IS BLEEDING TOO HEAVY ?

P. D . L I YA N AG A M A , 2 0 1 4 S E P

IRREGULAR BLEEDING PV

IDEA OF LEARNING IRREGULAR BLEEDING

• 1.TO UNDERSTAND THE CAUSES OF IRREGULAR BLEEDING• 2. KNOW THE PRINCIPLES OF INVESTIGATION AND

TREATMENT

NORMAL MENSTRUAL CYCLE

• IS A MENSTRUAL CYCLE • WHICH OCCURS EVERY 22 TO 35 DAYS• LASTING NOT MORE THAN 7 DAYS • BLOOD LOSS NOT EXCEEDING 80 ml• AND CYCLE TO CYCLE VARIATION NOT EXCEEDING

7 DAYS

IT MEANS

• ONE WHO GETS CYCLES EVERY 22 TO 24 DAYS , DEVELOPS HER CYCLE IN 30 DAYS , THEN ITS ABNORMAL .• AND ONE WHO GETS CYCLES EVERY 34 DAYS ,

GETS HER CYCLES IN 23 DAYS NEXT TIME , THAT TOO IS IRREGULAR

BASIC PHYSIOLOGY OF MENSTRUAL CYCLE

• IT’S CONTROLLED BY HYPOTHALAMO PITUITARY OVARIAN AXIS [HPO ]• HYPOTHALAMUS SECRETES GnRH , WHICH

STIMULATES PITUITARY• ANT. PITUITARY SECRETES FSH, LH ,PROLACTIN• FSH & LH STIMULATES THE OVARIES TO SECRETE

OESTROGEN & PROGESTOGEN

NORMAL MENSTRUAL CYCLE

ENDOMETRIUM CHANGES IN A NORMAL MENSTRUAL CYCLE

SOME COMMONLY USED TERMS

• MENORRHAGIA [HYPERMENORRHOEA]• OLIGOMENORRHOEA• HYPOMENORRHOEA• POLYMENORRHOEA [ EPIMENORRHOEA]• METRORRHAGIA

METRORRHAGIA

• IS IRREGULAR ACYCLIC BLEEDING FROM UTERUS WITH VARIABLE FLOW AT VARIABLE CYCLES.

POLYMENORRHOEA [EPEMENORRHOEA]

• IS FREQUENTLY OCCURING CYCLES• ON OTHER WORDS CYCLES OCCURING LESS THAN

21 DAYS BUT GAP REMAIN CONSTANT

HYPOMENORRHOEA

• REDUCED FLOW

MENORRHAGIA

• IS REGULAR BUT HEAVY CYCLES [HEAVY FLOW]• PROLONGED CYCLES SHOULD NOT BE TERMED AS

MENORRHGIA.

OLIGOMENORRHOEA

• INFREQUENT CYCLES OR • ON OTHER WORDS ….MENSTRUAL CYCLES

OCCURING MORE THAN 35 DAYS APART.• SOME MISUSE THIS TERM AS REDUCED FLOW.

FLUCTUATION OF DIFFERENT HORMONE LEVELS IN A CYCLE

FLUCTUATION OF HORMONES

CAUSES FOR IRREGULAR BLEEDING PV

• ABNORMAL BLEEDING CAN BE A CONSEQUENCE OF PELVIC PATHOLOGY, INCLUDING MALIGNANT DISEASE,• BUT MAJORITY OF WOMEN WHO COMPLAIN

IRREGULAR OR HEAVY FLOW DOESNOT HAVE UNDERLYING ABNORMALITY.

• CONCERNS ABOUT THE WIDESPREAD USE OF UNNECESSARY HYSTERECTOMIES IN THIS THIS SITUATION HAS LED TO A WELL DEVELOPED EVIDENCE BASED GUIDELINES AND PROTOCOLS FOR PROPER MANAGEMENT OF IRREGULAR BLEEDING PV.• THIS TOGETHER WITH MEDICAL MX AND LESS

INVASIVE SURGICAL METHODS HAS INCREASED THE RANGE OF OPTIONS AVAILABLE FOR THE RELIEF OF MENSTRUAL BLEEDING PROBLEMS WORLDWIDE.

