dysfunctional uterine bleeding

DR. KAWITA BAPAT

UJJAIN CME

April 12, 2023 ONE DAY HYSTERECTOMY

Case 1•A

32-year-Amita presented with a 6-month history of increasingly heavy periods.

•Her menstrual cycle was regular, every 28 days, with bleeding lasting for 6 days.

• The loss was very heavy for 3 days with the passage of large blood clots and it gradually settled over the final 3 days.

•She experienced some lower abdominal discomfort when the bleeding was heavy, although she did not need to take analgesics.


Case 1•N

o mid-cycle or post-coital bleeding

•A recent negative smear.

•Two children, both delivered normally,

•Used a condom for contraception.

• Abdominal examination was unremarkable

• vaginal assessment revealed a healthy cervix, a fully mobile anteverted uterus and no other pelvic mass.


Q I: Which of the following would be appropriate management options?

•A: Hysterectomy.

•B: Administration of mefenamic acid.

•C: Administration of danazol.

•D: Diagnostic curettage.

•E: Administration of tranexamic acid.


Case 1•T

he haemoglobin concentration was 11.0 g

•After discussing the management options, the patient was advised to take tranexamic acid 1 g four times per day during her menstrual periods

• She was to be reviewed in3 months' time.

•At the next visit, her symptoms were unchanged. She was keen not to take any more medication.


Q2: How would you counsel her regarding further management?

•She considered that a hysterectomy was too radical at her age even though she did not wish to have any more children.

•She decided that she would undergo an endometrial resection.

• A date for surgery was arranged for 2 months later

•she was advised to take Danazol 200 mg three times per day for 4 weeks before surgery.

• An ultrasound scan showed a normal uterine cavity.


Q3: Which of the following are side effects of Danazol?

•A: Visual disturbance.

•B: Tinnitus.

•C: Irreversible deepening of the voice.

• D: Hirsutism.

•E: Leucopenia.


Case 1•A

fter taking the danazol for 1 week

• The woman was unable to tolerate the side-effects.

•She reported to the outpatient clinic,

•where she was given a subcutaneous injection of GNRH AGONIST (3.6 mg).


Q4: What are the immediate complications of endometrial resection

and what precautions would you take to avoid them?

Inform the patient that further pregnancy •risks of abnormal implantation and fetal malformation

•amount of systemic absorption of the irrigating fluid overload leads to haemolysis and hyponatraemia

• The immediate complications•excessive and uncontrollable bleeding •which may necessitate hysterectomy on rare occasions

•Uterine perforation

•catastrophic consequences with damage to bladder, bowel and major vessels

•Longer term

•Not effective

•Gradual regeneration •Intra uterine adhesions •Ashermans syndrome may cause pain April 12, 2023 ONE DAY HYSTERECTOMY

Case 1 •S

he underwent a laparoscopic sterilization and transcervical endometrial resection 3 weeks later

•The uterine cornua and the fundus was treated with the diathermy rollerball,

• with the remaining endometrium was removed with the diathermy loop to the level of the internal cervical os.


Case 1•T

he patient went home the following day and was given an outpatient appointment for 3 months later.

•After the operation she bled for 4 weeks, although the flow was not heavy, and it became more of a brown discharge after the first 2 weeks.

• She had no further bleeding before the outpatient attendance.

•Six months later, she was referred back with severe cyclical pain for 2 days every 4 weeks.

•It was suprapubic and she described it as a cramp. She had not had any vaginal bleeding


Q5: What is the problem and how would you deal with it?

•Hysteroscopic examination of the uterine cavity revealed synechiae between the anterior and posterior walls.

•It was possible to divide these with the hysteroscope and at the end of the procedure a multiload copper 250 coil was left in the uterus.

•The coil was removed 3 months later, but unfortunately the pain returned within 3 months although she continued to be amenorrhoeic.


Q6: Which of the following treatment options would you recommend?

•A: Repeat endometrial resection.

•B: Administration of the oral contraceptive pill.

•C: Administration of mefenamic acid.

•D: Hysterectomy.

•The patient elected to undergo hysterectomy. At the time of the endometrial resection, there was no significant uterine prolapse and the hysterectomy was carried out via the abdominal route.

