Abnormal Uterine Bleeding Lecture PDF

Abnormal uterine bleeding Department of Obstetrics & gynecology department  Learning objectives By the end of this lecture each candidate should : ​ Discuss the definition of abnormal uterine bleeding ​(AUB). Describe the causes of AUB. ​ Discuss the management approach fo...

Abnormal uterine bleeding Department of Obstetrics & gynecology department  Learning objectives By the end of this lecture each candidate should : ​ Discuss the definition of abnormal uterine bleeding ​(AUB). Describe the causes of AUB. ​ Discuss the management approach for patients with AUB.  Abnormal uterine bleeding Abnormal variations in the norm of the menstrual cycle characteristics is called AUB : Usual length : 28 days. Bleeding : 5 days. Amount : not exceeding 80 ml , not less than 5 ml. Regularity : regular (7-9) days AUB rates ranges from 10-30 % in US  AUB Terminologies Heavy menstrual bleeding [Menorrhagia]: excessive flow of mensuration, > 80 ml per cycle Prolonged bleeding : lasting > 8 days. Hypomenorrhea : bleeding amount is < 5 ml. Oligomenorrhoea : frequency > 38 days. Poly menorrhoea : frequency < 24 days. Amenorrhea : absence of cycle > 90 days or 3 months for regular cycles and >6 months for irregular mesnes Dysfunctional uterine bleeding (DUB) : AUB without identified underlying pathology Postmenopausal bleeding : bleeding after menopause Intermenstrual bleeding- metrrorhagia  Types of AUB Acute AUB : AUB which is sufficiently heavy to require immediate intervention to prevent ongoing losses. Chronic AUB : Abnormal bleeding which is present for the last 6 months.  Blood loss estimation 1. Hemoglobin / Hematocrit level. 2. No of pads or tampons per day 3. Pictorial blood assessment chart This will be done for all days & score > 100 Correlates > 80ml blood loss & considered heavy  Causes influenced by age group Causes according to age group Childhood :abnormal bleeding ; precocious puberty. Adolescence : an ovulation [immaturity of HPO axis]or coagulation defects. After adolescence : pregnancy complications & STDs. Perimenopause : HPO axis dysfunction, endometrial hyperplasia. Post menopause : endometrial hyperplasia, malignancies, atrophy.  PALM-COEIN Structural : Nonstructural : P : Polyp; endometrial or cervical C : Coagulation disorders (vWD). A : Adenomyosis. O : Ovulatory dysfunction. L : Leiomyoma. E : Endometrial dysfunction, endometritis M : Malignancy endometrial or cervical, I : Iatrogenic; contraceptives, anticoagulant endometrial hyperplasia. N: non classified ; infection , AV malformation, isthmocele  Pregnancy complications are common cause of AUB : Miscarriage Ectopic pregnancy Gestational trophoblastic diseases Endometritis & cervicitis can cause AUB  Nonstructural causes Coagulopathy : qHereditary disorders ( von Willbrand disease) qLiver failure Ovulatory disorders : Obesity Hypothyroidism PCOS, CAH , Cushing syndrome Hyperprolactinemia HPO axis immaturity or dysfunction  Diagnostic goal Rule out pregnancy Rule out cancer Determine underlying cause Work up of the patient HISTORY EXAMINATION INVESTIGATION  History Details of menstrual history ; menarche , amount , LMP Dysmenorrhea goes with structural causes ; pregnancy complications & infections. Contraceptive history. Details of the medications: anticoagulants, contraceptive pills. Family history of bleeding disorders or AUB or malignancies  Examination General : Pallor, BMI, vital signs. Signs of liver failure Abdominal examination : masses. Gynecology examination : uterine enlargement, adnexal masses, polyp ; differentiate from lower tract causes of bleeding.  Investigations Blood tests : 1. B-HCG ; to exclude pregnancy serum or urine. 2. CBC ; Hb (anemia) & platelet count ( thrombocytopenia ), WBC (infection). 3. Endocrine tests if history suggest : Thyroid function, prolactin level, FSH , estradiol, androgen levels 4. Coagulation test : if history suggestive of coagulation problems such as PT, PTT  Investigations Cervicitis tests : Screening for infections ; gonorrhea & chlamydia trachomatis ; wet preparation. Cytology [Pap smear testing]: If cervical cancerous or precancerous conditions are expected.  Imaging Transvaginal ultrasound : primary diagnostic modality Identifies structural lesions in the myometrium, endometrium & uterine surfaces as well as adnexal masses. Identifies endometrial disease which can be global [endometrial hyperplasia] or focal[polyp].  