ABNORMAL UTERINE - Urogynaecology
Transcript of ABNORMAL UTERINE - Urogynaecology
Dr Stephen Jeffery
ABNORMAL UTERINE BLEEDING
ABNORMAL UTERINE BLEEDING
Most common complaint in gynaecologicalpractice
Affects 1/3 women at some stage in her life
Key to management
- establishing cause
- instituting appropriate therapy
MENSTRUAL CYCLE
NORMAL PERIOD???
Variation in cycle length between different women ranges between 23 -39 days, mean 30 days
Duration of menstrual bleeding varies from 2 - 8 days
BLOOD LOSS
Objective menorrhagia:
- blood loss > 80ml/ cycle
- 60% of these women will have evidence of iron deficiency anaemia
BLOOD LOSS
Subjective menorrhagia:
- 50% of women presenting with heavy
menses will have measured blood loss within normal limits
- Must still be considered abnormal, and
investigated accordingly
DEFINITIONS
Polymenorrhoea: Menstruation with normal duration and flow, but shorted cycle with intervals < 25 days
Menorrhagia:
Heavy cyclical bleeding
Metrorrhagia:
Uterine bleeding independent of menstrual pattern
Menometrorrhagia:
Increased flow during menstruation and between menstrual periods
LOCAL UTERINE PROBLEMS
① Benign Neoplasms polyps, fibroids, hyperplasias
② Malignant Neoplasms
③ Congenital Uterine Anomalies
④ Trauma
⑤ Infection
⑥ Endometriosis/ Adenomyosis
IATROGENIC
① Hormonal contraceptives
② Hormone replacement therapy
③ Intrauterine devices
④ Anticoagulant therapy
⑤ Haemodialysis
ENDOCRINE AND SYSTEMIC DISORDERS
① Hypothyroidism
② Adrenal disorders
③ Hepatic disease
④ Renal Disease
⑤ Obesity
DYSFUNCTIONAL UTERINE BLEEDING
Defined as abnormal uterine bleeding in the absence of organic disease
Diagnosis of exclusion!
Accounts for 60% of cases of abnormal uterine bleeding
May be ovulatory or anovulatory
DYSFUNCTIONAL UTERINE BLEEDING
OVULATORY- majority of women, 90%
- due to local factors originating in the endometrium - prostaglandin and fibrinolytic systems
- often co-existing PMS and dysmenorrhoea
DYSFUNCTIONAL UTERINE BLEEDING
ANOVULATORY- 10%- due to abnormality of H-P-O axis- either excessive stimulation of the
endometrium by oestrogen, or inadequate stimulation
PCOS, Menarchal, Perimenopausal
DEFINITIONS
Polymenorrhoea: Menstruation with normal duration
and flow, but shorted cycly with intervals < 25 days
Menorrhagia/ Hypermenorrhoea:
Heavy cyclical bleeding
Metrorrhagia:
Uterine bleeding independent of menstrual pattern
Menometrorrhagia:
Increased flow during menstruation and between menstrual periods
HMB= Heavy menstrual bleeding
AUB = Abnormal Uterine Bleeding
Chronic AUB = abnormal in quantity, regularity and/or timing for >6 months
Acute – severe enough to require immediate intervention
IMB = Intermenstrual bleeding
Polyps
Adenomyosis
Leiomyomas
Malignancy/ hyperplasia
Coagulopathy
Ovulator y dysfunct ion
Endometr ia l d isorders
Iatrogenic
Not c lassi f ied
POLYP
PALM-COEIN
POLYP
PALM-COEIN
POLYP
PALM-COEIN
ADENOMYOSIS
PALM-COEIN
ADENOMYOSIS
PALM-COEIN
ADENOMYOSIS
PALM-COEIN
LEIOMYOMA (FIBROIDS)
PALM-COEIN
MALIGNANCY / HYPERPLASIA
PALM-COEIN
MALIGNANCY / HYPERPLASIA
PALM-COEIN
COAGULOPATHY
PALM-COEIN
OVULATORY DISORDERS
LACK OF CYCLICAL PROGESTERONE PRODUCTION
“LOOP” EVENTS
USUALLY UNKNOWN BUT CAN BE THYROID
PCOS
HYPERPROLACTINAEMIA
MENTAL STRESS
OBESITY
ANOREXIA
WEIGHT LOS
EXTREME EXERCISE
DRUGS
PALM-COEIN
ENDOMETRIAL LACK OF VASOCONSTRICTORS
???????????
PALM-COEIN
IATROGENIC
Break Through Bleeding (BTB)
MIRENA
PALM-COEIN
NOT CLASSIFIED
PALM-COEIN
HISTORY
① Normal cycle + changes
② Duration of flow, amount of blood loss, clots, flooding/ accidents, symptoms of ovulation.
③ Sexual history + contraception
④ General medical history + medication
⑤ Family history
GENERAL EXAMINATION
① Anaemia
② Purpura, petechiae
③ Stigmata of endocrine disease -goitre, obesity, striae, hirsutism
④ Breast exam
⑤ Abdominal exam
⑥ Pregnancy, pelvi-abdominal mass,
⑦ Liver, spleen
PELVIC EXAMINATION
Exclude bleeding from rectum and urethra
Vulva
Vagina
Cervix
Uterus & Adnexa
Rectal exam
SPECIAL INVESTIGATIONS
Basic Hb, FBC if anaemic Pregnancy test!!! Cervical smear Pelvic ultrasound Endometrial sampling
Occasional TSH, endocrine investigations if clinical suspicion
Referral for Hysteroscopy
Patient with prolonged chronic anovulation
Obese patient
Patient> 35-40 years with heavy or irregular bleeding
All postmenopausal bleeders
Patients who require endometrial sampling:
Chronic irregular bleeding
Peri-menopausal
Post-menopausal ET > 5mm
Ultrasound suggests fibroid or polyp
HYSTEROSCOPY
MANAGEMENT
Dictum: All postmenopausal (or perimenopausal) bleeding is considered to be caused by cancer until proven otherwise!
