208519196 abnormal uterine bleeding

8/18/2019 208519196 Abnormal Uterine Bleeding

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DEFINITION

he evaluation of abnormal uterinebleeding (AUB) requires characterization

and quantication of thebleeding,specically the onset, duration,frequency, amount,and pattern hich isoccurring both ithin and outside the

menstrual cycle!



MENSTRUAL DIMENSIONS



(2)



MENSTRUAL DIMENSIONS (3)

Duration of

menstrual bleeding

Prolonged

> 7 days



AUB

• Tabel 1. Diferential Dian!"i" !# AUB b$ Ae Gr!%&

'ilren A!le"*ent Re&r!%*ti+e ,eri-en!&a%"al

Men!&a%"al

a.,$"i!l!i*

b.%l+!+ainiti"

*.Tra%-a.Uretral

&r!la&"ee.En!*rin!&

atie"#. ,re*!*i!%"

&%bert$

.O+arian*$"t.Genital

tra*tne!&la"-

a! Anovulatorydue toimmaturity ofhypothalamic"pituitary"ovarian a#is

b! $oagulopathyc! %regnancyd! &aginal'pelvic

infectione! Benign lesions

f! edicationsg! lleriananomalies

h!*eneticabnormality

a! %regnancyrelated

b! Anovulatoryc! &aginal'pelvic

infectiond! %elvic tumore! ndocrinopath

iesf! $oagulopathy

a! Anovulatoryb! ndometrial

hyperplasiac! ndometrial

polypsd! -eiomyomase! Adenomyosisf! *enital tract

neoplasm

a! Atrophyb! ndometri

alcarcinoma

c! ndometrialhyperplasia

d! ndometrial polyp

e! -eiomyom

asf! .ormonereplacement therapy

Aa&te #r!- S/a$er 0M. ,at!&$"i!l!$ !# abn!r-al %terine bleein. Obstet



DIFFERENTIAL DIAGNOSIS OFAUB (2)

•

ian!"ti* Te"tin

rder laboratory serum testing for human chorionic

gonadotropin (0"h$*), thyroid stimulating hormone (T1.),follicle stimulating hormone (21.), prolactin, and completeblood count ($B$)!

n omen ith ris4 factors for neoplastic processes a tissue

diagnosis is required!

f anovulatory bleeding and pregnancy have been ruled out,evaluate for coagulation disorders!



EVALUATION OF AUB

ULTRASONOGRAFI

Transvaginal Ultrasonografi (TVUSTVUS is !sef!l to eval!ated for t"e #resens of fi$roids% intra!terine #regnan&y and e&to#i&

#regnan&y'

Saline Inf!sion Sonografi

It is t"e ost sensitive non invasive et"od of diagnosis for endoetrial #oly#s and

s!$!&o!s yoata' )!t% it does not disting!is" $et*een $enign and alignant #ro&esses'

+,ST-

ROS.OP,

• T"e

advantage of t"is #ro&ed!re is t"at it #rovide dire&t vis!ali/ation of t"e endoetrial &avity and

&an $e #erfored in t"e o#erating roo'

0AGN-TI. R-SONAN.- I0AGING (0RI

• .an $e

!sef!l in t"e diagnosis adenoiosis and &an a&&!rately lo&ali/e and eas!re fi$roids%

fa&iltating deterination of t"e $est treatent'



EVALUATION OF AUB (2)

-N1O0-TRIAL SA0PLING

Re&oended for a *oen over age 23 years *it" anov!latory $leeding and &onsidered in yo!nger *oen *it" a "istory of&"roni& anov!latory $leeding or ris4 endoetrial &ar&inoa'

T"e advantage is a ra#id% safe% and &ost effe&tive'

#otential dra*$a&4 is t"at t"e $io#sy does not sa#le t"e entireendoetri! and a lo&ali/ed lesion ay $e issed'

1ILATION and .URR-TAG-.

an $e $ot" diagnosti& and t"era#e!ti&%$!t in&!rs t"e &ost of an o#erating roo and&arries t"e ris4s of anast"esia'

It5s also &an $e indi&ated in *oen *it" nondiagnosti& endoetrial $io#si'



regnan!" Asso!iated Bleeding

Pregnan&y s"o!ld $e s!s#e&ted in any *oan in "er

re#rod!&tive years'

