1. ABNORMAL UTERINE BLEEDING
Dr farzipour

2. Abnormal uterine bleeding
Accounts 20% of all gynecologic visits The clinical approach begins with history Many phisycians have encompassed the all term menometrorrhagia Much more information gleamed from timing and character of bleeding There is increase in incidence of endometrial cancer with age 30 – 34(2.3/100,000) to age (6.1/100,000) Any woman older than 35 y/o with AuB endometrial assesstment to exclude cancer is indicated Hallmark of ovulation is regulation of cycle. Metrorragia: intermensfural irregular noncyclic bleeding Organic pathology polips , submucusal myoma hyperplasia or even frank carcinoma can cause irregular vaginal bleeding Menorrhagia without a component of metrorragia maybe physiologic (increasing parity)

3. Other historic information : Contraceptive method , possibility of pregnancy concomitant medications A thorough out pelvic examination is essential Pregnancy must be excluded Post menopausal bleeding : Any spotting bleeding or staining after 12 month of amenorrhea should be view endometrial cancer until proven otherwise

4. endometrial evaluation:
initially, curettage in hospital with anesthesia was the gold standard (1843) local lesion was missed (polyps) vacuum suction in office were cumbersome and discomfort (1970) subsequently cheaper, smaller, less painful plastic catheter was popular (pipelle) sensivity 82-93%

5. Transvaginal ultrasound
A degree of image magnification and sonomicroscopy Alternative method for D&C and endometrial biopsy Thin endometrial echo =<4-5mm effectively exclude significant tissue with bleeding Sono hystrography The use of fluid instillation in to the uterus coupled with high-resolutions transvaginal props Distinguish primenopausal patiets with DUB from those with globally thickened endometrium or focal abnormality

6. Timing of the procedure
Sonography performed as soon as after the bloody cycle is ended. The patient sometimes has irregular bleeding An empire course of a progestogen such as medroxyprogesterone acetate 10mg daily for 10 days as a medical curettage and then time the ultrasound evaluation to the withdrawal bleed.

8. Hysteroscopy
A procedure in which a small endoscope is inserted into the vagina and through the cavity Taking biopsy or removing endometrial polyps and submucusal myoma Diagnostic in office setting Must often accompanies D&C in an operating room

9. Management of abnormal uterine bleeding
Medical Surgical The most common cause of AuB in premenopausal is oligoanovulation endometrium become proliferative and some hyperplastic AuB can cause with anatomic disorder fibroid, polyps, hyperplasia, frank carcinoma Appropriate evaluation before therapy has been discussed Any bleeding in post menopausal women without hormone therapy must be evaluated The most common cause of such bleeding is endometrial atrophy, an organic pathology must be excluded Progestin based medical management maybe indicated with follow up evaluation after several month

10. Medical therapies
Hormonal management Oral contraceptive : Low dose oral contraceptive is first line treatment of AuB in otherwise healthy nonsmoking premenopausal women Ocp are not recommended for women with history of DVT over age 35 who smoke or with HTN

11. Continuous progestin only contraceptive:
Injectable long acting medroxy progesterone acetat in a depo form (DMPA) provided amenorrhea and contraception if needed A black box warning for DMPA loss of bone mass Levonorgestrel releasing intrauterine system is a cost effective alternative for hysterectomy 40% undergo hysterectomy For perimenopausal women with DuB and vasomotor symptom menopausal doses of estrogen can be added to DMPA or IUS system

12. Cyclic oral progestogen
Cyclic progestogen therapy d/mo in the past was standard
Parenteral estrogen
IV estrogen for acute excessive AUB
Increase risk of thrombosis
Gonadotropin-Releasing Hormon Agonist
Induse a reversible hypoestrogenic statue
Effective in reducing menstrual blood loss in premenopausal patient
Limited byexpensive and side effects(hot flash,reduction of bone density)

13. Non hormonal management
Nonsteroidal anti-inflammatory drugs
NSAIDs reduce endometrial prostaglandin levels
Therapy started 24-48H prior to menstrual onset and continued for 5 days or until cessation of mense
20-50% decrease menstrual blood loss, 70% improved dysmenorrhea
Iron
All women with AuB should evaluate for anemia due to iron deficiency
Iron supplementation may be appropriate

14. Surgical management
Dilation and curettage D&C requires general anesthesia When performed without concurrent hysteroscopy can miss localized disease Hysteroscopy allows for diagnostic and operative intervention

15. Endometrial destruction
Surgical techniques for endometrial resection and ablation are alternative to hysterectomy in selected patients
Ablative procedure are not successfully treated AuB when the anatomic lesion is located in uterine wall such as intramural myoma adenomyosis
Uterine artery embolization
A catheter is introduced into the femoral artery and advanced to the uterine artery under fluoroscopic guidance
Tiny particle embolize arterial blood flow and infarcts the fibroids
Hysterectomy
Hysterectomy (total or supraservical) is the only definitive cure for benign AuB that has failed to medical treatment.

16. Thank you