excellentview of the uterine cavity & diagnosis of polyps, submucous fibroid, hyperplasia. 2. Biopsy of the suspected areas. 3. Treatment - Endometrial ablation, removal of Polyp - Resection of Submucous myoma, Uterine septa - Resection of Intrauterine adhesion Hysteroscopy
- 40. Hysteroscopy 1. Acute andchronic upper genital tract infection. 2. Recent uterine perforation. 3. Pregnancy. • Contraindications
- 41. Complications of hysteroscopicmethods 1. Uterine perforation 2. Bleeding 3. Infection. 4. Fluid overload 5. Gas embolism 6. Complications of anaesthesia Hysteroscopy
- 42. Disadvantages 1. Cost ofthe apparatus. 2. Lack of availability or experience. Hysteroscopy
- 43. AUB- Treatment • Principleof management – Control of the bleeding followed by regulation of menses. – Induction of ovulation in patients with infertility.
- 44. Treatment A. General B.Management of bleeding Medical Surgical
- 45. 1. General measures •Treatment of iron deficiency anemia • Treatment of systemic diseases • Treatment of endocrinological diseases Treatment
- 46. Treatment < 20yrs 20-40 yrs > 40 yrs Medical always First resort after endometrial biopsy Temporary & if surgery is refused or imminent menopause Surgical never Seldom, only if medical treatment fail First resort if bleeding is recurrent Strategy of treatment
- 47. I. Non –hormonal 1.Antifibrinolytics 2. Prostaglandin synthetase inhibitors (PSI) 3.Ethamsylate II. Hormonal 1. Progestagen 4. Danazol 2. Oestrogen 5. GnRh agonist 3. COCP 6. Levo-nova (Merina) Medical therapy
- 48. 1. Antifibrinolytics Tranexamic acid(tranex) Mechanism of action: The endometrium possess an active fibrinolytic system, & the fibrinolytic activity is higher in menorrhagia. Effect: • ↓ menstrual bleeding > other therapies (PSI, oral luteal phase progestagen & etamsylate) • Is effective in treating menorrhagia associated with IUCD.
- 49. Side effects •Is doserelated. •GIT upset, dizziness. •Rarely: - Transient color vision disturbance - Intracranial thrombosis. 1. Antifibrinolytics
- 50. 2. Prostaglandin synthetaseinhibitors (PSI) Mefanemic acid Mechanism of action: Antiprostaglandins Effects: • Decrease MBL by 24% • The beneficial effect on other symptoms e.g. dysmenorrhea, headache, nausea, diarrhea & depression persists for several months.
- 51. Side effects • GITupset, dizziness. • Rarely: hemolytic anemia, thrombocytopenia. •The degree of reduction of MBL is not as great as it is with tranxamic acid but PSI have a lower side effect profile. 2. Prostaglandin synthetase inhibitors (PSI)
- 52. Mechanism of action:(Hemostatic) Maintain capillary integrity, anti-hyalurunidase activity & inhibitory effect on PGE2 Effect: • Starting 5 days before anticipated onset of the cycle & continued for 10 days • 20% reduction in MBL. Side effects headache, rash, nausea 3. Etamsylate (Dicynone)
- 53. •Norethisteron •medroxyprogesterone acetate •Effect: Effective ifgiven at higher dose for 3 w out of 4 w (5 mg tds from D5 to 26) •Side effects: weight gain, nausea, bloating, edema, headache, acne, depression, exacerbation of epilepsy & migraine, loss of libido Systemic progestagens
- 54. Levonorgestrel intrauterine system •levonova,Mirena:Delivers 20ug LNG /d. for 5 yr •Metraplant: T shaped IUCD & levonorgestrel on the shoulder & stem Intrauterine progestagens
- 55. Effect 1. Decrease MBLby 80%-90% 2. Cost effective (used for 5 yrs) 2. May be an alternative to hysterectomy in some patients Special indications 1. Intractable bleeding associated with chronic illness 2. Ovulatory heavy bleeding Intrauterine progestagens
- 56. Side effects 1. Breakthroughbleeding in the first 3-4 cycles 2. 20% develop amenorrhea within 1 yr Intrauterine progestagens
- 57. Mechanism of action: Ovulationsuppression Effect Reduce MBL by 50% Side effects headache, migraine, weight gain, breast tenderness, nausea, cholestatic jaundice, hypertension, thrombotic episodes The combined contraceptive pill COCP
- 58. synthetic androgen withantioestrogenic & antiprogestagenic activity Mechanism of action Inhibits the release of pituitary Gn & has direct suppressive effect on the endometrium Effect Reduction in MBL , amenorhea at doses >400 mg/d Danazol
- 59. Side effects headache, weightgain, acne, rashes, hirsuitism, mood & voice changes, flushes, muscle spasm, reduced HDL, diminished breast size. Rarely: cholestatic jaundice. It is effective in reducing blood loss but side effects limit it to a second choice therapy or short term use only
- 60. Injectable : SC,Monthly for 3-6 months Side effects hot flushes, sweats, headache, irritability, loss of libido, vaginal dryness, lethargy, reduced bone density. GnRH analog
- 61. Surgical treatment 1. Endometrialablation Destruction of the basal layer of the endometrium So little or no remaining endometrium can regenerate
- 62. I.Hysteroscopic: 1. Laser 2. Electrosurgical a.Rollerball b.Resection II.Non-hysteroscopic: 1. Thermal ut. balloon 2. Microwave. 3. Heated saline Surgical treatment 1. Endometrial ablation Methods:
- 63. Indications 1. Failure orcontraindication of medical treatment 2. Family is completed 3. Uterine cavity <10 cm 4. Submucos fibroid <5 cm 5. Endometrium is normal or low risk hyperplasia. 1. Endometrial ablation
- 64. 2. Hysterectomy Indications: 1. Failureof medical treatment 2. Failure of endometrial ablation 3. Family is completed Routes: 1. Abdominal 2. Vaginal 3. Laparoscopic Surgical treatment
- 65. Advantages 1. Complete cure 2.Avoidance of long term medical treatment 3. Removal of any missed pathology Disadvantages 1. Major operation 2. Hospital admission 3. ↑ Mortality & morbidity 2. Hysterectomy