?Abnormal

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?Abnormal uterine bleeding
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DEFINE 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
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CLINICAL TYPES Polymenorrhoea frequent (lt21 d)
menstruation, at regular intervals Menorrhagia
Excessive (gt80 ml) / or prolonged menstruation,
at regular intervals Metrorrhagia Excessive (gt80
ml) / or prolonged menstruation at irregular
intervals. Menometrorrhagia both. Intermenstual
bleeding episodes of uterine bleeding between
regular menstruations Hypomenorrhoea scanty
menstruation. Oligomenorrhea infrequent
menstruation (gt35 d)
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CAUSES . Dysfunctional uterine bleeding .
Pregnancy complications Abortion, Ectopic
pregnancy, Trophoblastic disease . Genital
disease . Tumors Benign fibroid, polyps
(cervical, endometrial, fibroid)
Malignant cervical, endometrial, ovarian
(estrogen secreting) . Infection PID .
Endometriosis, adenomyosis . IUCD . Marked
uterovaginal prolapse or retroversion
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. Extragenital . Endocrine hypo or hyer
thyroidism . Haematological Idiopathic
thrombocytopenic purpura, Von-Willebrand
disease . Chronic systemic disease liver
failure, renal failure, hypertension with uterine
artery atherosclerosis. . Iatrogenic Sex
hormones, anticoagulants. . Emotional (change of
country, climate work stress psychosomatic
disorders) . Obesity increased peripheral
estrogen conversion
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Dysfunctional uterine bleeding Define Abnormal
uterine bleeding in absence of pelvic organ
disease or a systemic disorder Incidence 60 of
AUB
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Pathology Endocrine
abnormality
Endometrium Anovulatory 90 Insufficient
follicles Inadequate
proliferative or atrophic
Persistent follicles
Proliferative or hyperplastic

Ovulatory 10 Short proliferative phase
Normal
Long proliferative phase
Normal Insufficient C. luteum
Irregular or deficient
secretory leading to short
luteal phase Persistent C
luteum leading to Irregular shedding
long luteal phase


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Risk of endometrial cancer Chronic anovulation
has 3 times increased risk (Coulam,1989). Chronic
proliferation of the endometrium leading to
adenomatous hyperplasia, leading to atypical
adenomatous hyperplasia, leading to endometrial
carcinoma. Transition can take up to 10 yrs or
more.
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Diagnosis Aim 1. Nature severity of
bleeding 2. Exclusion of organic
causes 3. Ovulatory or anovulatory How
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I. History 1. Personal age, wishes of the
patient 2. Menstrual 3. Obstetric 4. Past 5. Prese
nt amount, duration, color, smell, relation to
sexual intercourse, associated symptoms
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II. Examination 1. General pallor,
endocrinopathy, coagulopathy, pregnancy 2. Abdomin
al liver, spleen, pelvi abdominal
mass 3. Pelvic origin of the bleeding, cause
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III.Investigations Systemic 1. CBC (for all,
Grade A) 2. BHCG 3. Prolactin
TSH 4. Prothrombin time, partial thermoplastic
time, bleeding time, platelets, Von Willebrand
factor
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Local 1. Pap smear 2. Endometrial biopsy 3. D
C 4. Hysteroscopy 5. U/S
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Assessment of the amount of the bleeding 50 of
excessive menstruation have normal amount of
blood loss by objective methods 1.Subjective
methods history of passage of clots, flooding,
use of large number of pads, do not reflect the
actual blood loss 2.Semiobjective i.Iron
deficiency anemia ii.Menstrual calendar
(August,1996) III. Pictorial blood loss
chart(Higham,1990)
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Menstrual calender (August,1996) Saturday 7 14 2
1 28 Sunday 1 8 15 22 29 Monday
2 9 16 23 30 Tuesday 3 10 17 24 31 Wednesday 4
11 18 25 Thursday 5 12 19 26 Friday
6 13 20 27 . Spotting - Slight loss O
Moderate loss Very heavy loss
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Pictorial blood loss chart (Higham,1990)
Days of the bleeding
Score 1 2 3 4 5 6
7 8 Towel
1 ponit
5
ponits
10 points Clots

