A Quick Overview on Menstrual Irregularity... A Newer Approach (AUB)

8/10/2019 A Quick Overview on Menstrual Irregularity... A Newer Approach (AUB)

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A quick

overview onMenstrual

irregularity

And a newer approach to

abnormal uterine

bleeding


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Menstruation

Menstruationis the periodic discharge of bloodand mucosal tissue from the inner lining of theuterus through the vagina due to, orderly cyclichormone production and parallel proliferation of

the uterine lining preparing for implantation of theembryo.

The time frame from the start of one menstrual

episode to the start of next menstrual episode iscalled Menstrual Cycle.

The number of days the menstrual bleedingpersists is called menstrual Period.


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The parameters of Normal

Menstruation

Duration of flow 3-7 days (average 4 days)

Cycle length 21 - 35 days (average 29 days)(28 days +/- 7 days}

Blood loss < 80 ml (average 30-35 ml)

ny deviation from this

normal parameter is

abnormal menstruation


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When will we call it Abnormal

Menstruation??

Duration of flow more than 7 days (If flow is normal) or

more than 5 days (if flow is heavy)

Less than 2 days

Menstrual cycle is Less than 21 days

More than 35 days

Flow is heavy blood loss of greater than 80 ml

Passing of large blood clot during menstruation

Enough flow to soak a pad or tampon every hour for 3consecutive hours. (Each soaked tampon holds 5ml of blood)

Night time bleeding that requires getting up to change pads or

tampons


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Here are the

Classic

Terminologies

we used toDescribe

AbnormalMenstruation

Dysmenorrhoea

Menorrhagia

Polymenorrhea

Polymenorrhagia

Oligomenorrhoea

Hypomenorrhoea

Metrorrhagia

Metropathia

Haemorrhagica


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Parameters of Classic terminologies

Description Cycle Period

Normal

menstruation

Normal period of

menstruation

2135 days 37 days

Dysmenorrhoea Painful menstruation

as to hamper day today life

2135 days 37 days + PAIN

Menorrhagia Normal Cycle with

Excessive amount /

Period of bleeding

2135 days >7 days + normal flow

>5 days + heavy flow

Polymenorrhoea Decreased Cycle

with normal period

Less than 21 days 37 days

Polymenorrhagia Decreased cycle with

Excessive amount /

Period of bleeding

Less than 21 days >7 days + normal flow

>5 days + heavy flow


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Description Cycle Period

Oligomenorrhoea prolonged Cycle with

normal period

more than 35 days 37 days

Hypomenorrhoea prolonged Cycle with

Decreased period

more than 35 days Less than 2 days

Metropathia

Haemorrhagica

A special type of

anovulatory uterine

bleeding

6 - 8 weeks of

amenorrhoea

followed by

28 weeks of

bleeding which is

painless and life

threatening

Metrorrhagia Irregular, acyclical

bleeding

Can not be specified

into definative cycle

Can not be specified

into definative

period

Parameters of Classic terminologies


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Classic approach to diagnose a case of

Menstrual Irregularity

Fibroid

PID

Adenomyosis

Endometrosis

DUB

Painless

To diagnose exclude

Pubertal age Hypothyroidism

(TSH, T4)

Bleeding disorder(BT, CT)

Reproductive ageAbortion

Ectopic PregnancyMolar Pregnancy

IUCD in utero

Break through bleeding

Peri menopausal ageCa cervix

Endometrial polyp

Endometrial carcinoma

HRT treatment if

Stopped abruptly

Dysmenorrhoea

Menorrhagia(Regular/Cyclical) Metrorrhagia(Irregular/Acyclical)


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The problems of Classic terminology And the

move to refine it

Over the past decade it has become

abundantly clear that many terms used todescribe menstrual symptoms and causes of

abnormal menstrual bleeding are ill defined

and confusing.


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So, a formal initiative was established with aninternational workshop in Washington, D.C., in

2005, Which yielded the FIGO (InternationalFederation of Gynecology and Obstetric)Classification in 2009 at Cape town.

This Classification looks to refine the Illdefined Terminologies to a better defined welldemarcated territory of Newer TerminologyThat Is,

BNORM L UTERINE BLEEDING

The problems of Classic terminology And the

move to refine it


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BNORM L UTERINE

BLEEDING

Abnormal Uterine Bleedingis defined as

bleeding from the uterine corpus that isabnormal in regularity, volume, frequency, or

duration and occurs in the absence of

pregnancy in women of reproductive age.


