ABNORMAL UTERINE BLEEDING ASSOCIATE PROFESSOR IOLANDA BLIDARU MD, PhD

ABNORMAL UTERINE BLEEDING

ASSOCIATE PROFESSOR

IOLANDA BLIDARU MD, PhD

DEFINITION

•Any deviation in normal frequency, duration or amount of menstruation in women of reproductive age.

•NORMAL MENSES•Frequency: 21-35 d•Duration: 3-7 d•Volume: 30-80 ml

CLINICAL TYPES•Polymenorrhea: frequent (<18 d) menstruation, at regular intervals•Menorrhagia (hypermenorrhea): Excessive (>80 ml) & / or prolonged menstruation, at regular intervals•Metrorrhagia, spotting: bleeding at irregular intervals.•Menometrorrhagia: both.•Hypomenorrhea: scanty menstruation.•Oligomenorrhea: infrequent menstruation (>45 d)

CAUSESGENITAL

1. Dysfunctional uterine bleeding2. Pregnancy complications3. Genital diseases Tumors: • Benign• Malignant Infection: PIDEndometriosis, adenomyosisIUDProlapse or retroversion

Extragenital causes

•Endocrine: hypo or hyperthyroidism•Haematological: Idiopathic thrombocytopenic purpura, Von-Willebrand disease•Chronic systemic disease: liver failure, renal failure, HTA•Iatrogenic: Sex hormones, anticoagulants.•Emotional: psychosomatic disorders •Obesity: increased peripheral estrogen conversion

DYSFUNCTIONAL UTERINE BLEEDING

Definition• DUB is abnormal bleeding that has no

organic cause (such as pregnancy, inflammation or neoplasia).

• can coexist with organic pathology

Incidence• 60 % of AUB (puberty and perimenopause)

Pathophysiology Endocrine abnormality Endometrium

Anovulatory90% Insufficient follicles Inadequate proliferative or atrophic Persistent follicles Proliferative or hyperplastic

Ovulatory10% Short proliferative phase Normal Long proliferative phase Normal Insufficient C. luteum Irregular or deficient secretory → short luteal phase Persistent C luteum leading to Irregular shedding long luteal phase

Risk of endometrial cancerChronic anovulation has 3 times increased risk. Chronic proliferation of the endometrium → adenomatous hyperplasia → atypical adenomatous hyperplasia → endometrial carcinoma. Transition - up to 10 years or more.

I. History: Age, Menstruation, Obstetric / gynecologic conditions

II. Clinical Examination1. General: pallor, endocrinopathy, coagulopathy,

pregnancy2. Abdominal assessment: liver, spleen, pelvic-

abdominal mass3. Pelvic assessment: origin of the bleeding,

cause

Diagnosis

Local examination + investigations

1. Pap smear2. US – TVS, TAS3. Endometrial biopsy: D & C, Hysteroscopy

D & CIndications:1.Mandatory after 4o yrs - Fractional curretage: 2 samples: endocervical + corporeal2. Persistent / recurrent bleeding between 20 & 40 yrs

Diagnosis of the type of the endometrium: hyperplastic, proliferative, secretory, irregular ripening, shedding, atrophic.

Curettage is essentially a diagnostic & not a therapeutic procedure.

III. Laboratory Investigations

Systemic:1.CBC2. β HCG3. Prolactin, TSH, T, LH, FSH, T44. Coagulation factors

TreatmentA. General - of iron deficiency anemia

B. MedicalC. Surgical

B. MedicalI. Hormonal 1.Progestagens, LNG-IUS (Mirena)2.Estrogen3.COC4.Danazol5.GnRH agonist II. Non –hormonal1.Prostaglandin synthase inhibitors (PSI)2.Antifibrinolytics Tranexamic acid

3.Ethamsylate

Progestagens Systemic: Norethisterone, medroxyprogesterone acetate, lynestrenol - p.o. 5 mg /d from d 5-15 to 25Intrauterine: Levonorgestrel intrauterine system Mirena- delivers 20ug LNG /d. for 5 years

Effect 1.Comparable to endometrial resection 2.Superior to PSI & antifibrinolytics3.May be an alternative to hysterectomy in some

patients

The combined contraceptive pill (COC) Reduce MBL by 50%Mechanism of action: endometrial suppression

Danazol: synthetic androgen with antiestrogenic & antiprogestagenic activity; Dose: 200 mg/dMechanism of action: inhibits pituitary gonadotropins & endometrial suppression

GnRH analog

• nasal sprays: nafarelin and busereline • daily subcutaneous injections: busereline• i.m./ s.c. depot: gosereline, leuprorelin,

triptorelin (Diphereline).

Prostaglandin synthase inhibitors (PSI)Mechanism of action: ↓ endometrial PG conc.

Mefenamic acid Effect (prolonged) on MBL & dysmenorrhea, headache, nausea, diarrhea & depression Tranexamic acid – antifibrinolytic

EtamsylateMechanism of action: maintain capillary integrity, anti-hyaluronidase activity & inhibitory effect on PGDose: 500 mg x 4 / d, starting 5 days before anticipated onset of the menstruation & continued for 10 days

C. Surgical

1. Endometrial ablation

2. Hysterectomy

Surgical treatmentEndometrial ablationMethods:I.Hysteroscopic: Laser, Electrosurgical

II.Non-hysteroscopic: Microwave.

Dysmenorrrhea

• symptom / disease

• painful menstruation

• classification:

1. primary (idiopathic)

2. secondary

Dysmenorrrhea

• primary (idiopathic)associated symptoms:headache, backache, nausea, vomitingTreatment:• antiprostaglandins• progestins• analgesics, antispasmodics• resection of presacral nerve (Cotte

op.)

• secondary

1. chronic PID2. endometriosis3. uterine myomas4. cervical stenosis5. pelvic adhesions