Upload
drfariha-farooq
View
691
Download
0
Embed Size (px)
Citation preview
Management of Abnormal Uterine Bleedingin Perimenopausal Women
Dr.Fariha FarooqAssoc.Prof.Obs & Gynae
Akhtar Saeed Medical & Dental College
Perimenopause
• Perimenopause (around menopause) is a transition phase, begins several years before menopause.
• Estrogen levels gradually decline.
• Irregular menstrual periods, hot flashes, vaginal dryness, sleep disturbances, and mood swings are common, normal signs of perimenopause.
Perimenopause
Menstrual Cycle
Anovulatory Bleeding
• Corpus luteum is not produced– Ovary fails to secrete progesterone– Continuous, unopposed E stimulation of
endometrium:• Endometrial proliferation without P-induced
differentiation / stabilization– Endometrium becomes excessively
vascular without stromal support fragility and irregular endometrial bleeding
New FIGO Nomenclature & classification of AUB
Suggested “normal limits” for uterine bleeding in the mid-reproductive years
Abnormal Uterine Bleeding New Terminology by FIGO
Term HMB (Heavy mentrual bleeding) has replaced the term Menorrhagia:
Bleeding that occurs at regular intervals, loss of ≥ 80 mL blood per
DUB has been replaced by BEO(Bleeding of Endometrial origin)
Terminology abandoned by FIGO Munro et al. Int J Gynecol Obstet 2011; 113: 3-13
FIGO 2015
FIGO- PALM-COEIN classification
Causes of heavy menstrual bleeding
‘PALM’(structural abnormalities)-Polyp–Adenomyosis
–Leiomyoma
–Malignancy and hyperplasia
‘COEIN’(non-structural abnormalities)–Coagulopathy
–Ovulatory dysfunction
–Endometrial
–Iatrogenic
–Not yet classified
ENDOMETRIAL POLYP
AdenomyosisTVS
Fibroid Uterus
Submucous Fibroid
Invasive cervical cancer
Carcinoma endometrium
Anovulatory Bleeding:Later Reproductive Age (40-Menopause)
• Incidence of anovulatory bleeding increases due to declining ovarian function.
• Incidence of endometrial CA in women 40-49 years: 36.2/100,000
• All women >40 yrs who present with suspected anovulatory bleeding merit endometrial bipsy.
Each case has 1 identified abnormality
>1 positive category
Diagnosis of Abnormal uterine bleeding
• Medical history• Physical examination• Laboratory tests• Imaging tests
• Age of onset of menses• Frequency/duration of menses• Quantity of flow,number of pads,passage of
clots and flooding• Intermenstrual bleeding• Postcoital bleeding• Dyspyerunia• Use of contraceptives/medication• Family history of menarche,
menopause,malignancy
AUB-History
AUB-History
• Pelvic Pain• Postcoital pain• Vaginal Discharge• Excessive bruising/bleeding from other
sites• History of post partum haemorrhage• Family history of bleeding problems• Urinary symptoms• Weight change ,heat or cold intolerance • Stress
Physical examination
• General examination• Abdominal examination• Vaginal / per speculum and pelvic B/M
examinations
Examination
• GPE Assess for obesity, hirsutism, stigmata of
thyroid disease (hypothyroidism associated with anovulation), signs of hyperprolactinemia (visual field testing, galactorrhea)
• ABDOMINAL EXAMINATION Abdominal masses
• CBC,Coagulation screen– Assays for thyroid hormone
• HVS,endocervical swab,Pap smear• Pelvic ultrasound
– Abdominal/Transvaginal Ultrasonography (TVS)– Sonohysterography,saline infusion
• Endometrial biopsy– Endometrial sampling by Pipelle– Hysteroscopy– Dilation and Curettage (D&C)
Biopsy should be performed as first line test(ACOG)• Aged >45 years • Irregular or intermenstrual bleeding
CT scan and MRI(special circumstances))
Laboratory and Imaging Tests
Transvaginal ultrasound
Saline infused sonohysterography
Sonohysterogram
Hysteroscopy
Evaluating endometrial cavity
Hysteroscopy “Gold standard” for endometrial assessment• Office procedure• Thorough, direct inspection of endometrial cavity• Directed biopsy or treatment possible (e.g., polyp
excision)
Drugs for HMB• NSAID’s• Tranexamic acid• COCP’s
– YAZ– Diane-35– Meliane
• Progyluton/Climen• Oral Progestogens• Mirena• Danazol/GNRH analoges
Progyluton
Composition
•Composed of estradiol-17 valerate and cyproterone acetate
* Presented in calendar packs of 21 tablets each
* First 11 tablets contain estrogen only; the other 10 contain both hormones
Climen
Contraindications of HRT
• PREVIOUS THROMBOEMBOLIC DISEASE• IMPAIRED LFT/ LIVER DISEASE• CARCINOMA BREAST• CARCINOMA ENDOMETRIUM• FIBROIDS &ENDOMETRIOSIS(relative)
HYPERTENTION,DIABETES,CARDIO-VASCULAR DISEASE ARE NOT C/I
Oral Progestogens
• Norethisterone acetate(Primolute N)
• Dose is 5-10mg three times a day from day 6 to 26 of the cycle
The levonogestrel intrauterine system (LNG-IUS),
Mirena
What is Mirena® used for?Indications:
–Contraception
–Treatment of heavy menstrual bleeding (idiopathic menorrhagia)
–Protection from endometrial hyperplasia during oestrogen replacement therapy
Endometrial effects with Mirena®
Before Mirena®
Endometrial changes
OvulationMenstruation
Reducedmenstruation
After Mirena®
Ovulation
Surgical treatment
Endometrial ablation•First-generation:
– Rollerball– Transcervical resection of the endometrium
•Second-generation:– Impedance-controlled bipolar radiofrequency– Balloon thermal– Microwave– Free-fluid thermal
Surgical treatment
• Uterine artery embolization(UAE)• Hysteroscopic myomectomy• Myomectomy• Hysterectomy
– Abdominal– Vaginal– Laparoscopic
Uterine artery embolization for Fibroids
• Defintion:Post menopausual bleeding is defined as: vaginal bleeding after the menopause in women who are not taking HRT.
• Aetiology:• Atrophic vaginitis • Endometerial polyp• Endometerial hyperplasia • Endometerial carcinoma• Cervical carcinoma
Post menopausal bleeding
MANAGEMENT OF PMBDiagnosis Management Atrophic vaginitis Topical oestrogen cream, oestrogen pessaries or
estringTM oestrogen ring pessary.
Cervical polyp Remove via speculum examination using polyp forceps
Endometrial polyp Remove under direct visualization at hysteroscopy
Simple hyperplasia
Progestogens: oral preparation or LNG-IUS (Mirena)
Complex hyperplasia
Progestogens: oral preparation or LNG-IUS (Mirena)
Atypical hyperplasia
Total abdominal hysterectomy as significant risk of progression to malignancy.
Endometrial cancer
Total abdominal hysterectomy + BSO + Washings ± adjuvant therapy.
QUESTIONS?