ABNORMAL UTERINE BLEEDING ASSOCIATE PROFESSOR IOLANDA BLIDARU MD, PhD

DEFINITION Any deviation in normal frequency, duration or amount of menstruation in women of reproductive age. NORMAL MENSES Frequency: d Duration: 3-7 d Volume: ml

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)

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

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

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)

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

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.

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

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

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.

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

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

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

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

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).

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

C. Surgical 1.Endometrial ablation 2.Hysterectomy

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

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

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