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DYSFUNCTIONAL DYSFUNCTIONAL UTERINE UTERINE BLEEDINGBLEEDING
Gem Ashby MDGem Ashby MDOB/GYNOB/GYN
Cancer Support Services is committed through a spirit of volunteerism to the care of persons with cancer and to bring comfort and support to the affected relatives and dependents.
DYSFUNCTIONAL UTERINE DYSFUNCTIONAL UTERINE BLEEDING BLEEDING
DUBDUB• Bleeding is heavier (passing large clots, soaking Bleeding is heavier (passing large clots, soaking
through a sanitary pad or tampon every hour for 2 through a sanitary pad or tampon every hour for 2 - 3 hours in a row) - 3 hours in a row)
• Bleeding or spotting that occurs between periods Bleeding or spotting that occurs between periods
• Time between menstrual periods changes with Time between menstrual periods changes with
each cycle each cycle
• Bleeding lasts for more days than normalBleeding lasts for more days than normal
CAUSES OF DUB CAUSES OF DUB
• GYN cancersGYN cancers• AnovulationAnovulation• FibroidsFibroids• PolypsPolyps
• Systemic illnessSystemic illness
WORK UP FOR DUBWORK UP FOR DUB
• History and examHistory and exam• Blood work/PAP smearBlood work/PAP smear• Pelvic USPelvic US• Endometrial biopsyEndometrial biopsy• D&C, hysteroscopyD&C, hysteroscopy
A: Cervical cancerA: Cervical cancerB: Endometrial(Uterine) cancerB: Endometrial(Uterine) cancerC: Ovarian cancerC: Ovarian cancer
Which two cause DUB?Which two cause DUB?
Which one has been linked to a viral Which one has been linked to a viral infection?infection?
Which one is often diagnosed at a very Which one is often diagnosed at a very late stage?late stage?
CERVICAL CANCERCERVICAL CANCER
• Cervical cancer is the second most frequent Cervical cancer is the second most frequent cancer in women in the world cancer in women in the world
• Third greatest cause of death from cancer in Third greatest cause of death from cancer in womenwomen
• 90% of cervical cancer is cause by HPV90% of cervical cancer is cause by HPV
• Of the estimated more than 270 000 deaths from Of the estimated more than 270 000 deaths from cervical cancer every year, more than 85% occur cervical cancer every year, more than 85% occur in developing countriesin developing countries
Stats from WHOStats from WHO
CERVICAL CANCER AND DUBCERVICAL CANCER AND DUB• Early cervical cancer is frequently asymptomaticEarly cervical cancer is frequently asymptomatic
• The most common symptoms at presentation are:The most common symptoms at presentation are:• Abnormal bleeding Abnormal bleeding • Postcoital bleeding Postcoital bleeding • Vaginal discharge that may be watery, mucoid, or Vaginal discharge that may be watery, mucoid, or
purulent and malodorous purulent and malodorous
TREATMENT OF CERVICALTREATMENT OF CERVICAL
• Surgery to remove the cancer
• Radiation therapy, which uses high-dose X-rays or implants in the vaginal cavity to kill cancer cells. It is used for certain stages of cervical cancer. It is often used in combination with surgery
• Chemotherapy, which uses medicines to kill cancer cells. Chemotherapy may be used to treat advanced cervical cancer
ENDOMETRIAL CANCERENDOMETRIAL CANCER
• Endometrial cancer is cancer of the lining of the uterusEndometrial cancer is cancer of the lining of the uterus
ENDOMETRIAL CANCERENDOMETRIAL CANCER• Endometrial cancer is rare in women under the age of 45
• The average chance of a woman being diagnosed is about one in 37
• This cancer is slightly more common in white women, but black women are more likely to die from it
RISK FACTORS FOR RISK FACTORS FOR ENDOMETRIAL CANCER ENDOMETRIAL CANCER
• Being obese. Fat cells make extra estrogen, but the body Being obese. Fat cells make extra estrogen, but the body doesn't make extra progesterone to balance it outdoesn't make extra progesterone to balance it out
• Taking estrogen without taking a progestinTaking estrogen without taking a progestin
• Polycystic ovary syndrome. This can cause you to produce Polycystic ovary syndrome. This can cause you to produce too much estrogen and not enough progesteronetoo much estrogen and not enough progesterone
• Having type 2 diabetesHaving type 2 diabetes
• Never having been pregnantNever having been pregnant
ENDOMETRIAL CANCER AND ENDOMETRIAL CANCER AND DUBDUB
The most common symptoms include:The most common symptoms include:
•DUBDUB•BLEEDING AFTER MENOPAUSEBLEEDING AFTER MENOPAUSE•Pain during sexPain during sex•Pelvic painPelvic pain
TREATMENTSTREATMENTS• Surgery to remove the uterus (and cervix), ovaries, and Surgery to remove the uterus (and cervix), ovaries, and
fallopian tubes (hysterectomy with bilateral salpingo-fallopian tubes (hysterectomy with bilateral salpingo-oophorectomy)oophorectomy)