•The ovaries were conserved.


Q7 Which of the following are complications of hysterectomy?

•A: Lymphocyst formation.

•B: Premature menopause.

•C: Internal iliac artery aneurysm.

• D: Uterovaginal fistula.

•E: Irritable bowel syndrome.


Case 1•

The operation was uncomplicated

•The patient made a good recovery

• When she was seen 2 months later, the pain had completely resolved.

•She was happy


Q2: Explain the differences between menorrhagia, heavy periods and dysfunctional uterine bleeding (DUB).

•Menorrhagia is an 'excessive' regular menstrual blood loss.

`Excessive' is objectively defined as menstrual blood loss greater than 80 ml.

However, estimation of blood loss is not feasible in current routine clinical practice.

•Heavy periods is a subjective symptom;

approximately 30% of women who seek medical treatment do not actually have lossgreater than average

You are obliged to ascertain from the history,

the degree of blood loss and its effect on the quality of life

Indirect objective evidence should be sought to support the symptomatology

This includes anemia and iron deficiency anemia

•Dysfunctional uterine bleeding (DUB) is a collective term to describe a condition where the clinician has failed to find a cause for heavy periods. DUB should really be described as ovulatory menorrhagia


Medical optionCombined oral contraceptive pills

•contraception by inhibiting ovulation

•causes a 50% reduction in menstrual blood loss by

regular shedding of a thinner endometrium Cheap

• Effective

•Additional benefit of contraception

•Disadvantage

Overweight

VTE

Regularity


Medical optionNon Steroidal Anti-Inflammatory Drugs

•Endometrial prostaglandins are elevated with excessive menstruation

•non- steroidal anti-inflammatory drugs (NSAIDs) reduce prostaglandin levels through the inhibition of the cyclo-oxygenase enzyme

•with reduction in menstrual blood loss of 25- 35%


Medical option Anti-fibrinolytic agents

•Tranexamic acid, a synthetic derivative of the amino acid lysine

• exerts an antifibrinolytic effect through reversible blockade on plasminogen

•producing a 50% reduction in menstrual loss

•not associated with an increase in side effects


Medical option Progestogens only

•Progestogens administered from the fifteenth day or from 19th - 26th day of the menstrual cycle were significantly

• less effective in reducing menstrual blood loss when compared to other medical therapies

•Although most commonly prescribed

• cheap

• side effects

breast tenderness

Mood swings

break through bleeding


Medical option Anti estrogens Danazol

•synthetic steroid that suppresses estrogen and progesterone

•receptors in the endometrium, leading to endometrial atrophy (thinning of the lining of the uterus)

•reduce menstrual loss.

•It is an effective treatment for heavy menstrual bleeding

•However, its side-effect profile,its lack of acceptability to women

and the need for continuing treatment limits its use.


Medical optionGnRH agonists

•Gonadatrophin-releasing hormone (GnRH) agonists induce a reversible hypoestrogenic state,

• Reducing total uterine volume.

•They are highly effective,

•but their side-effects make them suitable only for short-term use

•GnRH agonists may obviate emergency surgery in patients with high surgical risk


The levonorgestrel intrauterine system (LNG IUS)

•Intrauterine device

•releasing a steady amount of levonorgestrel (20μg /24 hours) from a steroid reservoir around the vertical stem of the device.

•It reduces menstrual blood loss by 80%,

•more effective than cyclical norethisterone,

•patients being more satisfied

•willing to continue with treatment.

•side effects such as

•inter-menstrual bleeding and

•breast tenderness .

•produces smaller mean reduction in menstrual blood loss,

•LNG-IUS appears equally beneficial in improving quality of life and may control bleeding as effectively as conservative


Surgical options•L

aser /thermal/cold/diathermic ablation

•Trans-cervical resection of endometrium

•

Balloon

• Microwave

•Hysterectomy


Q10: What are the advantages and disadvantages of endometrial resection or ablation over hysterectomy for women with heavy periods?

•Endometrial resection or ablation

•shorter operating time

•lower postoperative complication rate than hysterectomy.