1p clot 1 point
5p
clot 5 points Flooding
5 points
Score gt100 Menorrrhagia























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Endometrial biopsy Indications .Between 20
40 .If endometrial thickness on TVS is gt12mm,
endometrial sample should be taken to exclude
endometrial hyperplasia (Grade A). Failure to
obtain sufficient sample for H/P does not require
further investigation unless the endometrial
thickness is gt12 mm (Grade B) Aim diagnosis of
the type of the bleeding
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Methods As an outpatient procedure, without
general anesthesia. 1.Pipelle curette 2.Sharman
curette, Gravlee jet washer, Isac cell
sampler 3.Accrette 4.vabra aspirator Advantages
An adequate acceptable screening procedure in
females under 40 yrs
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D C Indications 1. Mandatory after 4o yrs 2.
Persistent or recurrent bleeding between 20 40
yrs Aim 1.Diagnosis of organic disease e.g.
endometritis, polyp, carcinoma, TB,
fibroid 2.Diagnosis of the type of the
endometrium hyperplastic, proliferative,
secretory, irregular ripening, shedding,
atrophic. This provides a guide to etiology
treatment
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3.Arrest of the bleeding, if the bleeding is
severe or persistent, particularly hyperplastic
endometrium. Curettage is essentially a
diagnostic not a therapeutic procedure. Disadvan
tages 1.Small lesions can be missed 2.The
sensitivity of detecting intrauterine pathology
is only 65
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Fractional curretage Indication gt40 yrs Method
3 samples endocervical, lower segment upper
segment
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Hysteroscopy Indications Mandatory after 40
yrs 1. Erratic menstrual bleeding 2. Failed
medical treatment 3. TVS suggestive of
intrauterine pathology e.g. polyp, fibroid (Grade
B)
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Aim 1.Excellent view of the uterine cavity
diagnosis of polyps, submucous fibroid,
hyperplasia. 2.Biopsy of the suspected
areas 3.Treatment
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Advantages over D C 1.The whole uterine cavity
can be visualized 2.Very small lesions such as
polyps can be identified biopsed or
removed 3.Bleeding from ruptured venules
echymoses can be readily identified 4.The
sensitivity in detecting intrauterine pathology
is 98 (Loffer,1989) 5.Outpatient procedure
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Disadvantages 1.Cost of the apparatus 2.Lack of
availability or experience
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Ultrasonography 1. TAS can exclude pelvic
masses, pregnancy complications 2. TVS More
informative than TAS. Measurement of the
endometrial thickness is not a replacement for
biopsy. All endometrial carcinoma in
postmenopausal with endometrial thicknessgt4 mm
(Osmers,1990) 3. Saline sonography an
alternative to office hysteroscopy in selected
cases. It is better tolerated than office
hysteroscopy or HSG
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TVS is recommended in 1. Weight gt90 Kg 2. Age gt
40 yrs 3. Other risk factors for endometrial
hyperplasia or carcinoma e.g. infertility,
nulliparity, family history of colon or
endometrial cancer, exposure to unopposed
estrogen (Grade B)
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Treatment A. General 1. Menstrual
calendar 2. Treatment of iron deficiency anemia
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B. Medical I. Hormonal 1.Progestagen 2.Oestrogen
3.COCP 4.Danazol 5.Gnrh agonist 6.Levo-nova
(Merina) II. Non hormonal 1.Prostaglandin
synthetase inhibitors (PSI) 2.Antifibrinolytics 3.
Ethamsylate
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C. Surgical 1. Endometrial ablation 2. Hysterectom
y
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Strategy of treatment
lt20 yrs 20-40 yrs
gt 40 yrs Medical Always
First resort after endometrial biopsy
Temporizing if

surgery is refused or

imminent
menopause Surgical Never Seldom, only if
medical treatment fail First resort if bleeding

