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Tulburarile ciclului menstrual:

Sngerarea uterin anormal

Stelian Hodorogea
Caracteristicele unui ciclu menstrual normal
Dereglarile ciclului menstrual

Sngerare uterin anormal (SUA)


Clasificarea PALM-COIEN a cauzelor SUA
Diagnosticul si tratamentul SUA
Hypothalamus-pituitary-ovarian
hormonal axis

Ovarian changes

Endometrial changes
Caracteristicele unui ciclu menstrual normal
Durata medie 28 zile (variind de la 21 la 35 sile)
Regulat (nu-s diferente de durata mai mari de 8
zile)
Durata medie a sangerarii menstruale - 4 zile
(variatii 3-8 zile).
Pierderea medie de sange 35-40 mL. Se
considera patologica - daca e peste 80 mL.

De asemenea:
Este ovulator
Nu este foarte dureros .
Dereglarile ciclului menstrual
De regularitate
De frecventa
De durata a sangerarii
De volum a sangelui pierdut

Anovulatia
Dysmenorea
Dereglarile regularitatii
Amenorrhea absenta menstruatiilor.
Mensruatii neregulate variatii de durata a
ciclului menstrual mai mari de 8 zile.
Dereglarile frecventei

Polymenorrhea cicluri menstruale la intervale <


21 zile.
Oligomenorrhea - cicluri rare >35 zile
Dereglarile duratei si volumului
sngerrii
'Hypomenorrhea' patologic scurta (<2 zile)
'Menorrhagia' (meno = prelungita, rrhagia =
eliminari) cresterea patologica a volumului
(>80 ml) si duratei sngerrii menstruale (>7
zile) la intervale regulate.

Hemoragii uterine patologice (HUP -


AUB)

Menorrhagia: hemoragii excesive la intervale regulate


Metrorrhagia: hemoragii excesive la intervale neregulate
Menometrorrhagia: excesive, prelungite, neregulate
Intermenstruale: hemoragii intre menstruatii

Polymenorrhea: frecvente, regulate, < 21 zile

Postmenopauza
Pre-menarhe (9 ani)
Cauzele hemoragiilor uterine
patologice
Pregnancy-related Systemic
Miscarriage Thyroid disease
Ectopic pregnancy Liver disease
Gestational trophoblastic disease Coagulation disorders
Infection Sepsis
Cervicitis Iatrogenic
Endometritis Oral contraceptives
Neoplasm Progestin-only contraceptives
Cervical dysplasia/carcinoma Intrauterine devices
Endometrial hyperplasia/carcinoma Hormone replacement therapy
Submucous leiomyomas Steroids
Endometriosis Anticoagulants
Estrogen-producing ovarian tumors
Hemoragii uterine disfuncionale

Hemoragii uterine disfunctionale (HUD) HUP


intre menarhe si menopauza care nu pot fi
atribuite nici unei cauze evidente
(medicamente, coagulopatii, afectiuni sistemice,
traume, neoplasme ori sarcina).

Hemoragia uterin disfunctional diagnostic


de excludere
Review of current terminology in medical and historical literature
reveals confusing and inconsistent definitions referring to
menstrual bleeding.
As a result, the FIGO Menstrual Disorders Working Group (an
international expert consensus committee) has developed new
guidelines for terminology related to this topic.

Grupul de lucru FIGO a propus noi criterii de definire a


Sangerarilor Uterine Anormale (SUA) i de a elimina
termenii menorrhagia, metrorrhagia, si hemoragii
uterine disfunctionale.
Limitele normale ale parametrilor
ciclului menstrual
Clinical Parameter Descriptive term Normal limits (595th
percentiles)

Frequency of menses (days) Frequent <24


Normal 2438
Infrequent >38

Regularity of menses, cycle Absent No bleeding


to cycle (Variation in days Regular Variation 220 days
over 12 months) Irregular Variation >20 days

Duration of flow (days) Prolonged >8.0


Normal 4.58.0
Shortened <4.5

Volume of monthly blood Heavy >80


loss (mL) Normal 580
Light <5
Caracteristicele unui ciclu menstrual normal

Durata medie 28 zile (variind de la 24 (21) la


(38) 35 zile)
Regulat (nu-s diferente de durata mai mari
de 20 (8) de zile)
Durata (variatii 3-8 zile).
Pierderea de sange - se considera patologica
daca e peste 80 mL
Sngerare uterin anormal
Sngerare uterin anormal (SUA-AUB) este o
hemoragie uterina care este anormala
(patologica) in regularitate, volum, frecventa,
ori durata in lipsa sarcinii.
Sangerari menstruale abundente pierdere
excesiva menstruala de sange care afecteaza
starea de bine fizic, emotional, social si
material a femeii
Cea mai frecventa forma de SUA:
Sangerari menstruale abundente pierdere
excesiva menstruala de sange care afecteaza
starea de bine fizica, emotionala, sociala si
materiala a femeii
Structural causes: Polyps

Polyps (endometrial and


cervical) are classified as
absent, or present (AUB-P)
Through imaging
(radiological or
hysteroscopic) or histology.
Structural causes: adenomyosis
Diagnosis based on:
Clinical sings
Ultrasound
MRI

AUB-A
Structural causes: leiomyoma
Most relevant: sub-mucous leiomyoma
Diagnosis:
Bimanual exam
Ultrasound
Other radiological

AUB Lsm
AUB Lother
Structural causes:
Malignancy and hyperplasia

Factoi de risc
Varsta
Obezitatea
Anovulatia cronica .
Diagnostic histologia
Non-structural causes: coagulopathy
Initial screening for an underlining disorder of hemostasis in patients
with AUB should be by a structured history:
1. HMB since menarche
2. One of the following:
Post-partum hemorrhage
Surgical related bleeding
Bleeding associated with dental work
3. Two or more of the following symptoms:
Bruising 1-2 times/months
Epistaxis 1-2 times/months
Frequent gum bleeding
Family symptoms of bleeding symptoms
Non-structural causes: Iatrogenic
AUB-I comprises the spectrum of uterine bleeding problems
related to intrauterine contraceptive systems, exogenous
sex-steroid administration or agents such as gonadotrophin
releasing hormone agonists that directly affect sex steroid
production.

Also include those related to changes in target tissue drug


bioavailability.
Ex.: anti-epileptic or anti-tuberculous drugs such as
carbamazepine or rifampicin, respectively, significantly altering
hepatic enzyme activity.
Non-structural causes: Ovulatory disorders
1. Diseases causing deviation from normal ovulation and
regular progesterone withdrawal from the corpus
luteum such as hyperprolactinemia or polycystic ovarian
syndrome.
2. Anovulation, especially at the extremes of reproductive
life (adolescence or premenopausal).

AUB-O
Hemoragii ovulatorii vs Anovulatorii
Ovulatorii de regula regulate si asociate cu
symptome premenstruale and dysmenorrhee.

Hemoragii anovulatorii, care sunt mai


frecvente imediat dupa menarche sau in
perimenopausa, de obicei sunt neregulate,
fara simptome premenstruale si dureri.
Non-structural causes: Endometrial
dysfunction
AUB-E is presently reserved as a diagnosis of
exclusion among other causes of AUB, and may
represent a primary endometrial disorder.

Most AUB-E cases appear to be due to


disturbances of metabolic molecular pathways,
such as those involving tissue fibrinolytic activity,
prostaglandins, other inflammatory or vasoactive
mediators
Non-structural causes: Endometrial
dysfunction
To be confident of attributing AUB-E as the
primary cause of a womans symptoms, as no
validated tests are currently available for
clinical use, all other causes of AUB need to be
considered and then determined less likely to
be causative.
Not otherwise classified
AUB-N is reserved for those causes that
require further description or delineation in
their clinical relevance, such as uterine
arterio-venous malformations or chronic
endometritis.
Metodele de diagnostic
Tratament
Medical treatment initial pentru majoritatea HUP
Chirurgical in PALM sau ineficienta tratamentului
medical. Depinde de varsta si necesitatea pastrari
functiei reproductive.

Etapele tratamentului
Stoparea hemoragiei acute, abundente
Prevenirea recurentei
Tratamentul cauzei
1. Stoparea hemoragiei in
hemoragia uterin abundent
1. Intravenous estrogen at 25mg every 4 hours for
12 hours is said to be the treatment of choice
OR
2. Intravenous conjugated equine estrogen
(Premarin) at 1.25mg every 4 hours is a good
alternative
THEN
Estrogen at 1.25mg per day of conjugated estrogen
can be administered for 7 to 10 days, PLUS a
progestational agent such as MPA 10 mg/day
1. Stoparea hemoragiei uterine
moderate
1. Monophasic oral contraceptives (MOC) to be
taken 3 to 4 times per day for a week, then start
a new pack of pills one pill a day after this week
OR
MOC 5 times per day first day, 4 times
second, 3 times third, 2 times fourth and 1
pill per day till full 21 days course
OR
2. MPA10 mg daily for 10 days
2. Prevenire recurentei:
hemoragii moderate si recurente
1. COC - cel putin 6 luni
ORI
2. MPA 10 mg zilnic cate 10 zile fiecare ciclu nu este effectiv
- Trebuie adminstrate de la a 5 pana la a 28 zi a ciclului menstrual
ORI
3. Depo Provera intramuscular150mg fiecare 3 luni
ORI
4. DIU cu progestin (Mirena)
ORI
5. Antiinflamatoare nesteroidiene (Acid Mefenamic cel mai eficient)
ORI
6. Antifibrinolitice: acid tranexamic (Etamsilat s-a docvedit ca este
ineficient)
Tratement chirurgical
Vacuum aspiratie
D&C
Endometrial ablation
Uterine artery embolization
Polypectomy or miomectomy
Hysterectomy

Nu numai in PALM, dar si in COEIN


Caracteristicele unui ciclu menstrual normal

Durata medie 28 zile (variind de la 24 (21) la


(38) 35 zile)
Regulat (nu-s diferente de durata mai mari
de 20 (8) de zile)
Durata (variatii 3-8 zile).
Pierderea de sange - se considera patologica
daca e peste 80 mL
Ovulator
Fara dureri puternice
Sngerare uterin anormal
Sngerare uterin anormal (SUA-AUB) este o
hemoragie uterina care este anormala
(patologica) in regularitate, volum, frecventa,
ori durata in lipsa sarcinii.
Metodele de diagnostic
Tratamentul
Medical treatment initial in majoritatea
cazurilor SUA
Anti-inflamatoare nesteroidiene
Tranexamic acid
COC
DIU cu progestin (Mirena)
Alte progestine
Chirurgical in PALM sau cand medicale sunt
ineficiente