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Uterine
Bleeding
Nadya Al-Faraidy
98240015
21 October 2003
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Definition
DUB is abnormal uterine
bleeding with no pathological or
congenital cause.
diagnosis of exclusion
Can be:
w/in the period: menorrhagia
intermenstrual bleeding
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Terminology
Primary Amenorrhea:
no menstruation by age of 14 in
absence of secondary sexual
characteristics OR before 16 yrs in
presence of secondary sexual
characteristics
Secondary Amenorrhea:
cessation of menstruation or 6
months or more in a patient who was
menstruating regularly or 12 months
in a patient who had a history of
oligomenorrheaWWW.SMSO.NET
Menorrhagia:
excessive &/or prolonged regular
menstruation
Polymenorrhea:
frequent regular menses at intervals <21
days
Polymenorrhagia:
frequent but w/ prolonged &/or excessive
bleeding
Metrorrhagia:
irregular periods of uterine bleeding
Oligomenorrhea: WWW.SMSO.NET
Pathophysiology
DUB is most common near the beginning and end of a
woman's reproductive life, but may occur at any time.
first 18 months after menarche: immature
hypothalamin-pituitary axis obese women: non-ovarian
endogenous estrogen production may upset the normal
menstrual cycle.
Menopause: anovulatory DUB.
anovulatory cycles resulting in menometrorrhagia
luteal phase deficiency cause the loss of LH surge, may
be especially prominent in amenorrheic athletes.
>40 years: number and quality of ovarian follicles.
(OCPs),
Endocrine disorders . Hyperprolactinemia Polycystic
ovary disease Hypothyroidism, hyperthyroidism, and
Cushing's disease, premature ovarian failure
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Causes
Pregnancy complications
Abortion
Ectopic pregnancy.
Molar disease.
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Causes
Vulvar lesions:
Trauma.
Infection.
Ulcer.
Inflammatory lesion.
Condylomata.
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Causes
Vaginal lesions:
Vaginitis.
Atrophic vaginitis (common in post
menopausal women).
Foreign bodies e.g. forgotten
tampons.
Traumas and lacerations.
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Causes
Cervical lesions:
Polyps.
Cervicitis.
Cervical condyloma.
Cervical tumors.
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Causes
Uterine lesions:
Fibroid.
Adenomyosis and endometriosis.
Endometrial Polyps.
Endometrial hyperplasia
Endometritis.
Uterine malformation: if severe,
menorrhagia
Precocious puberty.
IUCD.
Endometrial ca.
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Causes
Ovarian lesions:
Salpingo-oopheritis (PID).
Endometriosis.
Ovarian cyst.
Ovarian tumors.
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Causes
GU and GI lesions:
Hematuria.
Hemorrhoids.
Fissures.
Rectal cancer.
Colon cancer.
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Causes
General disease:
Coagulation disorders.
Liver disease.
Renal disease
Thyroid disease.
Adrenal disease.
Pituitary disease.
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Causes
Blood Dyscariasis:
ITP
Von-Willibrand disease
Leukemia
Anemias
SCA
Thalassemia
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Causes
Medications:
Exogenous hormones eg Hormone
Replacement Therapy
Oral contraceptives.
Aspirin.
Anticoagulant therapy.
Digitalis.
Corticosteroids.
Others.
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Incidence
. One of the most common symptoms
in gynecology.
. Most frequently at the extremes of
age:
an-ovulation or Imbalance.
6months – 1 year after menarche and
post menopause.
Menorrhagia affects approximately
22% of healthy women.
In the United States, approximately
7.6 million pre-menopausal women
aged between 30 and 55 perceive
their menstrual bleeding to be
excessive. WWW.SMSO.NET
Evaluation
Age
HistoryMost common cause of bleeding
age New born Maternal estrogen
Menstrual history.
Childhood Foreign body, cancer
Amount of
bleeding.
Adolescence due to hormonal imbalance
Duration of the Due to weaning of ovarian function
Perimenopausal
loss.
reproductive -Pregnancy and its complications.
Interval between -Anovulation due to:
episodes. 3.polycystic ovarian disease
Associated 4.idiopathic
symptoms. 5.stress
Drugs ingested 6.hypothyroidism
esp use of 7.hyperprolactinemia b/c of:
Variation in galactorrhea
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weather,
Postdiet andHormone replacement cancer
Evaluation
Physical Examination
Examination of all symptoms.
