Abnormal Beeding2014

8/17/2019 Abnormal Beeding2014

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Abnormal Uterine Bleeding

Karen Carlson, M.D.

Assistant ProfessorDepartment of Obstetrics and Gynecology

University of Nebrasa Medical Center


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Ob!ectives• P"ysiology

•Definitions• #tiologies

• #val$ation

• Management – Medical – %$rgical


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Phases of Reproductive Cycle

• Follicular phase

• Ovulation

• Luteal phase

• Menses


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– Onset of menses to LH surge

– 1 days !varies"

– #ominant follicle

• greatest num$er of granulosa cells and F%H

receptors• Ovulation

• Luteal phase


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• Ovulation

– &'(&) hours after LH surge

• Luteal phase

– LH surge to menses

– 1 days !constant"


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Menses

• *nvolution of corpus luteum

• #ecrease progesterone and estrogen• +'()' cc of dar, $lood and endometrial

tissue


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Ho- does Ovulation happen.

• Positive feed$ac, to pituitary from estradiol

• LH surge

• Ovulation triggered

• /ranulosa and theca cells no- produce

progesterone

• Oocyte e0pelled from follicle

• Follicle converts to corpus luteum


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Luteal Phase

• Predominance of progesterone

• $dominal $loating

• Fluid retention

• Mood and appetite changes


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• 2ndometrium – Proliferative phase

– %ecretory phase


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$normal uterine $leeding

• Change in fre3uency4 duration and amount

of menstrual $leeding


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#efinitions

• 5ormal menses

•2very +6 days 78( 9 days

• Mean duration is days:

• More than 9 days is a$normal:


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verage $lood loss -ith

menstruation is &;(;'cc:

)'cc:

5ormal Menses


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#efinitions

Menorrhagia?

Prolonged $leeding

@ 9 days or @ 6' cc

occurring at regular intervals:


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Fre3uency of AB

• Menorrhagia occurs in


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#efinitions

Metrorrhagia?

Aterine $leeding occurring at

irregular $ut fre3uent

intervals:


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#efinitions

Menometrorrhagia?

Prolonged uterine $leeding

occurring at irregular

intervals:


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#efinitions

Oligomenorrhea?

•Reduction in fre3uency of menses

•Bet-een &; days and ) months:


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#efinitions

menorrhea?

•Primary amenorrhea

•%econdary amenorrhea

5o menses for &() months


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Primary amenorrhea

• 5o menses $y age 1&

• 5o secondary se0ual development

• 5o menses $y age 1;

• %econdary se0ual development present


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#efinitions

• Menarche

– average age 1+:& years

• Menopause

– average age ;1: years

• Ovulatory cycles for over &' years


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Menstrual $leeding stops *F?

• Prostaglandins cause contractions and

e0pulsion

• 2ndometrial healing and cessation of

$leeding -ith increasing estrogen


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%ystemic 2tiologies

• Coagulation defects – *P

– DonEille$rands


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Routine screening for coagulationdefects should $e reserved for the

young patient -ho has heavyflo- -ith the onset of

menstruation:

Comprehensive /ynecology4 th edition


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von Eille$rands #isease isthe most common inherited

$leeding disorder -ith afre3uency of 186''(1''':

Harrisons Principles of *nternal Medicine4

1th edition


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Hypothyroidism can $e

associated -ith menorrhagia ormetrorrhagia:

he incidence has $een reported

to $e ':&(+:;=:

Eilans,y4 et al :4 1


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Most Common Causes of

Reproductive ract AB

• Pre(menarchal

– Foreign $ody

• Reproductive age

– /estational event• Post(menopausal

– trophy


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Reproductive ract Causes

• /estational events

• Malignancies

• Benign – trophy

– Leiomyoma

– Polyps – Cervical lesions

– Foreign $ody

– *nfections


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• /estational events

– $ortions – 2ctopic pregnancies

– ropho$lastic disease

– *AP


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• Malignancies

– 2ndometrial

– Ovarian

– Cervical


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1'= of -omen -ith

postmenopausal $leeding -ill $e

diagnosed -ith endometrialcancer

Garlsson4 et al :4 1


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F*/O %ystem

• PLM(CO2*5 – Polyp

– denomyosis

– Leiomyoma – Malignancy and hyperplasia

– Coagulopathy

– Ovulatory disorders – 2ndometrium

– *atrogenic

– 5ot classified


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Reproductive ract Causes of

Benign Origin

• Aterine

• Daginal or la$ial lesions

• Cervical lesions

• Arethral lesions

• /*


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Benign Origin

• Aterine

– Pregnancy – Leiomyomas

– Polyps

– Hyperplasia – Carcinoma


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Proposed 2tiologies of

Menorrhagia -ith Leiomyoma

• *ncreased vessel num$er

• *ncreased endometrial surface area• *mpeded uterine contraction -ith menstruation

• Clotting less efficient locally

Eegien,a4 et al :4 +''&


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Leiomyoma in any location isassociated -ith increased ris,s

of gushing or high pad8tamponuse:

