Abnormal uterine bleeding

1. Abnormal uterine bleeding professor Miami Abdul Hassan F.I.C.O.G 2019-2020

2. Regular cyclic menstruation results from the relationship between the endometrium and its regulating factors. Changes in either of these frequently results in abnormal bleeding

3. Characteristics of normal and abnormal menstruation: Normally the menstrual cycle occurs at each 28 days (the normal range is 21 to 35 days) and lasting for average 5 days (the normal range is 2 to 8 days)

4. and the average loss of blood in each cycle is 40 ml (the normal range 20-80ml).

5. So any alteration in this normal pattern will be regard as (AUB) this AUB is a symptom, not a disease and it occur in various forms:

6. Menorrhagia: is a cyclic bleeding at normal interval, but it is excessive in amount (>80 ml) and /or duration (>8 days).(excessive bleeding at regular interval over several consecutive cycle ).

7. Heavy menstrual bleeding (HMB) is now a preferred description. It replaces the older term ‘menorrhagia HMB is defined as excessive menstrual blood loss (over several consecutive cycles)

8. Polymenorrhea: (frequent cycle) is cyclic bleeding which is normal in amount but occurs at too frequent interval (<21 days).

9. Oligomenorrhea:( infrequent cycle). is a regular cycle but occur at intervals of >35 days to 6 months (i.e. infrequent cycle), or less than 8 cycles per year.

10. Metorrhagia: uterine bleeding occurring at completely irregular but frequent intervals, the amount being variable.

11. Intermenstrual bleeding: bleeding of variable amounts occurring between regular menstrual periods.

12. Intermenstrual bleeding • may be associated with polypi or submucus fibroid. If regular cyclic, it is often dysfunctional due to fall of estrogen following ovulation

13. Intermenstrual bleeding • Careful examination of the CX.is essential , any suspicious finding s are indication for colposcopy.In young woman Chlamydia infection should be excluded especially if bleeding is confined to midcycle

14. PCB: • bleeding after sex. Often associated with: • cervical abnormalities .Premalignant • and malignant disease of the lower genital tract).

15. Causes of AUB: are divided into organic and non – organic.

16. Organic cause • Reproductive Tract Disease . • systemic • pregnancy related Complications.

17. Organic cause • Reproductive Tract Disease • systemic • pregnancy related Complications

18. Benign pelvic lesions • Leiomyomata. • Endometrial or endocervical polyps. • Adenomyosis and endometrios

19. Pelvic infections (PID) • Intrauterine contraceptive device (IUCD) • Trauma • Foreign bodies (IUD, sanitary products)

20. PID

21. Malignant pelvic lesions • Endometrial hyperplasia • Endometrial cancer • Cervical cancer • Less frequently: vaginal,vulvar, fallopian tube cancers • estrogen secreting ovarian tumors granulosa-theca cell tumors

22. . endom.ca

23. Cervical ca

24. Systemic disorder • Endocrine disorder • Hematological disorders • Liver disorders • Renal disease

25. Medications: such as • steroid hormones • Anticoagulants • neuroleptics, • and cytotoxic agents.

26. Emotional stress and psychological upset • : these may affect the hypothalamus and the higher centers

27. pregnancy complications These are the most common cause of AUB in females of 20-40 years age . These include: • Ectopic pregnancy, • Miscarriage • Gestational trophoblastic disease.

28. some time the bleeding is not from the genital tract but it comes from the urethra or rectum, so these causes should be taken in a consideration.

29. B) Non – organic cause i.e. dysfunctional uterine bleeding (DUB): DUB : Is an abnormal uterine bleeding in the absent of apparent organic cause, so the diagnosis is made by exclusion of all organic cause of AUB.

30. One system that is increasingly recognized is the PALM–COEIN system developed by (FIGO), in which the nemonicPALM • Polyps, • Adenomyosis, • Leiomyoma, • Malignancy COEIN for causes unrelated to structural anomalies: Coagulopathy, • Ovulatorydisorders, • Endometrial, • Iatrogenic, • Not classified causes (see Further reading).

31. New definition HMB of endometrial origin Bleeding of endometrial origin (BEO)

32. Evauation of DUB • Age, • menstrual pattern, • sexual activity, • trauma, infection, • systemic disease, • stress • history of bleeding tendency, • hormonal therapy or IUD

34. Symptoms which can be associated with HMB and related pathologies ( Endometrial or cervical polyp) • Irregular bleeding • Intermenstrual bleeding • Postcoital bleeding.

35. (Coagulation disorder) • Excessive bruising/bleeding from other sites • History of postpartum haemorrhage (PPH) • Excessive postoperative bleeding • Excessive bleeding with dental extractions • Family history of bleeding problems

36. Unusual vaginal discharge(Pelvic inflammatory disease ) • (Urinary symptoms (Pressure from fibroids • Weight change, skin changes, fatigue (Thyroid disease)

37. examination: General:signs of anaemia, evidence of systemic coagulopathy (bruising, petechiae) and thyroid disease (goitre). Abdominal:Pelvic&abdominal swelling, liver, spleen Pelvic: infections, lesions, lacerations, polyps, fibroids

38. Investigations:

39. 1-Full blood count (should be send for all the patient) 2.Coagulation screen. Referral for a haematological opinion should be considered in women with a history consistent with a coagulation disorder

40. 3-β-hCG 4- PAP smear. 5-Hormone testing should not be performed routinely

41. 5.A pelvic ultrasound scan (USS) should be performed: when a pelvic mass is palpated on examination (suggestive of fibroids); when symptoms suggest an endometrial polyp, e.g.irregular or intermenstrual bleeding;

42. TV U/S TV/US to: detect any pelvic pathology and to assess the thickness of the endometrium especially in postmenopausal women ( < 5 mm, endometrial cancer is unlikely)

43. 6.High vaginal and endocervical swabs High vaginal and endocervical swabs should be taken: • when unusual vaginal discharge is reported or observed on examination; • where there are risk factors for PID

44. 7-Endometrial sampling It is recommended in the evaluation of AUB in: • 1.Woman aged > 45 years • 2.Those with high risk for endom.ca (obesity, hypertension, diabetes, chronic an ovulation, nulliparity with history of infertility, family history of colonic& endom.ca & tamoxifen therapy Plan your Lecture

45. 7-Endometrial sampling 3.In younger woman it is indicated when the AUB doesn't resolved with medical treatment or when inter menstrual bleeding persist

46. The most common methods for endom.sampling are: • 1.Aspiration curettage (pipelle, vabra, sharman). • 2. D&C • 3.Hysteroscopy .

47. pipelle

48. D&C

49. hysteroscope

50. Treatment of abnormal uterine bleeding :when an organic cause is detected treatment is directed to it, e.g. : Fibroids:GnRH agonists, myomectomy or hysterectomy, uterine artery embolization.