Abnormal uterine bleeding 1262022 1 AUB Def any

Abnormal uterine bleeding 1/26/2022 1

AUB. . • Def: any bleeding from the uterus that differs from the usual menstrual cycle in frequency, amount, duration of flow. 1/26/2022 2

Normal menstrual Cycle • Cycle length 24 to 35 days, normal amount of menstrual blood per cycle 30 to 50 ml , abnormal if > 80 ml 1/26/2022 3

Physiology of normal menstrual bleeding • Is post ovulatory est- progesterone withdrawal bleeding. 1/26/2022 4

Physiology…. • Follicular phase Ovary secret estrogen -endometrial proliferation • Secretory phase after ovulation , C. Luteum secret Pro + estrogen 1/26/2022 5

Secretory… • Pro limits endometrial growth & cause it to differentiate • If no pregnancy –C. luteum regresses & hormonal support of the endometrium ceases__ initiates a cascade of events that results in menstrual bleeding. 1/26/2022 6

Physiology… a. Rhythmic VC of spiral arterioles leads to ischemia, necrosis and sloughing of the surface endometrium b. Lytic enzymes from Ic lysosomes and matrix metalloproteinases. breakdown of endometrial tissue. 1/26/2022 7

Normal menstrual bleeding is self-limited It is a universal endometrial event Menstrual changes occur simultaneously in all segment of the endometrium • The endometrial tissue is structurally stable and random break down of tissue due to fragility is avoided -Because it has responded to appropriate sequence of est and progestone • 1/26/2022 8

patterns of AUB • Menorrhagia – hypermenorrhea -heavy or prolonged menstrual flow Causes • submucous myoma • Complications of pregnancy • adenomyosis • Endometrial hyperplasia • malignant trs, DUB 1/26/2022 9

Hypomenorrhea – cryptomenorhea - Light menstrual flow Causes. . Hymenal or cervical stenosis. Uterine synechia, ocp Metrorrhagia – intermenstrual bleeding • bleeding occur at any time between menstrual periods Causes: . end polyps , endometrial and cervical Ca. exogenous est 1/26/2022 10

Menometrorrhagia • period that occurs at irregular intervals. irregular, prolonged and excessive in amount. • Causes. anovulation. est secreting trs 1/26/2022 11

Polymenorrhea • period that occurs too frequently • a menstrual cycle interval of < 21 days causes. Anovulation. shortened luteal phase Oligomenorrhea menstrual periods that occurs more than 35 days apart causes. . An ovulation. est secreting trs 1/26/2022 12

Patterns. . Contact bleeding- post coital bleeding • Must be considered a sign of cervical Ca until proved other wise. Other causes cervical polyp cervical or vaginal infection 1/26/2022 13

Causes of AUB • • prepubertal –premenarchal Vulval lesions –vulval fissure, maceration, condy lomas F. body Vulvovaginitis Precocious puberty Trauma - abuse, penetration Vaginal and ovarian trs Exogenous hormones 1/26/2022 14

Causes of AUB… Adolescence • anovulation (90%)- hypothalamic immaturity • pregnancy related bleeding • exogenous hormones • Hematologic abnormalities ITP, Vonwillebrand’s disease 1/26/2022 15

Adolescence AUB… - infections- cervicitis, PID - endocrine or systemic problems. thyroid and hepatic dysfunction. PCOS - Anatomic causes. Mullerian abnormalities Long vaginal septa UX didelphis 1/26/2022 16

Reproductive age group pregnancy related bleeding DUB Exogenous hormones, endocrine causes Anatomic causes * Myoma, adenomyosis , endometrial polyps * cervical lesions –polyps, infections, lesions , condyloma , HSV ulcer Hematologic causes Coagulation abn – thrombocytopenia, v. will brand’s - Leukemia Neoplasia – Ca (cervical , endometrial , vaginal) 1/26/2022 17 • •

Dysfunctional uterine bleeding Def-abnormal Ux bleeding for which no specific organic cause can be found , after a thorough evaluation and work up of Pt. • Most often occurs in the absence of the cyclic hormonal changes that regulate the menstrual cycle. 1/26/2022 18

• Is often a dx of exclusion – organic causes must be excluded • AUB at extremes of reproductive life usually is due to anovulation (DUB) Pathophysiology of DUB • Most common etiology is est. withdrawal or est break through bleeding • In absence of ovulation est stimulates the endometrium without production of progesterone 1/26/2022 19

Pathophysiology. . • unopposed est leads to excessive glandular proliferation with lack of stromal support unstable, fragile, hetrogenous endometrium prone to superficial breakdown and bleeding. • endometrium slough off in isolated location, the remaining raw surface is restimulated by est and heals as another part of endometrium is slough off 1/26/2022 20

Etiology of DUB A. Causes of anovulation or oligoovulation • Anovulatory cycles are sms of disruption of the normal regulatory mechanisms that control menstrual cycle. • abnormalities at any site of hypothalmopituitary ovarian axis 1/26/2022 21

1. Dysfunction of hypothalamic pituitary ovarian axis • Any factor that interferes with the normal pulsatile secretion of Gn. RH leads to an ovulation Causes –. Hyperprolactinemia – P. adenoma, psychotropic drugs, hypothyroidism • stress and anxiety • rapid weight loss • anorexia nervosa 1/26/2022 22

2. Immaturity of hypothalamic pituitary ovarian axis -in post pubertal adolescence shortly after menarche 3. Abnormalities of normal feed back signals Estradiol levels play a critical role in controlling the sequence of events during normal ovulatory cycles • medical conditions – hepatic ds , thyroid abnormalities affect metabolism and clearance of estradiol 1/26/2022 23

