Abnormal Uterine Bleeding (DUB) - University of Duhok - PDF

Univercity of Duhok Collage of medicine Abnormal Uterine bleeding Dysfunctional uterine Dr. Iman Yousif bleeding Abdulmalek Professor Department of Obstetrics and Gynecology  Key points Normal menstrua...

Univercity of Duhok Collage of medicine Abnormal Uterine bleeding Dysfunctional uterine Dr. Iman Yousif bleeding Abdulmalek Professor Department of Obstetrics and Gynecology  Key points Normal menstrual cycle - Abnormal uterine bleeding - Causes of abnormal uterine bleeding - Definition of dysfunctional uterine bleeding - How the patient presented to you - How you will deal with her - Manegment - Prognosis - prevention - MENSTRUAL CYCLE  What is the normal length of menstrual- ? cycle 21-35 days ? How long dose menses normaly last- 3-7 days What is the amount of blood in menses which- ? considered asnormal 80 CC  Common abnormal bleeding patterns abnormal uterin bleeding Polymenorrhea (epimenorrhea): abnormally frequent.menses at interval less than 21 days (cyclic) ex. 7/20 Menorrhagia (hypermenorrhea) : excessive > 80 ml and or prolonged HMB > 7 days menses occurring at.normal intervals (cyclic) Regular Metrorrhagia: irregular episoid of uterine bleeding.(acyclic) Polymenorrhagia: is cyclical bleeding which is excessive & too frequent.ex:12/20 Menometrorrhagia : heavy and irregular uterine  New Items for abnormal Vaginal Bleeding HMBMenorrhagia IMB PMB PCB BEO bleeding of endometrial origin (DUB)  -: Causes of abnormal uterine bleeding Organic condition Genital tract (Local Causes) Problem.1 Trauma & Psychological causes.2 Hepatic & Thyroid & Hypertension & blood Dyscrasias , 3.Systemic disorders.Pregnancy status  RPOG , ectopic pregnancy & HM.4 Iatrogenic Exogenous estrogen (eg. oral.5 contraceptive) ,progestins contraception, injectable steroid , Aspirin, Heparin, Warfarine , Tamoxifen,.Intrauterine device Oligomenorrhea & Hypomenorrhea- if the cycle less than 3* )days or more than 35 days :Some of items Menopause , Postmenopausal bleeding Menarche (average 12 years) Perimenopause ( age of 40 until menopause ( average 51) *In general: *Heavy periods-menorrhagia (HMB). regular *Heavy and frequent- polymenorrhagia. *Frequent-polymenorrhea *Irregular acyclic-metrorrhagia. *Heavy and irregular-  If the bleeding is not due to these causes this mean it is: Dysfunctional uterine bleeding (non- organic) Is defined as abnormal uterine bleeding in women between menarche & menopouse that cannot be attributed to medication, blood dyscrasias, ,systemic diseases trauma, uterine neoplasm or pregnancy (Bleeding from endometrial.origin) About half the cases occur in women over 45 years of age & about on.fifth occur in women under age 20 PALM-COEIN FIGO Classification: PALM ((structural)- COEIN* :(functional) There are 9 main categories, which are arranged according to the  DUB /Risk facrors  Age: more common in teens at the beginning of the reproductive years, and in perimenopausal women at the.end of their reproductive years weight smoking Poly cystic ovary syndrom (pocs)  : Causes :Most common Anovulatory DUB % 85 The corpus luteum does not form in an anovulatory cycle, resulting in a failure of the cyclical secretion of.progesterone Without progesterone, there is continuous unopposed production of estradiol, which stimulates overgrowth of the endometrium. The endometrium grows thick until it outgrows its blood supply, resulting in necrosis and.irregular bleeding.In adolescents and in perimenopausal women  :Ovulatory DUB The progesteron level prolonged with irregular shedding of endometrial + estrogen level is low like during menses, with.luteal cyst sometimes, presents as menorrhagia A less common cause of DUB; believed to be caused by a defect in local* endometrial hemostasis. The mechanism is unknown, but theories include prostaglandin imbalance and alterations in fibrinolysis. Prostaglandin F2α causes constriction of spiral arteries found in the endometrium (vasoconstriction+ muscle contraction), whereas prostaglandin E2 has vasodilating properties and antiplatelet. effects (vasodilatation+ contraction), & PGI2 which causes (vasodilatation) Alterations in prostaglandin production, with a shift toward more prostaglandin E2 and less prostaglandin, PGF2α lead to increased fibrinolytic activity noted in the.)endometrium of women with menorrhagia relaxation  