PELVIC PATHOLOGIES RESPONSIBLE FOR IRREGULAR OR HEAVY BLEEDING

ANY UTERINE PATHOLOGY THAT COULD CAUSE VASCULAR CONGESTION OR INCREASED SURFACE AREA OF THE ENDOMETRIUM CAN CAUSE SUCH BLEEDING.Ex ; UTERINE FIBROIDS ADENOMYOSIS / ADENOMYOMA ENDOMETRIAL POLYPS ENDOMETRIAL HYPERLASIA ENDOMETRIAL CARCINOMA

UTERINE FIBROIDS ..TYPES

HYSTEROSCOPIC VIEW OF ENDO POLYP

US FEATURES OF ENDO POLYP

US FEATURES OF ENDO POLYP

US ENDO POLYP

CERVICAL PATHOLOGIES

• CAN ALSO CAUSE SUCH BLEEDING• Ex: 1. EXTENSIVE CERVICAL ECTROPION• SOME MISUSE THE TERM CERVICAL

EROSION • 2. CERVICAL GROWTHS • 3. CERVICAL POLYPS

MANAGEMENT FOR SUCH

• IS TO REMOVE THE PATHOLOGY IN CASES OF FIBROIDS / POLYPS/ ADENOMYOSIS ETC• ENDOMETRIAL HYPERPLASIA ,. • IF SIMPLE HYPERPLASIA WITHOUT ATYPIA • MANAGEMENT IS MODERATELY HIGH DOSES OF

PROGESTOGENS INTO 2 CYCLES OF 21 DAYS WITH A 7 DAY GAP ,…AND REPEAT ENDOMETRIAL BIOPSY,• IF PATHOLGY PERSISTS EVEN WITH MEDICAL

Mx.. , THEN CONSIDER SURGICAL OPTION.

DUB [ DISFUNCTIONAL UTERINE BLEEDING]

• IS ABNORMAL BLEEDING PV WITHOUT ANY DEMONSTRABLE PATHOLOGY IN THE GENITAL TRACT,• AND ALSO WITH THE EXCLUSION OF ANY

BLEEDING DYSCRASIAS LIKE VONWILL-BRAND DISEASE , CERTAIN CLOTTING FACTOR DEFICIENCY• 7/8/9/11 , CHRISTMAS DISEASE ETC, • AND SYSTEMIC DISORDER LIKE HYPOTHYROIDISM.

THEN WHAT CAUSES THIS IRREGULAR BLEEDING

• MENSTRUAL BLOD LOSS IS CONTROLLED WITH THE HELP OF ANTIFIBRINOLYTIC SYSTEM.• ANY IMBALANCE IN THE ABOVE SYSTEM COULD

CAUSE IRREGULAR OR HEAVY BLEEDING.• ENDOMETRIUM IS SECRETING CERTAIN FACTORS ,

WHICH ALSO CAUSE SUCH BLEEDING,• EX: PROSTAGLANDINS , INTRLEUKIN, TNF

[ TUMOUR NECROSIS FACTOR] ETC.

INVESTIGATIONS

• 1. GOOD HISTORY TAKING• 2. ABDOMINAL -PELVIC EXAMINATION• 3. TVS / TAS

MANAGEMENT

• 1. ANTIFIBRINOLYTIC DRUGS LIKE TRANEXAMIC ACID.• 2. DRUGS WHICH ACT AGAINST THOSE CHEMICAL

FACTORS SECRETED BY ENDOMETRIUM, Ex; ANTI-PROSTAGLANDINGS [mefenamic acid] ,NSAIDS CAN ALSO REDUCE BLOOD LOSS.• 3. ANY MEDICAL DRUG OR INVASIVE TECHNIQUE

WHICH CAN INACTIVATE ENDOMETRIUM CAN ALSO REDUCE BLOOD LOSS.

• 1.MEDICAL MANAGEMENT• 2. INVASIVE TECHNIQUES• 3. SURGICAL OPTIONS

MEDICAL MANAGEMNT

• Non hormonal therapy• Hormonal therapy

NON HORMONAL THERAPY

• For women with menorrhagia requiring non hormonal Rx, antifibrinolytic agents …• Such as TRANEXAMIC ACID • And • NSAIDS like mefenamic acid …• Are the first line drugs…• As both these drugs have different mechanisms

of action in menorrhagia, they may be more effective when used in combination.

