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