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Abnormal Uterine Bleeding

Dr. Mashael Shebaili Asst. Prof. & Consultant Ob/Gyne Department

Normal menstruation 
Rhythm:

regular from 21-35 213-7 days

days 
Duration:  Amount:  Flow:

between 30-50 mls 30-

non clotted fluid blood

Disorders in rhythm, amount or duration 
Menorrhagia  Polymenorrhea  Oligomenorrhea  Metrorrhagia

Causes of Menorrhagia 
DUB  Pelvic

pathology 

Medical  Clotting

defect

life.Dysfunctional uterine bleeding Definition: Definition: uterine bleeding in the absence of an organic disease Incidence: 10-20% Incidence: 10-20% usually at extremes of reproductive life. .

Diagnosis (by exclusion)  History  General examination examination to  Abdomino-pelvic Abdomino Investigations (mainly exclude organic causes) .

Non-steroidal anti-inflammatory Nonanti  drugs Mechanism of action: inhibit cyclocyclo-oxygenase enzyme and the production of prostaglandins Phospholipids phospholipase A2 arachidonic acid cyclo-oxygenase cycloprostaglandins . Medical treatment A.Treatment I.

2) 3) . endothelins. growth factors and endothelins.Possible Pathophysiology 1) Shift in the endometrium conversion of the endoperoxide from vasovasoconstrictor PGF2E Increase in the level and activity of the endometrium fibrinolytic system Effect of other endometrial derived factors as cytokines.

Effectiveness: 1. Relief dysmenorrhoea Little effect on regularity of cycle or duration of bleeding . 3. Decrease measured menstrual loss by 40% in 75% of patients 40% 75% 2.

.Side effects:  Mainly mild gastrointestinal tract irritation  The treatment should start immediately with the start of bleeding.

Antifibrinolytic agents Mechanism of action: : Prevent conversion of plasminogen into plasmin which dissolve the fibrin clots occluding the blood vessels.B. vessels. .

related. The effect is dose related. days. . It should be given with the start of menstruation and continue for 3-4 days.Effectiveness:  Reduce measured loss by 40-50% 40-50%.

al.1991. 1996) . Comparative studies suggested that tranexemic acid is more effective inhibitors than PG synthetase et al.1991. (Milsom Bonnar and Shepard 1996).

Side effects: 1. Serious adverse effect has been documented (intracranial thrombosis ² central venous stasis retinopathy) but they are extremely rare. rare. . Mild gastrointestinal irritation tract 2.

No such complications occurred in Scandinavia over 19 years (1st line of treatment there 4. Should not prescribed for women with history of thrombo- embolism. .3.

Hormonal treatment: treatment: 1.II. Oral contraceptive pills  One of the most effective treatments available for both menorrhagia and dysmenorrhoea Can be used safely in women over 40 years if they are of low risk category  .

women. . by inducing endometrial atrophy with reduction in both PG synthesis Side effects: : That of oral contraceptive pills in general Socially unaccepted in single unmarried women.  i. fibrinolysis. Mechanism of action: : Mainly locally and fibrinolysis. ii.

Progestogens Norethisterone ² medroxymedroxyprogesterone acitate. Are the most commonly prescribed preparations in UK because it was wrongly thought that the majority of women with DUB are anovulatory .2.

for 21 days while Provera is given as 10 mg for 10-14 days during luteal phase.s. 10phase. . Mechanism of action: In anovulatory cycle it induce secretory changes but in ovulatory cycle it produce minimal changes Norethisterone is given as 5mg t. 1.d. 2.

2. Effectiveness: If given in high dose for 21 days especially in anovulatory cycle it reduce menstrual loss by 80% (Irvin et al. 1998) In anovulatory cycle it convert irregular. . unpredictable bleeding into regular controlled one which is an attractive feature for many women.. 1.

Side effects: Usually minimal as abdominal bloating and weight gain .

Progesterone releasing devices Produce marked reduction in menstrual blood loss up to 80% 80%  Mechanism of action: mainly locally action: leading to atrophic endometrium with very minimal systemic effect .

1991) showed decreased al.. Effectiveness: Effectiveness: Scandinavian study (milson et al. . 1991) menstrual loss by 90%. months. 90%  Side effects: effects: irregular bleeding is common especially in the in the early months.

Danazol: Danazol: Is an extremely effective drug for treatment of menstrual problems but its use is limited by its high androgenic side effects .

90% of cases.Gonadotrophin releasing hormone agonist  Mechanism of action: produce down action: regulation steroids  Effectiveness: Effectiveness: of pituitary gland that decrease gonadotrophins and ovarian relief amenorrhoea in 90% cases. Also relief PMS .