is
recurrent
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Medical treatment Antifibrinolytics Mechanism of
action The endometrium possess an active
fibrinolytic system, the fibrinolytic activity
is higher in menorrhagia. Effect Greater
reduction of menstrual bleeding than other
therapies (PSI, oral luteal phase progestagen
etamsylate)(Cochrane library,2002). Tranexamic
acid is effective in treating menorrhagia
associated with IUCD.
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Side effects is dose related. Nausea ,
vomiting, diarrhea, dizziness. Rarely transient
color vision disturbance, intracranial
thrombosis. But, no evidence that tranxemic acid
increases the risk in absence of past or family
history of thrombophilia. This treatment is not
associated with an increase in side effects
compared to placebo or other therapies (Cochrane
library,2002). Dose 3-6 gm /d for the first 3
days of the cycle
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PSI Mechanism the endometrium is a rich source
of PGE2 PGF2œ its concentrations are greater
in menorrhagia. PSI decreases endometrial PG
concentrations. Effect PSI decreased menstrual
blood by 24 norethisterone by 20. The
beneficial effect of mefenamic acid on MBL
other symptoms e.g. dysmenorrhea, headache,
nausea, diarrhea depression persists for
several months.
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Dose Mefenamic acid 500 mg tds during menses.
Side effects nausea, vomiting, gastric
discomfort, diarrhea, dizziness. Rarely
haemolytic anemia, thrombocytopenia. The degree
of reduction of MBL is not as great as it is with
tranxamic acid but PSI have a lower side effect
profile.
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Ethamsylate Mechanism of action maintain
capillary integrity, anti-hyalurunidase activity
inhibitory effect on PG Dose 500 mg qid,
starting 5 days before anticipated onset of the
cycle continued for 10 days
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Effect 20 reduction in MBL. There is no
conclusive evidence of the effectivness of
etamsylate in reducing menorrhgea (Grade A) Side
effects headache, rash, nausea
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Systemic progestagens Norethisterone
medroxyprogesterone acetate Effect Ovulatory
DUB not effective if given at low dose for short
duration (5-10 days) in the luteal phase.
Effective if NEA is given at higher dose for 3 w
out of 4 w (5 mg tds from D5 to 26) Anovulatory
DUB useful Side effects weight gain, nausea,
bloating, edema, headache, acne, depression,
exacerbation of epilepsy migraine, loss of
libido
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Intrauterine progestagens Levonorgestrel
intrauterine system levonova,Mirena Delivers
20ug LNG /d. for 5 yr Metraplant T shaped IUCD
levonorgestrel on the shoulder stem Azzam IUCD
Cu T levonorgestrel on the stem
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Effect 1.Comparable to endometrial resection
for management of DUB. 2.Superior to PSI
antifibrinolytics 3.May be an alternative to
hysterectomy in some patients
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Side effects 1.BTB in the first cycles 2.20
develop amenorrhea within 1 yr 3.Functional
ovarian cysts Special indications 1.
Intractable bleeding associated with chronic
illness 2. Ovulatory heavy bleeding
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The combined contraceptive pill Effect Reduce
MBL by 50 Mechanism of action endometrial
suppression Side effects headache, migraine,
weight gain, breast tenderness, nausea,
cholestatic jaundice, hypertension, thrombotic
episodes,
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Danazol synthetic androgen with antioestrogenic
antiprogestagenic activity Mechanism inhibits
the release of pituitary Gnt has direct
suppressive effect on the endometrium Effect
reduction in MBL (more effective than PSI)
amenorhea at doses gt400 mg/d
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Side effects headache, weight gain, acne,
rashes, hirsuitism, mood voice changes,
flushes, muscle spasm, reduced HDL, diminished
breast size. Rarely cholestatic jaundice. It is
effective in reducing blood loss but side effects
limit it to a second choice therapy or short term
use only (Grade A) Dose 200 mg/d
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GnRH analog Side effects hot flushes, sweats,
headache, irritability, loss of libido, vaginal
dryness, lethargy, reduced bone density.
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Surgical treatment Endometrial ablation Methods I
.Hysteroscopic 1. Laser 2. Electrosurgical a.
Roller ball b.
Resection II.Non-hysteroscopic 1.
Thermachoice 2. Microwave.
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Indications 1. Failure of medical treatment 2.
Family is completed 3. Uterine cavity lt10 cm 4.
Submucos fibroid lt5 cm 5. Endometrium is normal
or low risk hyperplasia.
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Complications of hysteroscopic methods 1. Uterine
perforation 2. Bleeding 3. Infection. 4. Fluid
overload 5. Gas embolism
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Hysterectomy Indications 1. Failure of medical
treatment 2. Family is completed Routes 1.
Abdominal 2. Vaginal
3. Laparoscopic
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Advantages 1. Complete cure 2. Avoidance of long
term medical treatment 3. Removal of any missed
pathology Disadvantages 1.Major
operation 2.Hospital admission 3.Mortality
morbidity
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Post menopausal Bleeding
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