Cystic glandular hyperplasia Here estrogen production raises to high level but there is no feedback inhibition of pituitary gland, so FSH secretion and.high E level continue perhaps for 6-8 wks There is amenorrhea during this time but prolongation of action of Estrogen.In the absence of progesterone lead to endometrial hyperplasia The bleeding is heavy ,prolong, irregular will happen due to.decrease in E. and the growth of endometrial blood supply  How the female presented to you History : female age between menarche & menopouse, most commonly obese complained fro ,or no. of pads /day) 1.period lasts longer than 7 days (Flood period less than every 21 days apart than.2 bleeding is heavier than normal.3 or 4.Irregular bleeding History of amenorrhea for 1 to 2 months the develop.5. heavy ,prolong and irregular bleeding may has a history of POCs or smoker.  How you will deal with this patient : After you finsh a history shift to Examination General examination + vital signs- Abdominal examination- Pelvic examination- - Pelvic examination  Investigation First you should exclude pregnancy laboratory evaluation.1 Full blood count (Iron therapy and blood transfusion) & Serum iron Coagulation screen Bleeding & Clotting time. Human chorionic gonadotrophin assay (B-hCG). screen High vaginal and endocervical swabs (HVS- if any vaginal discharge is reported or observed ,or there is a risk of PID). Prolactine levels. -Thyroid function test. Liver function tests. diagnostic prosedure.2 Cervical cytology (pap smear +HVS). -Endometrial  Treatment Note :treatment according to the cause of V. bleeding In DUB‫ أطالع‬:Massive intractable bleeding.1 *Admititon to hospital then 25mg IV of conjucated estrogens Continued management after massive bleeding has abated Adminster congucated estrogen, 2.5 mg orally daily for 25 days may double.the dose if bleeding recues or increase Progesteron treatment: *Add 10 mg of medroxyprogestron acetate for the last 10 days of treatment -Allow 5-7 days for withdrawal bleeding : Moderate Menometrorrhagia.2 ‫اطالع‬ Estrogen-progestron combination Administer conjugated estrogen, 1.25mg orally each day for 25 days with 10mg medroxyprogestrone orally for last 10.days of the estrogen treatment Administer oral contraceptive for 21 days with a 7 days withdrawal Cyclic progestin Adminster medroxyprogestron 10mg orally each day for.days each month , usually for 3 months trial 10-15 Mirena Intrauterine System with levonorgestrel-releasing.Intrauterine Device For older patient who do not response to.3 medical therapy and who donot anticipate later pregnancy : more radical and potrntially permanent -:therapeutic measures may considered endometrial ablasion.1  Endometrial ablasion Types of uterine ablation Balloon thermal ablation.1 Cryoablation or freezing.2 Electrosurgery.3 Hydrothermal ablation.4 Microwave.5 Radiofrequency.6 app: roches Hystroscopic.1 Non hystroscopic.2 complication Fluid over load -1 Uterine perforation -2 Thermal damage to adjusent organ -3 Contraindications 1-Desires future fertility 2-endometrial cancer 3-active genital or UTI 4-anatomical or pathological endometrial weakness  Hystrectomy Types : 1.Supracervical Hysterectomy (also called “Subtotal Hysterectomy” or “Partial Hysterectomy 2.Total Hysterectomy (“Traditional Hysterectomy”) 3.Radical Hysterectomy: Vaginal approch abdominal approch labroscopic approch complication: Bleeding.1 Damage to nearby organs.2 Infection either of wound or urinary tract.3 Wound dehiscence.4 Incisional hernia.5 Vault prolaps.6 others  Randomised trials comparing ablation & hysterectomy ablation success 90%- If retreat failures, 50% success- Shorter hospital stays, fewer complications, less cost and- earlier return to normal But Reoperation rates increase steadily with time - Hystrectomy BUT it carry more oparative side effect greater patient satisfaction  Prognosis Response to treatment for DUB is highly individual and is not easy to predict. The outcome depends largely on the woman's medical condition and her age. Many women, especially adolescents, are successfully treated with hormones (usually.oral contraceptives) As a last resort, hysterectomy removes the source of the problem by removing the uterus, but this operation is not without risk,.or the possibility of complications Prevention Dysfunctional uterine bleeding is not a preventable disorder `