Side effects: effects:  HypoHypo-estrogenic state and osteoporosis (add estrogen and progesterone if used for long period) Unless used to prepare the patient for endometrial ablation it is not accepted by most patients for long term. term.  .

hot microwaveballoon). balloon).roller ball . . Endometrial ablation/resection To remove or destroy the endometrium producing changes similar to Asherman¶s syndrome (Laser ± electrocautary . conceive.Surgical treatment Suitable for older patients who have no further wish to conceive. I.diathermy ± microwave.

2. 70% 70% or more were satisfied .Advantage over hysterectomy 1. 30-40% 30-40% experienced marked reduction in menstrual loss 3. Short hospital stay and return to work 50% 50% of patients were amenorrhoeic.

Disadvantages: Disadvantages: 1. 2. Needs experience Recurrence of about 20% 20% Operative complications as perforation Post operative pain . 3. 4.

bowel. bladder or bowel. 2. vaginal or laparoscopic) (total or subtotal) Disadvantages: Disadvantages: 1. . Mortality of 6/10000 procedures Injury of ureter. Hysterectomy Definitive cure for menorrhagia (Abdominal.II.

POSTMENOPAUSAL BLEEDING .

It is a serious symptom because in about 25% 25% of cases. it is due to a malignant lesion in the genital tract Prevalence About 7 per 1000 postmenopausal women.POSTMENOPAUSAL BLEEDING It is bleeding from the genital tract occurring 6 months or more after cessation of menstruation in a woman above the age of 40. . 40.

menopausal symptoms may lead to withdrawal bleeding. Oestrogen given for (25%).Aetiology (A) General Causes (1) Oestrogen therapy (25%). (4) anticoagulant therapy. (3) blood diseases as leukemia. . (2) hypertension.

urethral caruncle. tumour. body or pessary in the vagina. tumour. tumour. fibroid eiidometritis. Malignant tumour. senile endometritis. erosion and ulcers. endometritis. tuberculous eiidometritis. . Malignant tumour. Uterus. caruncle. trophic ulcer in prolapse. Malignant tumour. senile vaginitis.(B)Local Causes Vulva. tumour. Vagina. . leucoplakia. and retained foreign prolapse. vaginitis. fissured leucoplakia. Cervix. and direct trauma. Malignant tumour.

(C) In about 15% of cases no cause is 15% found after physical examination and uterine curettage which shows atrophic endometrium .tube carcinoma. This leads to a watery vaginal discharge which finally becomes blood stained Ovary. Carcinoma with metastases in the endometrium and oestrogenic ovarian tumours.F. tumours.

urinary and gastrointestinal symptoms (malignant invasion of bladder or bowel). and the presence of other symptoms as pain and foul discharge.g. endometrial and ovarian carcinoma. Present history Ask about the amount. 60(b) parity: some tumours are more common among nulliparae e.Diagnosis A. duration of menopause. character and duration of bleeding. . History Personal history (a) Age: The commonest age incidence for carcinoma of uterus is 55-70 years while that for carcinoma of the 55vulva is 60-70 years.

Family history Carcinoma of the body of the uterus and ovary have a familial tendency .Past history (a)Oestrogen therapy. (b) diseases as diabetes mellitus. Endometrial carcinoma is more common in diabetic hypertensive patients. hypertension and blood diseases as leukemia.

General Examination (I) Signs of anaemia. (5) estimation of blood pressure . (4) examination of heart and chest for secondaries. (3) presence of cachexia. (2) signs of bleeding disorders.B.

. The urethra and anal canal are excluded as being the source of bleeding.Pelvic Examination To detect a local cause for bleeding. D.C Abdominal Examination For a pelvi-abdominal mass and ascites pelviwhich is common with ovarian malignancy.

tubes. Taken in absence of bleeding to detect the presence of malignant cells which may come from the cervix.E. endometrium. or ovaries. Special Investigations Transvaginal sonography. . It excludes the presence of an ovarian tumour or a lesion in the uterus as endometrial carcinoma. 2. Cervical smear. 1.

or Hysteroscopy. Endometrial aspiration. as it is the only sure method to exclude endometrial carcinoma. . It must be done in every case of postmenopausal bleeding. Endometrial biopsy. Endometrial biopsy is taken by one of three methods.3. Fractional uterine curettage.

Laboratory tests. . or cervix. estimation of clotting factors if a bleeding disorder is suspected. Biopsy is taken from any suspected lesion in the vulva. These are done according to the clinical findings and include: a. 5.4. b. Complete blood count. bleeding time. vagina. Platelet count. coagulation time.

If bleeding recurs it is better to do hysterectomy and bilateral salpingosalpingooophorectomy which may reveal a missed early carcinoma of uterus or tube. If no cause can be detected the patient should be followed up. .Treatment It is treatment of the cause.

Thank you .