• Mefenamic acid reduces mean blood loss by about 20 %...• And Tranexamic acid reduces mean blood loss by

about 50%

HORMONAL CONTRACEPTIVES

• Combined oral contraceptives• Oral Progestogens• IM progestogens• Progesterone releasing IUCDs• Other medical therapies

COMBINED OCPS

• For women nrequiring contraception or for whom hormonal agents are acceptable cocp preparations are effectice and reduce mean blood loss by about 50%.• They also control cycle irregularities and relieve

menstrual pain.• In women after the age of 40 , COCP must be

used very CAUTIOUSLY as it could grow an endometrial cancer faster if given to a undiagnosed patient with endometrial carcinoma.

PROGESTOGENS

• Cyclical progestogens were used comonly in the past ,but current evidence does not support their use for menorrhagia when given only during LUTEAL PHASE. • They are effective when given at high doses

between day 5 to day 26. [total 21 days]• Oral medroxyprogesterone 10 bd • Or … norethisterone 5 mg tds

• Oral progestogens are in fact use to treat ENDOMETRIAL HYPERPLASIA WITHOUT ATYPIA.

IM PROGESTOGENS

• DMPA MAY BE HELPFUL IN CONTROLLING HEAY • BLEEDING PV , WHEN NOT RESPONDING TO

OTHER MEDICAL THERAPIES,• BUT THEIR USE IS LIMITED BY SIDE EFFECTS.

PROGESTOGEN RELEASING IUCD

• Mirena is an IUCD which releases LEVENOGESTROL 20 mcg per 24 hours ,for 5 years duration• Reduce mean blood loss by 80-85 %.• Very effective long term drug.• Short term Expensive • Irregular spotting is common during first 6

months, and patients to be councelled before inserting.• Breast tenderness is the other side effect.

OTHER MEDICAL THERAPIES

• Second line drugs are available for the control of severe bleeding when simpler measures have failed.• As they reliably induce amenorrhoea , are useful

in the management of severe anemia or in the presence of medical disorders when surgery may be contraindicated.• Androgens such as DANAZOL and GESTRINONE• Induce amenorrhoea by a combination of

negative feedback and direct effect on endometrium.

GNRH ANALOGUES

• THEY INDUCE HYPOGONADAL STATE VIA THEIR CENTRAL ACTION.• WHILE USEFUL , THEY ARE LIMITED TO SHORT

TERM USE BECAUSE OF THEIR SIDE EFFECTS.• THEY ARE ALSO VALUED AS ENDOMETRIAL

THINING AGENTS PRIOR TO HYSTEROSCOPIC AGENTS.• IN CASES OF SEVERE MENORRHAGIA, IN WHICH

SIMPLE MEASURES FAILED, LONG TERM GNRH WITH ADD BACK THERAPY CAN BE CONSIDERED.

OTHER INTERVENTION METHODS

• ENDOMETRIAL RESECTION • THERMAL BALOON ABLATION • LASER ABLATION OF ENDOMETRIUM• MICROWAVE ABLATION

TCRE

• TRANSCERVICAL RESECTION OF ENDOMETRIUM• USING ELECTROCAUTERY LOOP • OR … ROLLER BALLER DIATHERMY .• OBJECTIVE OF ALL ABLATIVE TECHNIQUES IS TO

ACHIEVE COMPLETE DESTRUCTION OF ENDOMETRIUM , THOUGH NOT 100% POSSIBLE .• ONLY 20 -30 % WILL GET AMENORRHOEA.• REST WILL HAVE SOME DEGREE OF BLEEDING PV.

TRANS-CERVICAL RESECTION OF ENDOMETRIUM

ROLLER BALL

ROLLER BALL TYPES

THERMAL BALOON ABLATION

• BALON IS INSERTED INTO UTERINE CAVITY CONNECTED TO A MACHINE.• SALINE IS HEATED TO 80 DEGREES FOR 15 TO 20

MIN.• ENDOMETRIUM IS THEN DESTROYED BY THERMAL

ACTION.