• Women require a shorter period in hospital

•Resume normal activities earlier

•Cost benefits but these must be offset against the need to Perform a hysterectomy in 23% of cases within 2 years.

•The long-term effects remain unknown.

•Not always successful in reducing menstrual loss,

•Dysmenorrhoea may increase.

•Initial patient satisfaction appears to disappear 4 months after the operation.


Case 2

•A 28-year-old single nulligravida

•Lawyer

•Divorced

•Referred to the gynaecology clinic

•with a 3-year history of increasingly heavy periods

•She had sought the advice of her general practitioner, who had prescribed norethisterone 5 mg three times daily with no good effect.


QI: Which of the following statements about norethisterone are correct?

A: it is a 19-carbon atom containing synthetic progestogen derived from testosterone.

•B: It is a 2I-carbon atom containing naturally occurring progesterone.

•C: 40% of women receiving medical treatment for menorrhagia are prescribed norethisterone.

•D: Norethisterone has been found to be no more effective than placebo in

the short-term treatment of menorrhagia.

E. Norethisterone should no longer be prescribed for the medical treatment of menorrhagiaApril 12, 2023 ONE DAY HYSTERECTOMY

Case 2 •Her menarche had been at the age of 14 years

•periods had always been regular, lasting 3-4 days every 26-28 days.

•recent normal cervical smear

•No complain of any inter-menstrual bleeding.

•o obvious history of previous pelvic infection.

•Over the preceding 2 years she had noticed increasing dysmenorrhoea lasting for 2 days.


Case 2

•The heaviness of her menstrual flow meant that she regularly missed 1 or 2 days of work most months

• she soiled her bedclothes despite wearing double protection.

•To her knowledge she had not been anaemic

• had not suffered any other medical or surgical illnesses.

•She had never practiced any form of contraception.

• She had no gastrointestinal symptoms.


Case 2 On examination

•The patient looked slightly pale but otherwise well.

•There was no goitre

•Her breasts were normal

•Abdominal palpation was normal with no masses found.

• Pelvic examination revealed a normal-looking vagina and cervix.

•The uterus was anteverted, mobile, tender and uniformly enlarged, approximately equal to an 8-week gravid uterus.

• There were no pelvic masses or uterosacral nodularity and the adnexae were not tender.


Q2: Which of the following conditions can cause uterine tenderness?

•A: Endometrial hyperplasia with severe architectural and cytological atypia.

• B: Endometritis.

•C: Salpingitis isthmica nodosa.

•D: Adenomyosis uteri.

•E: Fibromas.

•F: Endometriosis.


Case 2•A

full blood count revealed

• a haemoglobin concentration of 9.9 g

•(MCV) normal

•(MCH) normal.

• Thyroid function was normal

• •a

day 19 endometrial biopsy revealed secretory endometrium.


Q3: How would you describe the scan and what is the differential

diagnosis?

•A pelvic ultrasound scan

•Large ill-defined echogenic region

•adjacent to endometrial cavity

•with uterine enlargement


Q9: Which of the following statements concerning adenomyosis are

true

•A: Adenomyosis is the presence of endometrial glandular structures within

the myometrium.

•B: Concomitant endometriosis is found in 10-20% of cases of adenomyosis

at hysterectomy.

•C: Adenomyosis has a strong positive correlation with parity and is very

rare in nulliparous women.

•D: All cases of adenomyosis are symptomatic.

•E: Imaging techniques have a sensitivity and specificity of around 80% in

the diagnosis of adenomyosis.


Q6: What medical treatment options are available?

• Antifibrinolytic drugs,

• Non-steroidal anti-inflammatory agents

•An intrauterine progestogen delivery system

•

should be considered if uterine causes have been excluded


Q7: What are the surgical options available for this woman?

•HYSTERECTOMY

•Counseling fertility

myomectomy

•Endometrial resectionis preferred option in flits-Situation as the patient's dysmenorrhoea will not be treated

•Following detailed discussions she decided to have an abdominal hysterectomy with ovarian conservation.

•This was performed without complication and there was no evidence of peritoneal or ovarian endometriosis or previous pelvic inflammatory disease.



Health & Medicine

dysfunctional uterine bleeding