1. ABNORMAL UTERINE BLEEDING ASSOCIATE PROFESSOR IOLANDA BLIDARU MD, PhD

2. DEFINITION 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

3. CLINICAL TYPES Polymenorrhea: frequent (<18 d) menstruation, at regular intervals Menorrhagia (hypermenorrhea): Excessive (>80 ml) & / or prolonged menstruation, at regular intervals Metrorrhagia, spotting: bleeding at irregular intervals. Menometrorrhagia: both. Hypomenorrhea: scanty menstruation. Oligomenorrhea: infrequent menstruation (>45 d)

4. CAUSES GENITAL 1. Dysfunctional uterine bleeding 2. Pregnancy complications 3. Genital disease s Tumors: Benign Malignant Infection: PID Endometriosis, adenomyosis IUD Prolapse or retroversion

5. Extragenital causes Endocrine: hypo or hyperthyroidism Haematological: Idiopathic thrombocytopenic purpura, Von-Willebrand disease Chronic systemic disease: liver failure, renal failure, HTA Iatrogenic: Sex hormones, anticoagulants. Emotional: psychosomatic disorders Obesity: increased peripheral estrogen conversion

6. DYSFUNCTIONAL UTERINE BLEEDING Definition DUB is abnormal bleeding that has no organic cause (such as pregnancy, inflammation or neoplasia). can coexist with organic pathology Incidence 60 % of AUB (puberty and perimenopause)

7. Pathophysiology 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 → short luteal phase Persistent C luteum leading to Irregular shedding long luteal phase

8. Risk of endometrial cancer Chronic anovulation has 3 times increased risk. Chronic proliferation of the endometrium → adenomatous hyperplasia → atypical adenomatous hyperplasia → endometrial carcinoma. Transition - up to 10 years or more.

9. I.History: Age, Menstruation, Obstetric / gynecologic conditions II.Clinical Examination 1.General: pallor, endocrinopathy, coagulopathy, pregnancy 2.Abdominal assessment: liver, spleen, pelvic- abdominal mass 3.Pelvic assessment: origin of the bleeding, cause Diagnosis

10. Local examination + investigations 1.Pap smear 2.US – TVS, TAS 3. Endometrial biopsy: D & C, Hysteroscopy

11. D & C Indications: 1.Mandatory after 4o yrs - Fractional curretage: 2 samples: endocervical + corporeal 2. Persistent / recurrent bleeding between 20 & 40 yrs Diagnosis of the type of the endometrium : hyperplastic, proliferative, secretory, irregular ripening, shedding, atrophic. Curettage is essentially a diagnostic & not a therapeutic procedure.

12. III. Laboratory Investigations Systemic: 1.CBC 2. β HCG 3. Prolactin, TSH, T, LH, FSH, T4 4.Coagulation factors

13. Treatment A. General - of iron deficiency anemia B. Medical C. Surgical

14. B. Medical I.Hormonal 1.Progestagens, LNG-IUS (Mirena) 2.Estrogen 3.COC 4.Danazol 5.GnRH agonist II.Non –hormonal 1.Prostaglandin synthase inhibitors (PSI) 2.Antifibrinolytics Tranexamic acid 3.Ethamsylate

15. Progestagens Systemic : Norethisterone, medroxyprogesterone acetate, lynestrenol - p.o. 5 mg /d from d 5-15 to 25 Intrauterine: Levonorgestrel intrauterine system Mirena- delivers 20ug LNG /d. for 5 years Effect 1.Comparable to endometrial resection 2.Superior to PSI & antifibrinolytics 3.May be an alternative to hysterectomy in some patients

17. The combined contraceptive pill (COC) Reduce MBL by 50% Mechanism of action: endometrial suppression Danazol : synthetic androgen with antiestrogenic & antiprogestagenic activity; Dose: 200 mg/d Mechanism of action : inhibits pituitary gonadotropins & endometrial suppression GnRH analog nasal sprays: nafarelin and busereline daily subcutaneous injections: busereline i.m./ s.c. depot: gosereline, leuprorelin, triptorelin (Diphereline).

18. Prostaglandin synthase inhibitors ( PSI) Mechanism of action: ↓ endometrial PG conc. Mefenamic acid Effect (prolonged) on MBL & dysmenorrhea, headache, nausea, diarrhea & depression Tranexamic acid – antifibrinolytic Etamsylate Mechanism of action: maintain capillary integrity, anti-hyaluronidase activity & inhibitory effect on PG Dose: 500 mg x 4 / d, starting 5 days before anticipated onset of the menstruation & continued for 10 days

19. C. Surgical 1.Endometrial ablation 2.Hysterectomy

20. Surgical treatment Endometrial ablation Methods: I. Hysteroscopic: Laser, Electrosurgical II. Non-hysteroscopic: Microwave.

22. Dysmenorrrhea symptom / disease painful menstruation classification: 1.primary (idiopathic) 2.secondary

23. Dysmenorrrhea primary (idiopathic ) associated symptoms: headache, backache, nausea, vomiting Treatment: antiprostaglandins progestins analgesics, antispasmodics resection of presacral nerve (Cotte op.) secondary 1. chronic PID 2. endometriosis 3. uterine myomas 4. cervical stenosis 5. pelvic adhesions