POSTMENOPAUSAL BLEEDING
Menarchal girl with irregular period and no other obvious pathology
Reproductive age (less than 40) with CYCLICAL, heavy bleeding and normal uterus and not yet tried medical therapy
Obvious cause of anovulatory bleeding eg PCOS and not yet tried medical therapy eg COC
Post-menopausal and ET <5mm, normal Pipelle
WHEN IS IT OK TO NOT INVESTIGATE FURTHER?
ACUTE BLEEDING EPISODE
① Haemodynamic stabilization
② Thorough history and examination
③ Hormonal therapy
(a) High-dose oestrogen for atrophic endometriumor (b) High-dose combined oral contraceptive pill if
bleeding not too severeor (c) Provera 5mg daily for anovulatory bleeding
PLUS Cyclokapron 1,5g 8 hourly IV or 1g 6hrly po
DEFINITIVE MANAGEMENT
• EXPECTANT MANAGEMENTmenstrual calendar x 3/12ths
may resolve spontaneously correction and prevention of anaemia
• MEDICAL MANAGEMENT
• SURGICAL MANAGEMENT
Should be individualized
MEDICAL MANAGEMENT
1. ANTIFIBRINOLYTIC DRUGS
Tranexamic acid ( Cyclokapron)
Prevents activation of plasminogen
Decreases blood loss by 47% in women with menstrual blood loss > 80 ml/ cycle
1. ANTIFIBRINOLYTIC DRUGS
1/3 of patients report side effects
- nausea, dizziness, tinnitus, rashes,
abdominal cramps
Case reports of serious thrombosis
- caution advised in patients with past
history or risk factors of thrombotic
disorders
Underlying pathophysiology:
- altered ratio of prostaglandin E2 to F2
- increased ratio of of prostacyclin to
thromboxane synthesis
Will reduce flow by 40-50%
Mefenamic acid (Ponstan) 250-500 mg po qid with onset of menses for 7 days.
2. NSAIDS
Will reduce flow by at least 50%
Advantages:
- cycle control
- reliable contraception
Side effects:
- weight gain, abdominal discomfort, spotting
Healthy, nonsmoking women with no cardiovascular or thrombotic risk factors can use the Pill up to menopause
3. LOW DOSE MONOPHASIC ORAL CONTRACEPTIVES
Cyclic Provera 10 mg po OD x 10 days per month
or Depo provera 150 mg IM q 3 month
Anovulatory DUB
Useful in patients in whom oestrogens are contraindicated and > 40 years old
Prescribed from day 16 - 25 of the cycle
Reduction in menstrual blood loss of 15%
Side effects include weight gain, bloating, oedema, headaches, and depression
4. PROVERA
5. MIRENA
5. MIRENA
Release intrauterine progesterone in controlled manner over 5 years
- Mirena: levonorgestrel 20µg/ 24 hours
Method of action:
- reduction in endometrial prostaglandin
synthesis
- production of an inactive endometrium
- reduction in endometrial fibrinolytic
activity
5. MIRENA
Reduction in menstrual blood loss
of 65 - 95%
Advantages:
- reliable contraception
- few side effects
SURGICAL MANAGEMENT
1. ENDOMETRIAL ABLATION
Destruction of the endometrial lining to treat excessive menstruation
1. ENDOMETRIAL ABLATION
Products available
① Thermachoice
② Cavaterm
③ Thermablate
④ Novasure
⑤ Microwave endometrial Ablation
Hysterectomy In The USA
Prolapse
14%
Endometriosis
18% DUB25%
Fibroids
25%
Pain
9%Precancer
9%
600,000 hysterectomies per year in USA
> $4 Billion in direct and indirect costs
37% of women have had hysterectomy by age 60
2.UTERINE ARTERY EMBOLISATION
3.HYSTERECTOMY
Definitive management for DUB in patients:
- who have completed their families
- with failed medical treatment
- over the age of 45
- with failed endometrial ablation
Can be performed either by abdominal or vaginal route
3.HYSTERECTOMY
Vaginal Hysterectomy
Total Abdominal Hysterectomy
Laparoscopic Assisted Vaginal Hysterectomy
Total Laparoscopic Hysterectomy
Subtotal Hysterectomy
Subtotal Laparoscopic Hysterectomy
Myomectomy
MANAGEMENT ACCORDING TO AGE GROUPS
PREPUBERTAL CHILD
Precocious puberty - 2o sexual characteristics
Foreign bodies
Vaginitis
Tumours
Iatrogenic - accidental ingestion of steroid hormones
Abuse
ADOLESCENCE
Almost always anovulatory!
First 30 - 40 cycles after menarche may be anovulatory
Management:
- exclude pathological cause
- reassure, counsel, haematinics
- low dose combined oral contraceptive
pill or cyclical progesterone
PERIMENOPAUSAL
> 40 years
May be due to organic cause or anovulatory DUB
DUB:
- due to alteration in pituitary-ovarian function preceding the menopause
- bleeding usually acyclical
- associated with endometrial
hyperplasia in 50% of cases
Endometrial sampling NB!!