4. other causes Pcos b. causes with ovulation • DUB 2 ry to hormonal causes may occur during ovulatory cycles • ovulatory pts with AUB are more likely to have an underlying organic pathology & are not true DUB pts 1/26/2022 24

Evaluation of AUB A. History • age, parity, marital status, sexual Hx • current pattern of bleeding • menstrual Hx – age at menarche, cycle frequency and duration, presence of molimina sms • contraceptive use & other medications - anticoagulants, psychotropic drugs 1/26/2022 25

Evaluation … • medical Hx – sms of endocrine & other organic diseases • bleeding tendency & family Hx of bleeding disorder • sms of stress & sms of PID 1/26/2022 26

Physical examination General P/E • thyroid enlargement, galactorrhea, ecchymosis, purpura • pallor, v/s Gynecologic exam • 2 ry sexual x-stics, vaginal trauma, sign of infection, atrophic vaginitis and F. body 1/26/2022 27

Lab evaluation based on Hx physical findings • CBC- Hgb & HCT, WBC, platlet count • Pregnancy test – should be done in all pre menopausal AUB • Test for -STI • Coagulation profile – PT, PTT • TSH, PRL, LFT 1/26/2022 28

• Androgen profile – Testesterone, DEA, 17 alpha hydoxy progestrone D. Diagnostic procedures 1. ultrasonography & sonohysterography • intra Ux polyps, submucous myoma, ovarian masses • Ux contour, endometrial thickness 1/26/2022 29

2 endometrial biopsy - to R/o endometrial ca Indication • those at risk for endometrial hyperplasia or ca • those older than 40 yrs of age • those younger than 40 yrs of age who have chronic unopposed est breakthrough bleeding 1/26/2022 30

3. D&C • replaced by endometrial biopsy in the office 4. Hysteroscopy with endometrial sampling Indication • cervical stenosis precluding adequate end ometrial biopsy • pt intolerance of endometrial biopsy • anatomic factors precluding adequate end biopsy 1/26/2022 31

Hysteroscopy… • presence of AUB in a pt undergoing another surgical procedure with GA • Direct visualization of endometrial cavity, allow targeted biopsy or excision of the lesion • Gold standard for Dx of AUB 1/26/2022 32

Management of AUB Depends on the etiology of the bleeding. In identifiable causes the Rx is targeted to wards the cause The Mx of DUB depends on • • - age of pt -severity of bleeding - desire for future pregnancy - presence of associated pathology Objective of Rx Control bleeding Prevent recurrence Preserve fertility 1/26/2022 Correct associated disorders 33

Rx… A. Hormonal Rx 1. progestins - Rx of choice for anovulatory DUB - stops endometrial growth, support & stabilize the endometrium an organized sloughing off the endometrium occurs after its withdrawal. - oral medroxy progesterone acetate 10 mg/day for the 1 st 12 days each month or day 16 through 25 of each cycle 1/26/2022 34

Rx… 2. oral contraceptive therapy • Convert a fragile, overgrown endometrium into a pseudo decidualized structurally stable lining • Controls bleeding with in 24 hrs 1/26/2022 35

OCP… • Low dose combined OCP 2 to 3 x a day for 5 to 7 days, then once a day for 3 months. 3. High dose estrogen - promotes rapid endometrial regrowth to cover denuded epithelial surfaces - conjugated equine estrogen 10 mg Po/day qid or 25 mg lv Q 2 to 4 hrs for 24 hrs then oral est 10 mg/day for 21 to 25 days and medroxy progesterone acetate 10 mg/day for the last 7 -10 days. - bleeding usually stops with in 24 hrs 1/26/2022 36

B. Medical therapy 1. non steroidal anti inflammatory agents - inhibit synthesis of PGs - alter the balance b/n thromboxane & prostacycline - effective in ovulatory DUB - eg. Ibuprofen, Naproxen 2. Gn. RH agonists - down regulate pituitary synthesis of FSH & LH and induce “medical menopause” - last resort when all modalities fail 1/26/2022 37

3. Rx of coagulation disorder - desmopressine factor VIII - antifibrinolytic agents – E. aminocaproic acid tranexamic acid 1/26/2022 38

Surgical therapy 1. D&C with or without hysteroscopy • Done in pts with bleeding refractory to medical therapy • Can be diagnostic & therapeutic modality • In age above 40 yrs it must be done • Age 20 to 40 yrs postponed • Age <20 yrs should be deffered 1/26/2022 39

Surgical … 2. Hysterectomy • If failed to respond to medical Rx, repeated curettage, endometrial ablation • More definitive -consider age of the pt, her desire for future fertility 1/26/2022 40

3 Endometrial ablation • • • Destruction of the endometrium For woman who are not candidate for hysterectomy Using laser, electrocautery, thermal destructive technique 1/26/2022 41

Post menopausal bleeding • Defn. – bleeding that occurs after 12 months of amenorrhea in a middle aged woman • more likely to be caused by pathological disease • must always be investigated • at least ¼ of PMB woman have neoplasia 1/26/2022 42

PMB… Etiology - Exogenous hormones -30% HRT – frequency of bleeding depends on the regimen used • atrophic endometritis/ vaginitis -30% • Commonest cause of pmb • due to hypoestrogenism results in a thin surface that is prone to bleed especially after trauma 1/26/2022 43

- Endometrial ca-15% - endometrial or cervical polyps-10% - endometrial hyperplasia -5% - miscellaneous- cervical ca - uterine sarcoma -10% - ovarian ca - vaginal ca Dx – pelvic examination endometrial sampling – office biopsy - hysteroscopy - D&C Pelvic u/s Mx – cause directed 1/26/2022 44