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Caution

Abnormal Uterine Bleeding excludes thefollowing situations:

AUB Excludes Gravid patients. A pregnancy test is amust before trying out for AUB.

AUB deals only with women of reproductive age thatis from definitive onset of Menstruation tomenopause. So, pre-pubertal bleeding or post

menopausal bleeding is not included in AUB. Lower genital tract bleeding due to any cause is

opted out of AUB. So, cervical or vaginal tears ormalignancies must be excluded first.


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Types of AUB

Heavy Menstrual Bleeding Acute

AUB is defined as an episode of heavy bleeding that, in theopinion of the clinician, is of sufficient quantity to require

immediate intervention to prevent further blood loss Chronic

chronic AUB is defined as bleeding from the uterine corpusthat is abnormal in volume, regularity, and/or timing, and

has been present for the majority of the past 6 months Intermenstrual Bleeding

occurs between clearly defined cyclic and predictablemenses.


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Differential Diagnosis of AUB

AUB

Structural

P-Polyp (AUB-P)A-Adenomyosis (AUB-A)L- Leiomyoma (AUB-L)

M-Malignancy &Hyperplasia (AUB-M)

Non-Structural

C-Coagulopathy (AUB-C)O-Ovulatory dysfunction(AUB-O)

E-Endometrial (AUB-E)I-Iatrogenic (AUB-I)N-Not yet classified (AUB-N)


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P-Polyp (AUB-P) Polyps are epithelial proliferations

comprised of a variable vascular,glandular, and fibromuscular andconnective tissue components and

are often asymptomatic.

Yet, it is generally accepted that atleast some polyps contribute to thegenesis of AUB.

For the basic classification system,polyps are categorized as beingeither present or absent.


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A-Adenomyosis (AUB-A) The relationship between

adenomyosis and thegenesis of AUB is unclear,

though undeniable. As there exists both

sonographic and magneticresonance imaging (MRI)-

based diagnostic criteria,adenomyosis has beenincluded in theclassification system


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L-Leiomyoma (AUB-L) An Important cause

of AUB I has its own

primary, secondary

and tertiaryclassification system


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M-Malignancy & Hyperplasia (AUB-M) Although relatively

uncommon, atypicalhyperplasia and

malignancy areimportant potentialcauses of, or findingsassociated with AUB

and must be consideredin nearly all women ofreproductive age


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C-Coagulopathy (AUB-C) coagulopathy

encompasses the spectrumof systemic disorders of

hemostasis that may beassociated with AUB.

Coagulation Disorders

Inherited

von willibrands

haemophilia

Acquired

ITP

DIC

Leukemia

Drug Induced

Heparin

Warferin

Aspirine


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O-Ovulatory dysfunction (AUB-O) Ovulatory dysfunction can contribute to the genesis

of AUB.

Although most ovulatory disorders elude a defined

etiology, many can be traced to Endocrinopathies(e.g. polycystic ovary syndrome, hypothyroidism,

hyperprolactinemia, mental stress, obesity, anorexia,

weight loss, or extreme exercise such as that

associated with elite athletic training).

Also, unexplained ovulatory disorders frequently

occur at the Extremes of reproductive age.


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E-Endometrial (AUB-E)

When AUB occurs in the context of predictable and cyclicmenstrual bleeding, typical of ovulatory cycles, andparticularly when no other definable causes areidentified, the mechanism is probably a primary disorderof the endometrium.

Indeed, high-quality evidence has demonstrateddeficiencies in local production of vasoconstrictors suchas endothelin-1 and prostaglandin F2, and/oraccelerated lysis of endometrial clot because of excessive

production of plasminogen activator. the diagnosis of endometrial disorders should probably

be determined by exclusion of other identifiableabnormalitiesin women of reproductive age who seemto have normal ovulatory function.


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I-Iatrogenic (AUB-I) Drugs that may contribute to

AUB:

Hormonal therapy (estrogen,progesteron, androgens, Etc )

the use of anticoagulant drugssuch as warfarin, heparin, andlow molecular weight heparin

Systemic agents that interferewith dopamine metabolismhave the potential to cause AUB

Tricyclic antidepressants

phenothiazines


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N-Not yet classified (AUB-N)

Chronic endometritis

Arteriovenous malformations

Myometrial hypertrophy, Etc


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Notation for FIGO Classification


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Notation for FIGO Classification


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So, FIGO Notation for our patient

would be.


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Documents

A Quick Overview on Menstrual Irregularity... A Newer Approach (AUB)