If !rine 6".G is #ositive% a #elvi& e8aination !st $e

#erfored and an !ltrasonogra#"i& st!dy o$tained'

Any #atient *"o is "eodynai&ally !nsta$le% $leeding

"eavily% or se#ti& re9!ires s!rgi&al intervention'

:oen *it" issed or in&o#lete a$ortions *"o are

sta$le and not $leeding "eavily ay $e treated edi&ally*it" iso#rostol



D"sfun!tional uterine bleeding (DUB)

DEFINITION

1ysf!n&tional !terine $leeding (1U) is a diagnosis of e8&l!sion for AU) *it"o!t a

deonstra$le #at"ologi& &a!se and is fo!nd in a##ro8iately one t"ird of all #atients

eval!ated'

ETIOLO#$

T"e #redoinant &a!ses of 1U) are anov!lation or oligoov!lation'

Anov!lation is !ltifa&torial and related to alterations of t"e "y#ot"alai&#it!itaryovarian a8is'

longter anov!lation estrogen #rod!&tion o&&!rs *it"o!t t"e #rogesterone

#rod!&ed fro t"e &or#!s l!te! t"!s &reating an !no##osed estrogen state

ris4 for endoetrial "y#er#lasia

Anov!lation is also asso&iated *it" #oly&ysti& ovary syndroe% *"i&" also #la&es

*oen at ris4 for endoetrial "y#er#lasia'

0or$id o$esity

Peri#"eral &onversion of androstenedione to estrone o&&!rs in adi#ose tiss!e

#rod!&ing elevated estrogen levels

O&&asionally% 1U) ay $e asso&iated *it" ov!latory &y&les'



D"sfun!tional uterine bleeding (DUB) (2) %ANA#E%ENT

Adinistration of #rogestins

T"e levonorgestrelreleasing intra!terine syste (0irena

O.Ps also reg!late enses and often de&rease flo*'

Nonsteroidal antiinflaatory dr!gs (NSAI1s

1ana/ol

Antifi$rinolyti&Gonadotro#inreleasing "orone (GnR+ agonists

&U'#IAL T'EAT%ENT

• -ndoetrial a$lation is designed to a$late t"e f!ll t"i&4ness of t"e

endoetri!'

• )efore #erforing endoetrial a$lation in a *oan *it" anov!latory $leeding% endoetrial "y#er#lasia or &ar&inoa !st $e r!led o!t'

• overall s!&&ess rate is ;<= to <=% *it" 2<= to 3<= of *oen re#orting

aenorr"ea ? ont"s #ost#ro&ed!re' Still% *it"in 3 years% @3= *ill "ave a

se&ond a$lation and <= *ill "ave a "ystere&toy'

•-ndoetrial a$lation is not re&oended in *oen *"o desire f!t!refertility!



,ar-a*!l!i* Manae-ent !#Abn!r-al Uterine Bleein

9!r-!nalManae-ent

,r!e"tin"

a. Mer!:$&r!e"ter!ne (Provera) 1 - 3;<#!r 17 (a$" 1262=) !r #!r =61

b. N!retinr!ne a*etate ( Aygestin) = -3;< #!r 17 (a$" 12 an 2=) #!ran!+%lat!r$ bleein !r !n a$" =62= #!r!+%lat!r$ bleein

*. Mer!:$&r!e"ter!ne a*etate in>e*ti!n(Depo Provera) 1= - IM e+er$ 12 /? . Le+!n!re"trel6relea"in intra%terine

"$"te- (Mirena)

'!-binee"tr!en

an&r!e"tin"

a! /ral contraceptivesb! Transdermal preparations

c! &aginal ringd! .ormone replacement therapy

Anr!eni* "ter!i"

5anazol 677 mg'd

GnR9a!ni"t"a! -euprolide (Lupron) 8!9: mg 3'mo or ;;!6: mgevery 8 mo



,ar-a*!l!i* Manae-ent !#Abn!r-al Uterine Bleein (2)

N!n"ter!ial Anti6in@a--at!r$Dr%" (NSAID")

a. Me#ena-i* a*i = - 3;<b. Ib%&r!#en 6 - e+er$

r*. Me*l!#ena-ate "!i%- 1

- 3;<. Na&r!:en "!i%- == - ;

18 ten 2= - e+er$ r

AntiCbrin!l$ti* Aent" Trane#amic acid ; g >?'d on days ;to :@ or ;!: g 8?'d



'!a%lati!n Di"!rer"

enorrhagia during adolescence should be attributedto a coagulation disorder until proven otherise!

