Dr Stephen Jeffery

ABNORMAL UTERINE BLEEDING

ABNORMAL UTERINE BLEEDING

Most common complaint in gynaecologicalpractice

Affects 1/3 women at some stage in her life

Key to management

- establishing cause

- instituting appropriate therapy

MENSTRUAL CYCLE

NORMAL PERIOD???

Variation in cycle length between different women ranges between 23 -39 days, mean 30 days

Duration of menstrual bleeding varies from 2 - 8 days

BLOOD LOSS

Objective menorrhagia:

- blood loss > 80ml/ cycle

- 60% of these women will have evidence of iron deficiency anaemia

BLOOD LOSS

Subjective menorrhagia:

- 50% of women presenting with heavy

menses will have measured blood loss within normal limits

- Must still be considered abnormal, and

investigated accordingly

DEFINITIONS

Polymenorrhoea: Menstruation with normal duration and flow, but shorted cycle with intervals < 25 days

Menorrhagia:

Heavy cyclical bleeding

Metrorrhagia:

Uterine bleeding independent of menstrual pattern

Menometrorrhagia:

Increased flow during menstruation and between menstrual periods

LOCAL UTERINE PROBLEMS

① Benign Neoplasms polyps, fibroids, hyperplasias

② Malignant Neoplasms

③ Congenital Uterine Anomalies

④ Trauma

⑤ Infection

⑥ Endometriosis/ Adenomyosis

IATROGENIC

① Hormonal contraceptives

② Hormone replacement therapy

③ Intrauterine devices

④ Anticoagulant therapy

⑤ Haemodialysis

ENDOCRINE AND SYSTEMIC DISORDERS

① Hypothyroidism

② Adrenal disorders

③ Hepatic disease

④ Renal Disease

⑤ Obesity

DYSFUNCTIONAL UTERINE BLEEDING

Defined as abnormal uterine bleeding in the absence of organic disease

Diagnosis of exclusion!

Accounts for 60% of cases of abnormal uterine bleeding

May be ovulatory or anovulatory

DYSFUNCTIONAL UTERINE BLEEDING

OVULATORY- majority of women, 90%

- due to local factors originating in the endometrium - prostaglandin and fibrinolytic systems

- often co-existing PMS and dysmenorrhoea

DYSFUNCTIONAL UTERINE BLEEDING

ANOVULATORY- 10%- due to abnormality of H-P-O axis- either excessive stimulation of the

endometrium by oestrogen, or inadequate stimulation

PCOS, Menarchal, Perimenopausal

DEFINITIONS

Polymenorrhoea: Menstruation with normal duration

and flow, but shorted cycly with intervals < 25 days

Menorrhagia/ Hypermenorrhoea:

Heavy cyclical bleeding

Metrorrhagia:

Uterine bleeding independent of menstrual pattern

Menometrorrhagia:

Increased flow during menstruation and between menstrual periods

HMB= Heavy menstrual bleeding

AUB = Abnormal Uterine Bleeding

Chronic AUB = abnormal in quantity, regularity and/or timing for >6 months

Acute – severe enough to require immediate intervention

IMB = Intermenstrual bleeding

Polyps

Adenomyosis

Leiomyomas

Malignancy/ hyperplasia

Coagulopathy

Ovulator y dysfunct ion

Endometr ia l d isorders

Iatrogenic

Not c lassi f ied

POLYP

PALM-COEIN

POLYP

PALM-COEIN

POLYP

PALM-COEIN

ADENOMYOSIS

PALM-COEIN

ADENOMYOSIS

PALM-COEIN

ADENOMYOSIS

PALM-COEIN

LEIOMYOMA (FIBROIDS)

PALM-COEIN

MALIGNANCY / HYPERPLASIA

PALM-COEIN

MALIGNANCY / HYPERPLASIA

PALM-COEIN

COAGULOPATHY

PALM-COEIN

OVULATORY DISORDERS

LACK OF CYCLICAL PROGESTERONE PRODUCTION

“LOOP” EVENTS

USUALLY UNKNOWN BUT CAN BE THYROID

PCOS

HYPERPROLACTINAEMIA

MENTAL STRESS

OBESITY

ANOREXIA

WEIGHT LOS

EXTREME EXERCISE

DRUGS

PALM-COEIN

ENDOMETRIAL LACK OF VASOCONSTRICTORS

???????????

PALM-COEIN

IATROGENIC

Break Through Bleeding (BTB)

MIRENA

PALM-COEIN

NOT CLASSIFIED

PALM-COEIN

HISTORY

① Normal cycle + changes

② Duration of flow, amount of blood loss, clots, flooding/ accidents, symptoms of ovulation.

③ Sexual history + contraception

④ General medical history + medication

⑤ Family history

GENERAL EXAMINATION

① Anaemia

② Purpura, petechiae

③ Stigmata of endocrine disease -goitre, obesity, striae, hirsutism

④ Breast exam

⑤ Abdominal exam

⑥ Pregnancy, pelvi-abdominal mass,

⑦ Liver, spleen

PELVIC EXAMINATION

Exclude bleeding from rectum and urethra

Vulva

Vagina

Cervix

Uterus & Adnexa

Rectal exam

SPECIAL INVESTIGATIONS

Basic Hb, FBC if anaemic Pregnancy test!!! Cervical smear Pelvic ultrasound Endometrial sampling

Occasional TSH, endocrine investigations if clinical suspicion

Referral for Hysteroscopy

Patient with prolonged chronic anovulation

Obese patient

Patient> 35-40 years with heavy or irregular bleeding

All postmenopausal bleeders

Patients who require endometrial sampling:

Chronic irregular bleeding

Peri-menopausal

Post-menopausal ET > 5mm

Ultrasound suggests fibroid or polyp

HYSTEROSCOPY

MANAGEMENT

Dictum: All postmenopausal (or perimenopausal) bleeding is considered to be caused by cancer until proven otherwise!

POSTMENOPAUSAL BLEEDING

Menarchal girl with irregular period and no other obvious pathology

Reproductive age (less than 40) with CYCLICAL, heavy bleeding and normal uterus and not yet tried medical therapy

Obvious cause of anovulatory bleeding eg PCOS and not yet tried medical therapy eg COC

Post-menopausal and ET <5mm, normal Pipelle

WHEN IS IT OK TO NOT INVESTIGATE FURTHER?

ACUTE BLEEDING EPISODE

① Haemodynamic stabilization

② Thorough history and examination

③ Hormonal therapy

(a) High-dose oestrogen for atrophic endometriumor (b) High-dose combined oral contraceptive pill if

bleeding not too severeor (c) Provera 5mg daily for anovulatory bleeding

PLUS Cyclokapron 1,5g 8 hourly IV or 1g 6hrly po

DEFINITIVE MANAGEMENT

• EXPECTANT MANAGEMENTmenstrual calendar x 3/12ths

may resolve spontaneously correction and prevention of anaemia

• MEDICAL MANAGEMENT

• SURGICAL MANAGEMENT

Should be individualized

MEDICAL MANAGEMENT

1. ANTIFIBRINOLYTIC DRUGS

Tranexamic acid ( Cyclokapron)

Prevents activation of plasminogen

Decreases blood loss by 47% in women with menstrual blood loss > 80 ml/ cycle

1. ANTIFIBRINOLYTIC DRUGS

1/3 of patients report side effects

- nausea, dizziness, tinnitus, rashes,

abdominal cramps

Case reports of serious thrombosis

- caution advised in patients with past

history or risk factors of thrombotic

disorders

Underlying pathophysiology:

- altered ratio of prostaglandin E2 to F2

- increased ratio of of prostacyclin to

thromboxane synthesis

Will reduce flow by 40-50%

Mefenamic acid (Ponstan) 250-500 mg po qid with onset of menses for 7 days.

2. NSAIDS

Will reduce flow by at least 50%

Advantages:

- cycle control

- reliable contraception

Side effects:

- weight gain, abdominal discomfort, spotting

Healthy, nonsmoking women with no cardiovascular or thrombotic risk factors can use the Pill up to menopause

3. LOW DOSE MONOPHASIC ORAL CONTRACEPTIVES

Cyclic Provera 10 mg po OD x 10 days per month

or Depo provera 150 mg IM q 3 month

Anovulatory DUB

Useful in patients in whom oestrogens are contraindicated and > 40 years old

Prescribed from day 16 - 25 of the cycle

Reduction in menstrual blood loss of 15%

Side effects include weight gain, bloating, oedema, headaches, and depression

4. PROVERA

5. MIRENA

5. MIRENA

Release intrauterine progesterone in controlled manner over 5 years

- Mirena: levonorgestrel 20µg/ 24 hours

Method of action:

- reduction in endometrial prostaglandin

synthesis

- production of an inactive endometrium

- reduction in endometrial fibrinolytic

activity

5. MIRENA

Reduction in menstrual blood loss

of 65 - 95%

Advantages:

- reliable contraception

- few side effects

SURGICAL MANAGEMENT

1. ENDOMETRIAL ABLATION

Destruction of the endometrial lining to treat excessive menstruation

1. ENDOMETRIAL ABLATION

Products available

① Thermachoice

② Cavaterm

③ Thermablate

④ Novasure

⑤ Microwave endometrial Ablation

Hysterectomy In The USA

Prolapse

14%

Endometriosis

18% DUB25%

Fibroids

25%

Pain

9%Precancer

9%

600,000 hysterectomies per year in USA

> $4 Billion in direct and indirect costs

37% of women have had hysterectomy by age 60

2.UTERINE ARTERY EMBOLISATION

3.HYSTERECTOMY

Definitive management for DUB in patients:

- who have completed their families

- with failed medical treatment

- over the age of 45

- with failed endometrial ablation

Can be performed either by abdominal or vaginal route

3.HYSTERECTOMY

Vaginal Hysterectomy

Total Abdominal Hysterectomy

Laparoscopic Assisted Vaginal Hysterectomy

Total Laparoscopic Hysterectomy

Subtotal Hysterectomy

Subtotal Laparoscopic Hysterectomy

Myomectomy

MANAGEMENT ACCORDING TO AGE GROUPS

PREPUBERTAL CHILD

Precocious puberty - 2o sexual characteristics

Foreign bodies

Vaginitis

Tumours

Iatrogenic - accidental ingestion of steroid hormones

Abuse

ADOLESCENCE

Almost always anovulatory!

First 30 - 40 cycles after menarche may be anovulatory

Management:

- exclude pathological cause

- reassure, counsel, haematinics

- low dose combined oral contraceptive

pill or cyclical progesterone

PERIMENOPAUSAL

> 40 years

May be due to organic cause or anovulatory DUB

DUB:

- due to alteration in pituitary-ovarian function preceding the menopause

- bleeding usually acyclical

- associated with endometrial

hyperplasia in 50% of cases

Endometrial sampling NB!!