Abnormal uterine bleeding

15/4/2006Dr. Mahmoud Abdel-Aleem, 2012

Abnormal Uterine Bleeding

Dr. Mahmoud A. Abdel-AleemDiploma of Reproductive Medicine,

Geneva University, Suiss.M.D. Obstetrics and Gynecology.

Assiut University.


Mechanism Of Normal Menstruation


Menstruation occurs as a universal endometrial event following the withdrawal of estrogen and progesterone subsequent to a normal ovulatory cycle.

1. Phase of vasoconstriction:i. The first morphological effect is shrinkage of the

tissue due to spiral arteriole vasoconstriction, probably predominantly under the effect of PGF2a, leading to reduced blood Flow.

ii. The arterioles undergo episodic vasoconstriction and relaxation leading to endometrial ischaemia and reperfusion damage leading to local release of a range of cytokines.

iii. The vasoconstriction process is limited predominantly to the first 24 h.


2. Phase of shedding:i. With further shrinkage, a variable quantity of the functional layer breaks down into fragments which are shed into the cavity and expelled.ii. A variable quantity of blood and tissue Fluid is also lost during this process.


3. Phase of clotting:i. Fibrin generation is an essential part of normal blood clotting, and is stimulated in endometrium.

ii. The balance between generation of coagulation factors, to control bleeding, and fibrinolysis, to prevent clot organisation and intrauterine adhesions, shifts from being haemostatic in the secretory phase to be fibrinolytic during menstruation.


Causes of AUB


• Systemic disease: conditions of impaired hemostasis.

• Congenital:• Traumatic:• Inflammatory:• Neoplasms:• Causes of pelvic congestion: myoma,

prolapsed ovaries, uterine prolapse, chronic PID, R.V.F, chronic cervicitis.


• Complication of early pregnancy:• Iatrogenic:• Dysfunctional: diagnosis by exclusion; it is

the abnormal uterine bleeding in the absence of organic lesion, genital or extra genital.


Types of AUB


How to know that the patient is having abnormal uterine bleeding?

1.Bleeding away from the normal menses.2.Menses lasting ≥8 days .3.Menses occurring at intervals of ≤3 weeks.4.Menses requiring more sanitary pads “> 2-3/ day"5.Pallor" clinical sign " or anemia" laboratory term".6.Flooding of blood.7.Passage of blood clots " because the amount of blood is more than the capacity of the fibrinolytic system of the endometrium".


Metrrorhagia

Organic Dysfunctional

Polymenorrhea Menorrhagia

Regular=Ovular=Cyclic

Clinical Types of AUB

Irregular=Anovular=Acyclic


• Polymenorrhea: period occurs every less than 3 weeks.

• Menorrhagia: regular cyclic heavy "requiring more daily sanitary pads "and /or prolonged periods “lasting for 8 days or more".

• Polymenorrhagia: combination of the above 2 types.

• Metrorrhagia.• Intermenstrual bleeding: bleeding of variable

amounts occurring between regular menstrual periods.

• Postcoital (contact) bleeding: bleeding occurring after intercourse.

• Postmenopausal bleeding.


Dysfunctional Uterine Bleeding


• Definition:• Types:

– Ovulatory bleeding:• Polymenorrhea.• Menorrhagia.

– Anovulatory bleeding:• Metropathia hemorrhagica.• Threshold bleeding.


• Diagnosis: Obtain a good history

&Perform meticulous general and local

examination&

Do appropriate investigationsBecause

The aimis

to exclude all possible causes


History and Physical findings• Assessment of menstrual blood loss

A- Methods proved to be of little value:– History:– The number of sanitary pads or tampons used. – The duration of bleeding.– Hemoglobin concentration: as women with true

menorrhagia may not necessarily drop Hb their, as losses of 800–1000 ml can occur without anemia.


B- Semi-quantitative methods:• Pictorial blood loss assessment chart (PBAC):C- Quantitative methods:• Noninvasive ‘alkaline hematin method’, where sanitary devices are

soaked in 5% sodium hydroxide to convert the blood to alkaline hematin and optical density is measured.

• Weighing technique:

Ovulatory or non-ovulatory: Cyclic, predictable menses every 21-35 days are usually associated with ovulation, whereas anovulatory bleeding is typically irregular in timing and flow, and is often interspersed with episodes of amenorrhea.

Exclude coagulopathy: congenital or acquired coagulopathy by reviewing the medical and family history.

Bimanual examination: A careful bimanual examination of the corpus should be performed, seeking evidence of pregnancy, adenomyosis and leiomyomas, as well as findings that are suggestive of an adnexal mass or an ectopic gestation.


• Laboratory investigation– Hemoglobin.– Hematocrit.– Urinary (or serum) b-human chorionic

gonadotropin levels– Coagulation profile– Serum assay for progesterone– Anovulatory patients:

• TSH assay• Serum prolactin.• Serum free testosterone.


• Evaluation of the endometrial cavity• Histologic assessment:

– Recommended as an initial part of the investigation in women with AUB who are >40 years, or in women of any age with chronic anovulation.