THERMAL BALOON ABLATION

THERMAL BALOON ABLATION

INVASIVE TECHNIQUES

• LASER ABLATION: • IS LIMITED BY IT.S COST TO VERY LIMITED

CENTRES

MICROWAVE ABLATION

• PROBE WHICH INTRODUCE MICROWAVES IS INSERTED INTO UTERINE CAVITY AND THE PROBE IS MOVED UP AND DOWN WHILE EMITTING MICROWAVES

ENDOMETRIAL ABLATION

ENDOMETRIAL ABLATION

SURGICAL OPTIONS

• IN FAILURE OF ALL THE ABOVE TECHNIQUES , HYSTERECTOMY IS THE FINAL OPTION.• DRAW BACKS ARE , HIGH MORBIDITY, LONGER

RECOVERY TIME , GREATER COSTS.

POST MENOPAUSAL BLEEDING PV

• CAUSES• 1. ATROPHIC ENDOMETRITIS• 2. ENDOMETRIAL HYPERPLASIA• 3. ENDOMETRIAL CARCINOMA

ENDOMETRIAL TRIPLE LINE OR LAYER

TRIPLE LAYER CONSISTS OF

• OUTER LAYER BASALIS• INNER LAYER FUNCTIONALIS• MEDIAN LAYER COMPOSED OF MUCUS

LUTEAL PHASE ENDOMETRIUM

CA ENDOMETRIUM

CA ENDOMETRIUM US FEATURES

CA ENDO US FEATURES

CA ENDO US FEATURES

CA ENDO. PATHOLOGICAL SPECIMEN

ENDOMETRIAL CANCER

• USUALLY ARISE IN POST MENOPAUSAL WOMEN• HOWEVER ANY WOMAN PRESENTING WITH

IRREGULAR BLEEDING PV MUST BE INVESTIGATED TO EXCLUDE THE POSSIBILITY OF CA ENDOMETRIUM. • IN UK SECOND MOST COMMON GYNAECOLOGICAL

CA• …AND 5 TH MOST COMMON CANCER IN WOMEN•

AETIOLOGY

• WOMEN WITH RELATIVELY HIGH LEVELS OF CIRCULATING OESTROGENS , OR PROLONGED EXPOSURE TO OESTROGENS ARE HIGH RISK.• THEREFORE DO NOT ABUSE OESTROGEN

CONTAINING PILLS AFTER THE AGE OF 40.• OBESITY : DUE TO PERIPHERAL CONVERSION OF

ANDROGENS IN ADIPOSE TISSUE …ARE HIGH RISK• EARLY MENARCHAE AND LATE MENOPAUSE• PCOS• TAMOXIFEN THERAPY

• OESTROGEN THERAPY UNOPPOSED BY PROGESTERONES

PRESENTATION

• IRREGULAR BLEEDING PV• HEAVY PROLONGED BLEEDING PV• MENORRHAGIA[ HEAVY BUT REGULAR CYCLES]• INTERMENSTRUAL BLEEDING • DISCHARGE PV•

INVESTIGATIONS

• US PREFERABLY TVS WHEN BLEEDING PV STOPS• ENDOMETRIAL THICKNESS LESS THAN 4 mm IS

TAKEN AS NORMAL AFTER MENOPAUSE & UNLIKELY TO HAVE CA , AND ANYTHING ABOVE 4 MM SHOULD BE ARRANGED WITH ENDOMETRIAL SAMPLING.• IN PERIMENOPAUSAL AGE ENDOTHICKNESS IS

VARYING UPTO 15 mm and still could be normal.• ONE PATIENT WITH 7 mm ENDO. THICKNESS CAN

HAVE CA ,WHILE THE OTHER PERSON WITH 14 mm may not have CA.

THEREFORE

• ENDO BIOPSY IS IMPORTANT AFTER THE AGE OF 40 YEARS IN PATIENTS WITH IRREGULAR OR HEAVY CYCLES, IN ORDER TO EXCLUDE CA ENDO.

