Presentation on theme: "Abnormal uterine bleeding"— Presentation transcript:
1 Abnormal uterine bleeding Dr. Abdalla H. ElsadigMD
2 Normal values Duration of bleeding: 3-8 days Amount of bleeding: 30-80 mlLength of cycle:21-35 days, average 28 days
3 Causes:Abnormal uterine bleeding is a symptom and not a disease. Its causes include the following:Early pregnancy complications (abortion, ectopic pregnancy, hydatidiform mole).Pelvic inflammatory disease (PID).Benign tumors (uterine fibroids,cervical polyps endometriosis, adenomyosis)malignant tumors ( endometrial and cervical carcinoma)Dysfunctional uterine bleeding.
4 Clinical types: Menorrhagia (regular & cyclical): - cyclical bleeding at normal intervals which is excessive in amount or duration. e.g. 5/28 or 8/28.- causes: benign organic disease of genital tract(fibroids, adenomyosios, PID) and may be dysfuctional (ovulatory).2. Polymenorrhoea (regular & cyclical):- Cyclical bleeding which is normal in amount but occurring at too-frequent intervals of less than 21 days, e.g. 5/20. Her the uterus is normal.- cause: ovarian endometriosis, PID, DUB.
5 Clinical types: Polymenorrhagia: - Cyclical bleeding which is both excessive and too frequent, e.g. 9/20-12/20.- Caused by: DUB, PID.Metrorrhagia (irregular or acyclical):- bleeding of any amount which acyclical occurring irregularly or continuously.- always originates in the uterus.- causes(organic) : complications of early pregnancy, ulceration or infection of benign tumors, malignancies (perimenopausal)
6 5. Intermenstrual bleeding: Clinical types:5. Intermenstrual bleeding:- often dysfunctional (fall in oestrogen secretion following ovulation); 60% of ovulatory women have erythrocytes in their cervical mucus if examined.- common with cervical and endometrial polyps, fibroids and cervical carcinoma
7 Dysfunctional Uterine Bleeding (DUB) It is an abnormal bleeding from the uterus in the absence of organic disease of the genital tract.It is characterized by dysfunction of the uterus, ovary, pituitary, hypothalamus or other part of reproductive system.the pattern of bleeding is mainly heavy & regular (menorrhagia) but it could be irregular uterine bleeding or intermenstrual bleeding.
8 Classification of DUB: Primary DUB:Abnormal bleeding from the uterus where there is no disease of the genital tract, no other disease responsible for the bleeding, no IUCD and no history of sex hormone administration.Secondary DUB:Abnormal bleeding from the uterus secondary to:1. IUCD2. Administration of sex hormones.3. organic disease outside the genital tract e.g. hypothyroidism, bleeding disorders.
9 Pathophysiology of primary DUB: Depends on the pattern of bleeding and the age of the patient.Understand the mechanism of normal menstruation.PGF2∝: PGE2 is 1:1 in the follicular phase and 2:1 in secretary phase. This will → vasoconstriction of spiral vessels after 24 hrs of the menstrual cycle.Ovulatory DUB (heavy regular bleeding & painful):- present in young women.-↑ PGE2 leading to the reduction of PGF2∝: PGE2 ratio.-↓activity of endothelin (strong vasoconstrictor).- synthesis of prostacyclin in the myomertium from↑PGS endoperxides
10 Pathophysiology of primary DUB: Anovulatory DUB (heavy irregular bleeding):- Occurs after menarche and before menopause.- There is persistent proliferative endometrium in the second half of the cycle.- No ↑in PGF2∝(lack of progesterone), this will lead to:- ↓ PGF2∝: PGE2 ratio with a relative↑of PGE2 (vasodilator and antiplatelet-aggregator) .
11 Diagnosis of DUB: The diagnosis is by exclusion. History: Age of the patient, menstrual history, pattern and amount of menstrual loss.Examination: abdominal and pelvic examinationUltrasound (TAS & TVS).Hystrescopy.Endometrial biopsy (to exclude hyperplasia & carcinoma).Hormonal assays: progesterone, LH, FSH and thyroid function test.Blood tests: CBC, clotting screen
12 Management of DUB: Medical management: 1. Non-hormonal therapy: - Non-steroidal anti-inflammatory drugs (NSAID); e.g. mefenamic acid (ovulatory DUB).- Antifibrinolytic drugs; e.g. tranexamic acid (to inhibit the increased plasminogen activators & plasmin).2. Combined oral contraceptive pills.- low-dose oestrogen-progestogen is used (regulate the cycle and reduce the amount of blood loss).- progestogen dominant pills is used in progesterone deficiency and oestrogen dominant pills are used in oestrogen deficiency.
13 Medical management of DUB: 3. Progestogens:- used in anovulatory cycles to reduce the blood loss.- Norethisterone (primulot N) 5 mg tid and medroxy-progesterone acetate 10 mg tid.4. Levonorgestrel-releasing IUCD:- Induces endometrial atrophy with reduction of blood loss.5. Androgens and gonadotrophin releasing hormone (GnRH)- used when the above medical therapy has failed or surgery is contraindicated.- Androgens: danazol & gestrinone→ amenorrhoea by negative feedback and direct action on endometrium and- Gonadotrophin releasing hormone (GnRH)→ hypogonadal state
14 Surgical management of DUB: Endometrial ablation (resection):carried out under direct hysteroscopic vision using fluid for distension and irrigation. The techniques include:1. Laser ablation.2. Endometrial loop resection using electrodiathermy.3. Rollerbal electrodiathermy ablation.4. Thermal balloon ablation.Hysterectomy: