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BLEEDING
Oleh :
Adi Setyawan Prianto
DEFINITION
FIG. 1.
Figure 1. Molecular and cellular events occurring after progesterone withdrawal (Critchley et al., 2001).
Coincident events of progesterone withdrawal and hypoxia. Progesterone withdrawal results in an up-regulation o
production of MMPs, a leucocyte influx and expression of stromal KDR in the upper endometrial zones. There is co
an up-regulation of VEGF. VEGF binds to its type 2 receptor, KDR, and there is a paracrine/autocrine action on the
production in the same endometrial upper zone stromal cells. Menstrual sloughing takes place from the superficia
regions of the endometrium. KDR, kinase insert domaincontaining receptor or VEGF receptor 2; PGF2a, prostagla
ONSET Menstruation :
Basically, menstruation was envisioned as ischaemic necrosis of the end
vasoconstriction spiral arterioles in the basal layer, trigerred by withdra
progesterone.
Initiation of menstruation is an enzymatic autodigestion of
the endometrium with its subsurface capillary plexus, possibly extending
the spiral arteriol system in the basal layer.
CESSATION Menstruation:
Similarly, the end of menses was explained by longer and more intense
constriction, combine with coagulation mechanisms activated by vascula
endometrial collaps, aided by rapid reepithelization mediated by est
the emerging new follicular cohort.
STROMAL REGENERATION :
Figure 2. Breakdown and restoration in the endometrium. Tissue is shed as a result of the action of MMP.
Re-epithelialization is very rapid and occurs from theopen mouths of the glands and from the unshed portions of th
Leucocyte products and a variety of other factors derived from the epithelium itself are postulated to play a role in
Subsequent restoration of the underlying stroma includes proliferation of cells associated with blood vessels and en
the laying down of the extracellular matrix. These events are postulated to occur under the influence of increasing
concentrations and are probably locally regulated by a number of growth factors and other regulatory factors (Sala
membrane type 1; ET-1, endothelin 1; BMP-6, bone morphogenetic protein 6; BV, blood vessel; FGFs, fibroblast gro
The ESHRE Capri Workshop Group 424
It usually occurs only when endometrium has first been primed with endo
exogenous estrogen.
The amount and duration of bleeding can vary widely and generally corel
the level and duration previous estrogen stimulated endometrial prolifer
TABLE 4
Treatment Options for Abnormal Uterine Bleeding in Women Using Hormonal Contraception
Treatment
Dosage
Supplemental estrogen
Conjugated equine estrogens (Premarin)
Estradiol (Estrase)
ANOVULATORY BLEEDING
Session II
DYSFUNCTIONAL UTERINE
BLEEDING LECTURE
11 Oktober 2010 Revised
ANOVULATORY BLEEDING
Regression of most follicular cohort
Estrogen withdrawal
bleeding
ANOVULATORY BLEEDIN
1. Focal breakdown
Estrogen breakthrough
2. Structurally fragile endometriumbleeding
Clinical examples :
1.Polycystic ovary syndrome
2. Obese women.
3. Postmenarcheal adolesce
4. Perimenopausal women
Characterizes
Anovulatory Woman
DIFFERENTIAL DIAGNOSIS
1.
2.
3.
4.
5.
6
.
1. Uterine neoplasia
Possibility of underlying pathology2. Cervical and endometrial polyps
3. Adenomyosis.
Thyroid disorders
1. Hypothyroidism
2. Hyperthyroidism.
Anatomical lesion
Laboatory test :
PROGESTIN THERAPY
Androgen
Androgen
Aromatase
Aromatase
17-hydroxysteroid
dehidrogenase
Estradiol
Estrone
Sulfotransferase
Estradiol
sulfate
Sulfotransferase
Sulfatase
Estrone
sulfate
The ANTIMITOTIC
growth-limiting effects
on endometrium
Self-limited progesterone
withdrawal bleeding
Medroxyprogesterone acetate
(5-10 mg daily for 2 weeks every month)
When menses (-)
Possibility of a more profound
ovulatory dysfunction due to
Anovulatory with
metrorrhagia/polymenorrhea
Progestin treatment for 14 days
3.
Diagnostic evaluation
Prolonged episodes of
heavy anovulatory bleeding
Diagnostic evaluation
Transvaginal ultrasound examination
ESTROGEN THERAPY
Transvaginal ultrasound
1. Defining endometrial thickness
2. Anatomic abnormality of the uterine cavity.
Estrogen Therapy
Logical and best choice
Inducing pseudoathropy
1. Regress spontaneously
2. After curettage
3. With progestin therapy
In contrast,
Quite resistant curettage or prolongred high dose progestational therapy
Risk 10 30 % progression to adenocarcinoma
ENDOMETRIAL ABLATION
Persistent bleeding despite treatment
Lower risk
Fewer complication
More rapid recovery
Endometrial ablation
HysterectomyMore satisfied
with the outcome
Hysteroscopic technique
Non- hysteroscopy technique
A bipolar vaporizing electrode
Hydrothermal technique
Circulates heated water (87 5 C) inside in ballon
Using electrodes on the outer surface
And radiofrequency-induced thermal destruction
Result
better, if:
Normal endometrium. (2) Sagittal transvaginal US scan of the uterus shows the menstrual-phase endometrium (a
(normal thickness, 1-4 mm).
(3) Transverse transvaginal US scan shows the proliferative-phase endometrium (arrows) (normal thickness, 4-6
(4) Sagittal transvaginal US scan obtained during the periovulatory phase (day 15) shows the trilaminar endometr
with a thickness of approximately 11 mm (arrows).
(5) Sagittal transvaginal US scan shows the secretory-phase endometrium (cursors) (normal thickness, 8-16 mm)
Figures 8, 9. (8) Polyp in a 47-year-old woman with excessive bleeding. (a) Sagittal transvaginal US s
the endometrium with a thickness of 15 mm.
(b) Sagittal sonohysterogram shows a single polyp (arrowheads) with a catheter. The endometrium is no
(9) Polyps in a 56-year-old woman. (a) Sagittal transvaginal US scan shows the endometrium with a thick
(b) Sagittal sonohysterogram shows three polyps (P) with an otherwise thin (1-2-mm) endometrium.
Regular monthly periods that are heavy or prolonged are more likely
anatomical lesion or bleeding disorder than to anovulation.
A sensitive pregnancy test can quickly exclude any realistic possibility
related to an accident or complication of pregnancy.
thyroid disorders.
ULTRASOUND :
PROGESTIN THERAPY
Continued,.
medical curettage
Failed progestin treatment requires further diagnostic evaluation ????
To respite from heavy bleeding that only recently stopped, oral contrace
continued (one pill per day) until the package of pills is completed.
In women wih normal uteri, oral contraceptive reduce menstrual flow
from that in natural cycles.
For the short term, the decidual changes induced by treatment, provide so
and stop further random breakdown of an overgrown, vascular, and fragile
substantial amount of tissue remains to be shed upon estrogen-progestin w
ESTROGEN THERAPY
Estrogen therapy is also the logical and best choice for management of
episodic progesterone breakthrough bleeding, that commonly occured
receiving low-dose combination estrogen-progestin contraceptive, or depo
Progestin inducing pseudo atrophy.
Symptom is similar likely ; light spotting, staining or bleeding that similar
estrogen breakthrough bleeding with very low levels of circulating estroge
Continued, ..
In all such cases, a short interval of added estrogen :
Conjugated estrogen 1,25 mg , or micronized estradiol 2,0 mg
daily for 7 10 days)
If treatment failed, so..what ??????
Further evaluation can exclude possibilty of a previously
unrecognized endometrial polyp,
or sub mucous myoma
Dilatation and curettage is the most expeditious and effective way to sto
uterine bleeding.
Mechanisms of effects of curretage is not entirely clearbut
Surgical denudation of basal layer of endometrium is presumed to acute
normal processes involved in cessation of normal menstrual bleeding, lik
1. Local clotting mechanism
2. Vasoconstriction of basal arterioles
3. Rapid reepithelization.
ENDOMETRIAL ABLATION
Indication :
Persistent bleeding when medical treatment are rejected, unsuccessful,