ENDO BIOPSY METHODS

• D&C• PIPELLE [OFFICE PROCEDURE]• VABRA SAMPLING• HYSTEROSCOPIC ENDO SAMPLING [NOT FREELY

AVAILABLE IN MANY CENTRES & MORE TIME WASTING AND COSTY]

D&C

• SAMLING AREA IS MORE OR LESS 50%• BUT DETECTION RATE IS LOW ,AROUND 50%• NEED ANESTHESIA• COST IS MORE • NEED HOSPITAL STAY• INVESTIGATIONS PRIOR TO ANESTHESIA

PIPELLE

• ENDOMETRIAL SAMPLING AREA IS AROUND 5%• BUT DETECTION RATE FOR CA ENDOMETRIUM• OR ENDO. HYPERPLASIA IS HIGH AROUND 80 TO

85 %• IF PERFORMED BY EXPERIENCED PERSON.• OFFICE PROCEDURE• DOES NOT NEED ANESTHESIA • NO HOSPITAL STAY• CHEAP• NO NEED OF INVESTIGATIONS

• FOR MEDICALLY UNFIT HIGH BLOD PRESSURES, THYROTOXIC, UNCONTROLLED DM OR HIGH RISK FOR GA PATIENTS ,THIS IS A VERY USEFUL TECHNIQUE.• UNFORTUNATELY IN DEVELOPING COUNTRIES

ACCEPTANCE IS POOR AND MANY PATIENTS PREFER D&C.

IRREGULAR BLEEDING PV IMMEDIATELY AFTER MENARCHAE

• COMMON AMONG YOUNG GIRLS AND SCHOOL GIRLS• NO PATHOLOGICAL LESION IN OVER 99%

PATIENTS• IMMATURE H-P-O AXIS IS THE CAUSE.• COMBINED OCP IS THE DRUG OF CHOICE • IT TRAINS THE HPO AXIS TO SECRETE HORMONES

IN A REGULAR FASHION• FEW CYCLES WOULD DO THE JOB• ONLY IN A FEW , LONGER USE IS NECESSARY

IRREGULAR BLEEDING PV FOLLOWING DMPA OR JADEL

• CAUSE FOR THE BLEEDING IS DECENSITISED OESTROGEN RECEPTORS DUE TO LONG TERM USE OF PROGESTERONES.• DON’T EVER TREAT SUCH PATIENTS WITH

ANOTHER PROGESTOGEN.• DRUG OF CHOICE IS COMBINED OCP WHICH

CONTAINS BOTH OESTROGEN AND PROGESTOGENS.• FEW DAYS MEDICATION WOULD SETTLE THE

PROBLEM

USE OF ORAL PROGESTOGENS

ANOVULATORY BLEEDING : NORETHISTERONE 5 mg tds for 14 -21 days .

• TO DELAY PERIODS : start at least 3 days before your scheduled period and continue until the day you want free of periods ,but not exceeding 21 days.

IN IRREGULAR INTERMENSTRUAL BLEEDING

• Norethisterone 5 mg tds from day 5-26 [total 21 days]

• TO PREVENT RECURRENCE: NORETHISTERONE 5mg daily or bd from day 16- 25

ENDOMETRIOSIS

• NORETHISTERONE SHOULD COMMENCE BETWEEN DAY 1 – 5 OF THE CYCLE WITH 5 mg bd.• TREATMENT TO BE CONTINUED FOR 4 =6

MONTHS AT LEAST.• Dose can be increased to 5 mg tds or 10 mg

bd ,in the event of irregular spotting.• Once the spotting stops ,go back to 5 mg bd dose • With uninterrupted daily intake ,ovulation and

menstruation does not occur ,therefore the pain settles or significantly reduce .

CONCLUSION

• Idea behind this lecture is to educate medical persons to identify the causes for irregular bleeding patterns, and to properly investigate them and provide correct treatment when requires.• IN CA ENDOMETRIUM , EARLY DETECTION CAN

BRING CLOSE TO 100% SURVIVAL RATES….• WHILE LATE DETECTION WILL DRASTICALLY

REDUCE THE 5 YEAR SURVIVAL RATE …• SO PLEASE DON’T MISS THESE PATIENTS ..• YOU CAN PLAY A BIG ROLE

THANKYOU

• CRITISISM AND CORRECTIONS AND ANY NEW IDEAS ARE VERY WARMLY WELCOME …• PLEASE DISCUSS IF ANY….

TREAT YOUR IRREGULAR HEAVY BLEEDING PROBLEM AND BE HAPPY