Eegien,a4 et al :4 +''&


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Benign Origin

• Aterine

• Daginal or la$ial lesions – Carcinoma

– %arcoma

– denosis – Lacerations

– Foreign $ody


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Benign Origin

• Aterine

• Daginal or la$ial lesions

• Cervical lesions – Polyps

– Condyloma – Cervicitis

– 5eoplasia


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Causes of Benign Origin

• Aterine

• Daginal or la$ial lesions• Cervical lesions

• Arethral

– Caruncle – #iverticulum

• /*

– Hemorrhoids


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*atrogenic Causes of AB

• *ntra(uterine device

• Oral and inecta$le steroids

• Psychotropic drugs – MO*s


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Eith anovulation a corpus

luteum is 5O produced and

the ovary there$y fails tosecrete progesterone:

• Physiology of $normal Aterine Bleeding


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Ho-ever4 estrogen production

continues4 resulting in

endometrial proliferation and

su$se3uent AB:


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P/2+ vasodilation

P/F+I vasoconstriction

Progesterone is necessary to

increase arachidonic acid4 the precursor to P/F+I:

Eith decreased progesteronethere is a decreased

P/F+I8P/2+ ratio:


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2valuation and Eor,(up?

2arly ReproductiveJears8dolescent

• horough history

• %creen for eating disorder

• La$s? – CBC4 P4 P4F%H4 %H4 hC/


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2valuation and Eor,(up? Eomen of Reproductive ge

• hC/4 LH8F%H4 CBC4 %H

• Cervical cultures

• A8%• Hysteroscopy

• 2MB


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2valuation and Eor,(up? Post(menopausal Eomen

• ransvaginal A8%

• 2MB


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)'= atrophy

• Garlsson4 et al:4 1


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n endometrial cancer is diagnosed

in appro0imately 1'= of -omen-ith PMB:K

PMB incurs a )(fold increased ris,for developing endometrial C:

KGarlsson4 et al :4 1


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5ot a single case of endometrial

C -as missed -hen a >mmcut(off for the endometrial stripe

-as used in their 1' yr follo-(up

study:

%pecificity )'=4 PPD +;=4 5PD 1''=

/ull4 et al :4 +''&


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2MB

Complications rare: Rate of perforation 1(+814''':

*nfection and $leeding rarer:

Comprehensive /ynecology4 th ed:


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2MB• %ensitivity


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*ncidence of 2ndometrial Cancer

in Premenopausal Eomen

+:&81''4''' in &'(& yr old):181''4''' in &;(&< yr old

&)81''4''' in '(< yr old

CO/ Practice Bulletin 14 +'''


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herefore4 $ased upon age alone4

an 2MB to e0clude malignancy

is indicated in any -oman @ &;years of age -ith AB:

CO/ Practice Bulletin 14 March +'''


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2ndometrial Cancer

• Most common genital tract

malignancy: *ncidence 1 in ;'N• th most common malignancy

after $reast4 $o-el4 and lung:

• &4''' ne- cases annually

• @ )4''' deaths annually


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2ndometrial Cancer

Ris, Factors

• 5ulliparity? +(& times

• #ia$etes? +:6 times

• Anopposed estrogen? (6 times

• Eeight gain – +' to ;' pounds? & times

– /reater than ;' l$s? 1' timesN


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AB

Management Options?• Progesterone

• 2strogen• OCPs

• 5%*#s

• %urgical


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Progestins? Mechanisms of

ction• *nhi$it endometrial gro-th

– *nhi$it synthesis of estrogen receptors – Promote conversion of estradiol

estrone

– *nhi$it LH• Organied slough to $asalis layer

• %timulate arachidonic acid formation


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Management? Progesterone

Cycloo0ygenase Path-ay

rachidonic cid

Prostaglandins

P/F+Ihrom$o0ane Prostacyclin

5et result is increased P/F+I8P/2 ratio


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Progestational gents

• Cyclic Provera +:;(1'mg daily for 1'(1 days

• Continuous Provera +:;(;mg daily

• #epoProveraQ 1;'mg *M every & months

• Levonorgestrel *A# !; years"


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2ndometrial Hyperplasia

2MB path report

simple hypersplasia E*HOA atypia:

Progesterone therapy

ProveraQ ;(1' mg daily

Mirena *A#

Repeat 2MB in &() months


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Management acute Bleeding?

2strogen

*D 2strogen +;mg 3) hours

OR

PremarinQ 1:+;mg4 + ta$s *#


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AB Management? 5%*#s

rachidonic cid

Prostaglandins

hrom$o0ane Prostacyclin

cyclic endopero0ides

are inhi$ited

S

Causes vasodilation and inhi$its platelet aggregation


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%urgical Options?

•2ndometrial $lation

• Hysterectomy


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5ova%ure hermaChoice


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%ummary

• hin, coagulation defect in the menarchaladolescent patient -ith severe menorrhagia

• /estational events are the single most li,ely causeof AB in reproductive age -omen

• &; yrs and older -ith AB 2MB

• *f R0 estrogen $e sure to screen for

contraindications• Levonorgestrel *A# is e0cellent means to control

AB


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%ummary

• Most common cause of AB in post(menopausal-omen is atrophy

• D% is an e0cellent screening tool for the

evaluation of PMB• Eomen -ith recurrent PMB re3uire definitive F8A

• 2ndometrial C ris, factors? age4 o$esity4

unopposed estrogen4 #M4 and TBP

Abnormal Beeding2014

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