Dinesh a/l Veerapatran 0901111 Group F MBBS batch 16 Aimst University

A 45-year-old G2P0020, LMP 21 days ago, presents with heavy menstrual bleeding. Prior to 6 months ago her cycles came every 28-30 days, lasted for 6 days, and were associated with cramps that were relieved by ibuprofen. In the last 6 months there has been a change with menses coming every 25-32 days, lasting 7-10 days and associated with cramps not relieved by ibuprofen, passing clots and using 2 boxes of maxi pads each cycle. She is worried about losing her job if the bleeding is not better controlled. She denies dizziness, but complains of feeling weak and fatigued. Her weight has not changed in the last year. She denies any bleeding disorders or reproductive cancers in the family. She uses condoms for contraception. She takes no daily medications and has no other medical problems. She is married and works in a factory.

 On exam, BP=130/88; P= 100; Ht=56; Wt=150 pounds. She appears pale. Pelvic exam shows normal vulva, vagina and cervix: normal size, mildly tender, mobile uterus; non-tender adnexae without palpable masses. Labs show Hgb: 9.0, HCT: 27%, HCG: negative, Endometrial biopsy: normal secretory endometrium, Pelvic ultrasound: heterogeneous myometrium, endometrial lining 1.4cm and irregular consistent with endometrial polyp, normal ovaries.

Describe the etiologies of abnormal uterine bleeding

 Describe the etiologies of Heavy Menstrual Bleeding (HMB)

Etiologies of Heavy Menstrual Bleeding (HMB)

Fibroids Endometrial polyps Adenomyosis/endometriosis Coagulation disorders Pelvic Inflammatory disease Thyroid disease Drug therapy Intrauterine contraceptive devices (IUCD) Endometrial/Cervical carcinoma Bleeding of endometrial origin

FIBROIDS
- Benign tumors of the uterine smooth muscle cell origin , also known as

leiomyoma. - Submucus origin : causes menorrhagia -Vast majority of fibroids are asymptomatic -Common presenting symptoms will be menstrual disturbance and pressure symptoms

ENDOMETRIAL POLYPS
discrete overgrowths of the endometrium attached by a pedicle projecting beyond the endometrial surface Presents with intermenstrual bleeding , irregular bleeding or post coital bleeding Common abnormality will be endometrial hyperplasia (can be present in just the endometrial polyp tissue) with increasing age

ENDOMETRIOSIS
- Endometriosis is the presence of endometrial tissue outside the endometrial cavity. -Endometriotic tissue responds to cyclical harmonal changes and therefore undergoes cyclical bleeding and local inflammatory reaction -Clinical features: cyclical non colicky pain restricted around the time of menstruation, sometimes associated with heavy bleeding, dyspareunia

ADENOMYOSIS
Adenomyosis is a disorder in which endometrial glands are found deep within the myometrium. The gland tissue grows during the menstrual cycle and during menses tries to slough but the old tissues and blood cannot escape This trapping of the blood and tissue causes uterine pain in the form of monthly menstrual cramps and abnormal uterine bleeding. Clinical symptoms- severe dysmenorrhoea and increased menstrual blood loss In ultrasound, myometrium is thickened and has a heterogeneous echotexture

Coagulation disorder
Excessive bruising Excessive postoperative bleeding Family history of beeding disorders

Pelvic Inflammatory disease

Inflammation and infection arising from the endocervix leading to endometritis, salpingitis, oophoritis, pelvic peritonitis and subsequently formation of tubo-ovarian and pelvic abscess

Abdominal or pelvic pain Dyspareunia Pyrexia Tender adnexal or papable pelvic mass

Endometrial or Cervical Carcinoma

Intermenstrual bleeding Blood stained vaginal discharge Lower abdominal pain or dyspareunia Post-menopausal bleeding

Tyroid disease
Weight changes, skin changes, fatigue

Drug theraphy
Anticoagulant medications( ex: warfarin)

Intrauterine contraceptive device

Bleeding of endometrial origin

Diagnosis of exclusion This BEO relaces the older dysfunctional uterine bleeding Associated with disordered endometrial prostaglandin production and abnormalities of endometrial vascular development

1) 1)What possible etiologies could cause this patients bleeding?

 Important informations that can help in understanding the etiology of patients bleeding based on history. Age-45 G2p2? Heavy menstrual bleeding Change is duration of her menstrual cycle Pain not relieved by taking ibuprofen( which was relieved before)

 Passing clots and using 2 boxes of maxi pads each cycle Feeling week and fatigue No change in body weight for the past I year denies any bleeding disorders or reproductive cancers in the family

 uses condoms for contraception. No known underlying medical ilness Not on any daily medications

Patient appears pale Patients haemoglobin is 9 Haemotocrit 27% HCG: negative Endometrial biopsy: normal secretory endometrium Pelvic ultrasound: heterogeneous myometrium, endometrial lining 1.4cm and irregular consistent with endometrial polyp, normal ovaries.

 What possible etiologies could cause this patients bleeding?

- Heavy menstrual bleed (presence of clots) - Dysmenorrhea : cramps not relieved by ibuprofen
HEAVY MENSTRUAL BLEEDING WITH DYSMENORRHEA - No other medical problems and not on daily medications - No history of familial bleeding disorder - uses condoms for contraception -, no weight change - Normal vulva, vagina, cervix and adnexae - HCG negative Excluding extrauterine causes, pelvic inflammatory disease, pregnancy complications , coagulation disorders, thyroid diseases, drug therapy, chronic systemic disease, IUCD -normal size, mildly tender, mobile uterus - normal secretory endometrium biopsy - heterogeneous myometrium, endometrial lining 1.4cm and irregular consistent with endometrial polyp pelvic ultrasound Exclude endometrial carcinoma BENIGN UTERINE CAUSES OF HEAVY MENSTRUAL BLEEDING WITH DYSMENORRHEA

What are the possible underlying causes

 Endometrial polyps

Fibroids Endometriosis / adenomyosis Bleeding of endometrial origin (Dysfunctional uterine bleeding)