– Office endometrial sampling with narrow disposable catheters has generally been demonstrated to be equivalent to the so-called `formal' dilatation and curettage, utilizing dilators and sharp curettes.

– It is indicated for:• All women with abnormal bleeding aged more than 40 years

and in women who are at increased risk of endometrial cancer. Risk factors include nulliparity with a history of infertility, obesity (>90 kg), a family history of endometrial or colonic cancer, abnormal PAP-smear and tamoxifen therapy.


• Younger women:– if abnormal bleeding does not resolve with medical

treatment.– In polycystic ovary syndrome in which endometrial

hyperplasia is more common, endometrial assessment may be necessary if abnormal bleeding is a presenting feature, or unusual sonographic endometrial appearances are discovered.


• Imaging– TVS: it is a suitable screening test for

evaluation of the endometrial cavity.• Timing: should be performed after menstruation in

the follicular phase of the menstrual cycle.• Value:

– Sonohysterography is the sonographic evaluation of the endometrial cavity following the transcervical instillation of saline, an approach that has comparable results for structural anomalies of the endometrial cavity to those of hysteroscopy.

– Radiographic hysterography is less accurate than hysteroscopy for cavity evaluation.


• Hysteroscopy:– Hysteroscopy and biopsy is indicated for

women with erratic menstrual bleeding, failed medical therapy, or transvaginal ultrasound suggestive of intrauterine pathology such as polyps or submucous fibroids.

– Diagnostic hysteroscopy can be performed either as an outpatient procedure without anesthetic or as a formal theater procedure.


Individual types ofAUB


POLYMENORRHEA• The uterus is likely to be normal and the error is in the

ovary.• If affecting the luteal phase , it is due to poor function of

the corpus luteum" i.e. the premenstrual endometrial biopsy shows lagging secretory endometrium.

• Common causes:– Dysfunctional: common cause: LPD.– Organic: Pelvic Congestion Syndrome, because they reduce life

span of the corpus luteum.• Diagnosis:

– Clinical examination: to exclude organic causes.– U.S. an aid to exclude organic causes.

• Management:– Organic: of the cause.– Dysfunctional: hormonal treatment.


MENORRHAGIA• May be due to:

– Increased surface area of the endometrium.– Pelvic congestion.– Conditions of impaired hemostasis.– Dysfunctional:

Poor C.L.Persistent C.L. --->inadequate hormonal support to the endometrium ---> premature shedding of the endometrium ---> premenstrual spotting. D&C: lagging secretory endometrium and low progesterone levels during the luteal phase.

Incomplete and slow degeneration of C.L. ----> delayed shedding of the endometrium postmenstrual spotting.D&C: mixed endometrium "patchy progestational endometrium in a proliferative endometrium".


• Diagnosis:– Clinical examination:– U.S. and sonohysterography :an aid to exclude

organic causes.– Hysteroscopy.– D&C.

• Treatment:– Organic: treatment of the cause.– Dysfunctional:

• First type: hormonal treatment: progesterone 15th -25th day of the cycle.

• Second type: difficult; hormonal treatment: suppression of ovulation.


MetrorrhagiaMay be due to:• Organic:• Dysfunctional:


Threshold bleedingMetropathia Hemorrhagica[Shroider disease]

Ovarian underactivity.Flat ovary.Atrophic endometrium.Low FSH.Low estrogen.Common at extremes.TTT: sequential O&P

Ovarian hyperactivity.Cystic ovary.Thickened endometrium.No LH surge.High estrogen.Common at extremes.TTT: suppression

On-Off bleeding

Amenorrhea

Painless vaginal bleeding


Treatment of DUB


Aim of therapy

1. Control of bleeding.2. Achieve regular cycles.3. Induction of ovulation if there is infertility


General Lines

• Reassurance.• Iron and vitamin c.• Blood transfusion if there is a need for it

(Hb <6gm% or acute attack causing hemodynamic instability).


Medical Treatment

A- Non-Hormonal

Antifibrinolyticdrugs

Capillarystabilizers Anti-PGs

Tranexamic acid Daflon Mefenamic acid


B- HormonalAcute attacks

Estrogentherapy

High- doseE&P therapy[Medical curettage]

Oral- IV Oral - Parenteral


B- HormonalChronic Attacks

Ovular Bleeding Anovular bleeding

EndometrialSupport Suppression

Polymenorrhea

Menorrhagia [I]

Menorrhagia [II]

M. Hgica Thresholdbleeding

Follicular Cyst

Corpus Luteum

Endometrial

Building

Induction of ovulation


SurgicalTreatment

D&CHysteroscopy Hysterectomy

Diagnostic Diagnostic Therapeutic Therapeutic

RadiotherapyZERO


Postmenopausal Bleeding• Definition:• Causes:• The most common is-----------• The most risky is----------• All women should be subjected to:

– TVS– Endometrial assessment.


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ATTENTION

Abnormal uterine bleeding

Health & Medicine

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