• Surgery to remove lymph nodesSurgery to remove lymph nodes
• Radiation therapy to kill cancer cellsRadiation therapy to kill cancer cells
• Progestin hormone therapy to block cancer growthProgestin hormone therapy to block cancer growth
• Chemotherapy to kill cancer cellsChemotherapy to kill cancer cells
ANOVULATIONANOVULATION
• Anovulation is the absents of ovulation
ANOVULATION ANOVULATION • Polycystic ovarian syndrome• Peri-menopause• Thyroid dysfunction (either hyperthyroidism or
hypothyroidism)• Extremely high levels of stress
ANOVULATIONANOVULATIONTREATMENTTREATMENT
Hormonal manipulationHormonal manipulationOCP’sOCP’sNuvaringNuvaringDepo ProveraDepo ProveraNexplanonNexplanonMirena IUDMirena IUD
FIBROIDSFIBROIDS
• The most common pelvic tumor in women The most common pelvic tumor in women
• They are benign tumors arising from the smooth They are benign tumors arising from the smooth muscle cells of the myometriummuscle cells of the myometrium
• They can cause DUB, pain, voiding dysfunction They can cause DUB, pain, voiding dysfunction and may also have reproductive effects (e.g, and may also have reproductive effects (e.g, infertility, adverse pregnancy outcomes)infertility, adverse pregnancy outcomes)
FIBROID TREATMENTSFIBROID TREATMENTS
• There's no single best approach to uterine fibroid treatment; many treatment options exist
FIBROID TREATMENTSFIBROID TREATMENTS
• Hormonal Manipulation (OCP, Nuvaring, Depo Provera, Nexplanon, Mirena)
• Gonadotropin-releasing hormone (Gn-RH) agonists• Medications called Gn-RH agonists (Lupron, Synarel,
others) treat fibroids by putting you into a temporary postmenopausal state. With the decreased estrogen many fibroids tend to shrink
FIBROID TREATMENTSFIBROID TREATMENTS
• Uterine artery embolization• Small particles (embolic agents) are injected into the
arteries supplying the uterus, cutting off blood flow to fibroids, causing them to shrink and die
• SHOULD NOT BE DONE if the patient wants more children !!!
FIBROID TREATMENTSFIBROID TREATMENTS• Laparoscopic, robotic or open myomectomy
• In a myomectomy, your surgeon removes the fibroids, leaving the uterus in place
FIBROID TREATMENTSFIBROID TREATMENTS
• Endometrial ablation and resection of submucosal fibroids• A specialized instrument inserted into your uterus;
uses heat, microwave energy, hot water or electric current to destroy the lining of your uterus, either ending menstruation or reducing your menstrual flow
• Ablations DO NOT remove the fibroids
• SHOULD NOT be done if the patient wants more children
ABLATIONABLATION
FIBROID TREATMENTSFIBROID TREATMENTSHYSTERECTOMYHYSTERECTOMY
• Abdominal• Vaginal
• Laparoscopic • Robotic
FIBROID TREATMENTSFIBROID TREATMENTSHYSTERECTOMYHYSTERECTOMY
• A hysterectomy is an operation to remove a woman's uterus• Definitions:
• In a supracervial or subtotal hysterectomy, a surgeon removes only the upper part of the uterus, keeping the cervix in place
• A total hysterectomy removes the whole uterus and cervix
• The ovaries may also be removed -- a procedure called oophorectomy -- or may be left in place
POLYPSPOLYPS
• Overgrowth of cells in the lining of the uterus (endometrium)
• Are usually noncancerous (benign), although some can be cancerous or can eventually turn into cancer (precancerous polyps)
POLYPSPOLYPS
TREATMENT FOR POLYPSTREATMENT FOR POLYPS
• Hormonal Manipulation (OCP, Nuvaring, Depo Provera, Nexplanon, Mirena)
• Surgical removal: D&C hysteroscopy• A camera is used to look inside the uterus and then the
polyp is scraped out • An ablation can be done at the same time
AUBAUB
CausesCauses• GYN cancersGYN cancers• AnovulationAnovulation• FibroidsFibroids• PolypsPolyps
• Systemic illnessSystemic illness
TreatmentTreatmentSurgerySurgeryHormonal ContraceptionHormonal ContraceptionLupron, Surgery/UAELupron, Surgery/UAESurgerySurgery
Treatment based on Treatment based on affected organ systemaffected organ system
THANK YOUTHANK YOU
• Wright, Jason and Solange Wyatt. Wright, Jason and Solange Wyatt. The Washington Manual The Washington Manual Obstetrics and Gynecology Survival GuideObstetrics and Gynecology Survival Guide. Lippincott . Lippincott Williams and Wilkins, 2003. ISBN 0-7817-4363-X Williams and Wilkins, 2003. ISBN 0-7817-4363-X
• Bravender T, Emans SJ (June 1999). "Menstrual disorders. Bravender T, Emans SJ (June 1999). "Menstrual disorders. Dysfunctional uterine bleeding". Dysfunctional uterine bleeding". Pediatr. Clin. North Am.Pediatr. Clin. North Am. 4646 (3): 545–53, viii. PMID 10384806. (3): 545–53, viii. PMID 10384806.
• ^̂ "Dysfunctional Uterine Bleeding". "Dysfunctional Uterine Bleeding". http://www.sh.lsuhsc.edu/fammed/OutpatientManual/DUB.hthttp://www.sh.lsuhsc.edu/fammed/OutpatientManual/DUB.htm. Retrieved 2010-01-23. m. Retrieved 2010-01-23.