Saline infusion sonography is better in visualization of endometrial cavity lesions ; contraindicated in pregnancy, active pelvic infection.  Ultrasound Increased endometrial Saline infusion thickness in TVUSS sonography -Focal lesion  Endometrial sampling Endometrial sampling for those younger than 45 with 1. Failed initial medical management. 2. History of unopposed estrogen exposure such as in obesity or (PCOS). 3. Diabetic patients. 4. Ladies using Tamoxifen. 5. Genetically predisposed individual to uterine cancers.  Endometrial biopsy Endometrial sampling should be done for all ladies > 45 years with AUB – ACOG recommendation 2016 Pipelle endometrial sampling  Hysteroscopy Outpatient minimally invasive procedure Helps in diagnosing intracavitary lesions which could be missed by TVUSS & endometrial sampling. Aids in diagnosis & management of submucous fibroids & polyps. Shouldn't be done in advanced uterine & cervical cancer  Hysteroscopic images Uterine polyp through hysteroscopic Submucous fibroid view ​  Acute hemorrhage management Hemodynamically unstable patients : Fluid resuscitation, blood transfusion. Fluids : crystalloids ; normal saline & lactated ringer : 1-2 liters to start with. Blood transfusions : PRBCS , platelets, plasma.  Acute AUB Medical treatment for hemodynamically stable : qConjugated equine estrogen IV. qCombined Oral Contraceptive, estradiol content is 30 microgram. qHigh dose medroxy progesterone acetate or norethisterone. q Tranexamic acid.  Acute AUB Dilatation & Curettage (D&C) : to acutely arrest the bleeding if no response to medical treatment. https://www.youtube.com/watch?v=at-CfWUiClg  Chronic AUB Non hormonal : 1. NSAIDS [mefenamic acid], Affects cyclooxygenase pathway, used during cycle days & stopped after that 2. Tranexamic acid : antifibrinolytics ; also used during menses  Chronic AUB Hormonal treatment : 1. Levonorgestrel IUS: first line, reduces blood loss by up to 97% effective. 2. COC : combined oral contraceptives reduces loss up to 70 % 3. DMPA : Depot medroxy progesterone acetate 4. GnRH agonist : induces endometrial atrophy, can lead to amenorrhea & menopausal associated S.E such as bone loss 5. Androgen : danazol =induces endometrial atrophy but may cause androgenic side effects  Uterine procedures Endometrial ablation : Indicated if medical treatment was not successful with no desire to preserve fertility, permanently remove and destroy the uterine lining. Uterine Artery Embolization : Used for HMB from leiomyoma or AV malformation. Hysterectomy : It is definitive management if all methods failed & no desire to fertility.  Case scenario 1 A 14-year-old girl comes to the physician because of excessive flow and duration of her menses. Since menarche a year ago, menses have occurred at irregular intervals and lasted 8–9 days. Her last menstrual period was 5 weeks ago with passage of clots. She has no family or personal history of serious illness and takes no medications. She is at the 50th percentile for height and 20th percentile for weight. Physical examination shows no abnormalities. A urine pregnancy test is negative. Which of the following is the most likely cause of this patient's symptoms Case scenario : A. Endometrial polyp B. Decreased thyroxine production C. Inadequate gonadotropin production D. Defective von Willebrand factor E. Uterine fibroid  Case 2 A 14-year-old girl is brought to the physician because of a 10-day history of vaginal bleeding. The flow is heavy with the passage of clots. Since menarche 1 year ago, menses have occurred at irregular 26- to 32-day intervals and last 3 to 6 days. Her last menstrual period was 4 weeks ago. She has no history of serious illness and takes no medications. Her temperature is 37.1°C (98.8°F), pulse is 98/min, and blood pressure is 106/70 mm Hg. Pelvic examination shows vaginal bleeding. The remainder of the examination shows no abnormalities. Her hemoglobin is 13.1 g/dL. A urine pregnancy test is negative. Which of the following is the most appropriate next step in management? A. Tranexamic acid B. Endometrial ablation C. Uterine artery embolization D. Conjugated estrogen therapy E. Intrauterine tamponade Questions  Summary AUB can be caused by structural & nonstructural factors. The age group would determine certain causes. Management depend on the hemodynamic status age , desire to fertility , underlying cause  References WILLIAM'S AMBOSS WEBSITE LECTURIO GYNECOLOGY 4TH PLATEFORM EDITION TEXTBOOK Thank You