Abnormal uterine bleeding prof jamiyah hassan

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Abnormal Uterine

Bleeding

Jamiyah Hassan

UMMC

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Causes

FIGO Classification of Abnormal Uterine Bleeding (AUB)

Investigations

Management◦ Medical

◦ Surgical

◦ Interventional



Uterine fibroids

DUB

Adenomyosis/endometriosis

Uterine hyperplasia

Uterine malignancies

Genital infections

Coagulation disorders

Idiopathic

Polyps



Term “DUB” discarded

Menorrhagia replaced with heavy menstrual bleeding



New Classification of abnormal menstrual bleeding 2009





Notation. A. In all cases, the presence or absence of each criterion is noted using

“0” if absent, “1” if present, and “?” if not yet assessed. Each of the cases shown has 1

abnormality identified. From the top: at least one submucosal leiomyoma (LSM);

adenomyosis (A)—focal and/or diffuse; endometrial polyps (P); and an absence of any

abnormality, leaving endometrial causes (E) as a diagnosis of exclusion. B. Each of the cases

shown has more than 1 positive category. From the top: submucosal leiomyoma and

atypical endometrial hyperplasia (M), as diagnosed by endometrial sampling; endometrial

polyps and adenomyosis; endometrial polyps and subserosal leiomyoma (LO); and

adenomyosis, subserosal leiomyoma and coagulopathy (C), as determined by positive

screening test and subsequent biochemical confirmation of von Willebrand dis







General assessment

◦ Full blood count

Determine ovulatory status

◦ Detail structured history

◦ Progesterone assessment mid luteal

Screening for systemic hemostasis

◦ Bleeding disorders

◦ Von Willebrand factor

Evaluation endometrium

◦ Adequate endometrial sampling

Evaluation endometrial cavity

◦ Transvaginal ultrasound



Blood tests◦ FBC, thyroid, coagulation abnormalities

Pap test

Endometrial biopsy

Ultrasound scan



Exclusion of malignant causes is vital i.e. endometrial cancer or hyperplasia.

Benign organic causes of menorrhagia include endometrial polyps and sub mucous fibroids.



People with risk factors for endometrial cancer or hyperplasia. The following were found to be independently associated.

1. Obesity(>90kg);2. Infertility3. Nulliparity;4. Age >45 yrs; ( At 40 yrs 5/100,000, 45 yrs

13/100000, 55 yrs 32/100000)5. Family history of colon cancer



D&C is not performed as an initial work up. Should be performed in conjunction with hysteroscopy to evaluate endometrial cavity.

Pipelle endometrial biopsy appears at least as accurate as D&C, has high levels of patient acceptability, lower complication rates and do not require inpatient admission or GA.









No tissue found◦ Most likely endometrium is atrophic and

requires estrogen Simple proliferative

◦ This is normal and does not require treatment Endometrial hyperplasia

◦ Except atypical adenomatous requires progestins regimens

◦ Atypical adenomatous hyperplasia, hysterectomy advised

Endometrial carcinoma◦ Refer onco team





Overall health and the medical history

Cause and severity of condition

Tolerance of medications

Future childbearing plans

Effect of condition on lifestyle



Iron supplements Nonsteroidal anti-indflammatory

drugs(NSAIDs) Transnexamic acid Oral contraceptives Oral progestogen Hormonal IUS (Mirena) Danazol GNRH



MIRENA – now is first line medical therapy



Days of cycle

Ovulation

Ovulation

Menstruation



Bleeding patterns of LNG-containing intrauterine systems (Mirena®):

-3 -2 -1 1 2 3 4 5 6 7 8 9 10 11

In the first 3-6 months irregular bleeding and spotting

shorter, lighter and less painful periods

about 20% of women may have no bleeding after 1 year



Mirena effectively reduces menstrual blood loss (MBL)

0

50

100

150

200

Before

insertion

3 6 12

Months of Mirena use

Media

n M

BL (

mL)

* * *

* p<0.001

─86%─97%─91%

%

Reduction

(80mL MBL = menorrhagia)

Andersson JK, Rybo G. Levonorgestrel-releasing intrauterine device in the

treatment of menorrhagia. Br J Obstet Gynaecol. 1990; 97: 690-4



126

128

130

132

134

136

138

140

0 1 2 3 4 5 6 7 8 9 10 11 12

Months of Mirena use

Mean s

eru

m

haem

oglo

bin

(g/L

) **p<0.001###p<0.01



IUS

0

10

20

30

40

50

60

70

80

90

100

Mirena Control

Pro

po

rtio

n o

f w

om

en

(%

) *p<0.001; between groups

. Lähteenmäki P, Haukkamaa M, Puolakka J, et al. Open randomised study of use of

levonorgestrel releasing intrauterine system as an alternative to hysterectomy. BMJ

1998; 316: 1122-6



Compared to endometrial ablation◦ Slightly less mean reduction of blood loss but

equal patient satisfaction

◦ Similarly equal satisfaction to hysterectomy

◦ Higher continuation rate

◦ More cost effective

◦ Should be considered in women who failed medical therapy

◦ Added advantage of reliable contraception

◦ Risk of expulsion 10-20%

◦ Need trained staff for insertion



TCRE

Roller-ball

Laser

Thermal balloon

Heated free fluid

Cryoablation

Microwave endometrial ablation (MEA)

Radiofrequency electricity (NovaSure)



Better mean reduction of blood loss

Longer learning curve

Higher complication rate

Consider childbearing plan



Hysterectomy◦ Vaginal

◦ Abdominal

◦ Laparoscopic

Myomectomy



Hysterectomy◦ Provides definitive cure

◦ More expensive

◦ O.1 -1.1 cases of mortality per 1000 procedures

◦ Morbidity rate up to 40%





Percutaneous femoral artery puncture with selective catheterisation of each uterine artery in turn



Small vessels are accessed using a microcatheterOnce the catheter is in place, PVA particles are introduced until the blood flow stopped




Health & Medicine

Abnormal uterine bleeding prof jamiyah hassan