Bleeding from multiple sites (e!g!, nose, gingiva,intravenous sites, gastrointestinal, andgenitourinary tracts) may suggest coagulopathy!

here is a higher prevalence of bleeding disorders inomen ith menorrhagia!



!n illebran Di"ea"e

&onillebrand disease is the most common inherited bleeding disorder,aecting ;C to 6C of the population

3nomen ith v5, menorrhagia is the most common manifestation,occurring in <7C to D:C beginning at menarche!

omen

ith v5 are also li4ely to report postpartum or postoperative bleeding!/ther

coagulopathies may also cause AUB, including platelet abnormalities,idiopathic thrombocytopenic purpura, and hematologic malignancy (e!g!,leu4emia)!

Testing

for v5 should be considered in omen ith a history of une#plainedmenorrhagia beginning at menarche!

1creening for v5 in adolescents ith severe menorrhagia before startinghormonal therapy and in adult omen ith signicant une#plainedmenorrhagia!



ENDO'RINE DISORDERS

ndocrinopathies can cause anovulation, producingan estrogen ithout progesteron!

he endometrium eventually brea4s don, hichmay or may not lead to the formation ofhyperplasia!



9e&ati* D$"#%n*ti!n

ecreased metabolism of estrogen and decreasedclotting factor synthesis are common ramicationsof liver failure!

novulation may also ensue! enometrorrhagia iscommon!

iver function tests are necessary to ma4e thediagnosis, nding of Eaundice, ascites,hepatosplenomegaly, palmar erythema, pruritus,and spider angioma are suggestive of liver failure!



Mei*ati!n Sie Efe*t"

%sychotropic

edicationsa!$ertain

medications used in the treatment of psychiatric patients

b!Antipsychoticmedications (i!e!, dopamine antagonists) %henothiazines and antidepressants

.ormoneedications

a!edro#yprogesterone acetate

b!$ombination /$%s

c!%rogestationalagents

/ther edications

a!Anticoagulants

b!5igitalis,phenytoin, and corticosteroids

3ntrauterine5evices

a!$opper"containingintrauterine devices, unli4e the levonorgestrel"releasing irena intrauterine system

b!1uch bleeding isoften treated successfully ith F1A35s!



Benin ,at!l!$

Lei!-$!-ata-eiomyomata (broids) are the most common uterineneoplasm, and is the number one indication forhysterectomy in the United 1tates!

En!-etrial ,!l$&"

*enerally, benign endometrial lesions tend to beasymptomatic but may be present in ;7C to 88C ofomen ith complaints of bleeding, typicallymetrorrhagia!

En!-etrial 9$&er&la"iandometrial hyperplasia, a precursor to endometrialcarcinoma, is classied into simple or comple#, based onarchitectural features, and typical or atypical, based oncytologic features!



Malinan*$

ndometrial $ancer

ndometrialcarcinoma is rare in patients younger than age >7! %ostmenopausal bleeding,should be assumed to represent endometrial cancer until proven otherise!

$ervical$ancer

a!$ervicalcarcinoma is a disease of both the relatively young and the old it cause abnormalbleeding!

b! The mostcommon bleeding patterns associated ith cervical carcinoma are intermenstrualand postcoital bleeding

/varian$ancer

strogen"producing ovarian tumors, such as a granulosa"theca cell tumor, can produceendometrial hyperplasia and AUB!



1U**1T5 GA53F*1•

anagement of Anovulatory Bleeding! A$/* %ractice BulletinFumber ;>! American $ollege of /bstetricians and*ynecologists! 3nt H *ynaecol /bstet 677;@96(8)I6<8"69;!

•

on illebrand 5isease in omen! A$/* $ommittee /pinionFumber >:;! American $ollege of /bstetricians and*ynecologists! /bstet *ynecol 677D@;;>I;>8D";>>8!

•

acey H& Hr, $hia &! ndometrial hyperplasia and the ris4 of

progression to carcinoma! aturitas 677D@<8(;)I8D">>!

•

asablanca J! anagement of dysfunctional uterine bleeding!/bstet *ynecol $lin Forth Am 677K@8:(6)I6;D"68>, viii!

208519196 abnormal uterine bleeding

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