Basal temperature charting
Pelvic examination & speculum
examination
Recto-vaginal examination in
young children or single women
in which you can’t do pelvic
examination.
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Evaluation
Lab Investigations
CBC: Hb and Hct + WBCs
for infection
ESR Test Indication
Serum HCG
urine to rule outpregnancy
pregnancy
pregnancy.
test anemia
Urinalysis
CBC coagulpathy (especially in adolescents
Pelvic U.S.
PT/PTT cervical cancer
Hysterosalpingography
Pap smear* > 40IU/L suggests ovarian failure
(HSG).FSH liver disease
Endometrial biopsy.
liver function tests thyroid disease
Hysteroscopy.
TSH pituitary adenoma (with breast
prolactin
Dilatation level
and discharge)
curettage
(D & Serum
C) Diagnostic Ovulation luteal phase
and therapeutic.
progesterone
# Most of the time we
don’t need all these
investigation, Hb and
HCG will be enough.
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Management
Medical
Combined contraceptive pill: transforms uterus into
pseudo-secretory state “short secretory & short
proliferative & then shedding occurs
Progesterone: for 21 days if uterus hyperplastic
PGSI- PG Synthase Inhibitor:
Rationale: during DUB, there is excessive PG esp PGE2
which cause excessive bleeding
Eg indomethacin, mefenamic acid (Ponstan)
Rx 50-70% of DUB
Side effect: diarrhea
ECA:
Fibrinolytic
Causes thrombosis of spiral uterine blood vessels
causes decreased bleeding
> side effects
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How successful is HRT at
preventing menstrual
bleeding?
Continuous combined hormone
replacement usually results in amenorrhea
after about 3 months of use
intermittent bleeding during the first 3
months is common.
By 6 months, about 2/3's of women will
not have bleeding
at 1 year 80-85% will be without bleeding.
Increasing the estrogen dose as well as
the progestin dose may help stop some of
the bleeding. WWW.SMSO.NET
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Management
Surgical
Removal of the endometrium
If hormone therapy is not effective,
the endometrium may be removed.
Endometrial ablation is usually the
method of choice, although some
patients choose a hysterectomy or
D & C.
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Endometrial ablation
YAG LASER
Thermal balloon
Hydrothermablator
Resectoscope
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YAG LASER
Advantages
15 and 30 minutes.
discharged two or three
hours.
The patient should be
reassured that discharge is
normal
80% successful in reducing
heavy periods and may
eliminate menstruation
altogether.
Advantages of the
procedure over
hysterectomy
it is safer, less invasive,
and does not require a
surgical incision
it is less expensive
it requires a shorter
hospital stay WWW.SMSO.NET
YAG
Disadvantages
o fluid overload
o hyponatremia,
o perforation of the uterus or adjacent
organs,
o uterine rupture,
o infection or haemorrhage. Overall,
endometrial ablation has a
o morbidity rate of 3%.
o sterility
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The Novasure System
Another new
device, the
Novasure System™
, is now available,
and has a number
of advantages over
other systems. It
only takes a few
minutes and has an
excellent safety
record
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Thermal balloon
two components - a balloon catheter for heating and a
controller
local anaesthesia
87 degrees Celsius, for eight minutes.
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HTA Hydrothermablator
hot water, but allows it to circulate
freely in the endometrial cavity. It is
done under direct vision through a
hysteroscope
10 minutes
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Who should consider
endometrial ablation?
menstrual bleeding that is impacting
life, with no other problems that
require a hysterectomy >80ml per
cycle, >8 days
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Other Surgical Options
Hysteroscopy
Resectoscopy
Hysterectomy
D&C
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Is hysterectomy a better treatment
than endometrial ablation for bleeding
problems?
The two procedures are somewhat difficult
to compare.
outpatient vs. inpatient
1 week vs. 6 weeks
4 year study:
36% of the women having endometrial
ablation and 24% of the women having
hysterectomy required more sx
Satisfaction rates 80% in the ablation
group and 89% in the hysterectomy group.
(retreatment, PMS)
Endometrial ablation allows about 75% of
women to avoid hysterectomy
Hysterectomy was more successful in the
long run in treating the bleeding problems
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as well as premenstrual symptoms