Dysfunctional uterine bleeding

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DYSFUNCTIONAL UTERINE BLEEDING I unit OG,2k6 Batch MMC,madurai

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Page 1: Dysfunctional uterine bleeding

DYSFUNCTIONAL UTERINE BLEEDING

I unit OG,2k6 Batch MMC,madurai

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DYSFUNCTIONALUTERINE BLEEDING

INTRODUCTION

M.NITHYA I UNIT

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INTRODUCTION

Dysfunctional uterine bleeding is one of the most common and significant gynaecological problem of women attending OPD Cyclic interplay between hormones and uterus leads to visible loss of endometrial tissue and blood called menstruation.

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Purpose – to prepare endometrium for implantation and growth of fertilised ovum

This cyclical bleeding has been quoted as,

Acyclical or prolonged – Dysfunctional

THE CURRENT CONCEPT IS, The disturbance in endometrial blood vessels and

capillaries ,coagulation of blood in and around these vessels are probably due to alteration in the ratio of endometrial prostanoids.

“weeping of the disappointed uterus”

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Vaginal bleeding is considered abnormal when menstrual periods are too heavy /too light/lasts too long ,occurs too often are irregular .any vaginal bleeding that occurs before puberty or after menopause is abnormal until proven otherwise.

Bleeding may be abnormal in frequency ,duration,amount or combination of any of these as the diagnosis is based with the exclusion of organic lesion’s ,so with care and facilities such an organic lesion is excluded and DUB is diagnosed

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DEFINITION Dysfunctional uterine bleeding is defined as

an excessive state of abnormal bleeding from the genital tract without any clinically detectable and palpable organic pelvic pathology [tumour , inflammation] ,systemic illness and iatrogenic cause . It is a symptom ,not a disease.

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INCIDENCE 10-15 %

PREVALENCE Varies widely

AGE GROUP It can ocurr at any age group ,quite

frequently in the middle reproductive age group .

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CRITERIA FOR NORMAL MENSTRUATION

cycle length duration of bleeding amount of blood loss

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CYCLE LENGTH Interval between first day of one period and first

day of next .

NORMAL RANGE : 21-35 days

NORMAL MEAN:28 days

Regularity of cycle length depends on HPO [hypothalamo pituitary ovarian ]axis.

Irregular cycles ocurrs in post menarche and perimenopausal women.

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DURATION OF BLEEDING

Normal range: 2-7 days

Normal mean:5 days

AMOUNT OF BLOOD LOSS

Normal range:50-80ml

Normal mean:around 40ml

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MENSTRUAL CYCLE IRREGULARITIES

AMENORRHEA OLIGOMENORRHEA POLYMENORRHEA HYPOMENORRHEA DYSMENORRHEA MENORRHAGIA METRORRHAGIA MENOMETRORRHAGIA

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AMENORRHEA Absence of mensturation

It is a symptom not a disease.

OLIGOMENORRHEA infrequent,irregularly timed episodes

of bleeding occurs at intervals of more than 35 days.

POLYMENORRHEA frequent episodes of

menstruation ,occurs at intervals of 21 days or less.

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MENORRHAGIA Regularly timed episodes of

bleeding that are excessive in amount [>80 ml] and/or duration of flow [>5 days].

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METRORRHAGIA Irregularly timed episodes of

bleeding superimposed on normal cyclical bleeding.

MENOMETRORRHAGIA Excessive prolonged bleeding that

occurs at irregularly timed and frequent intervals.

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HYPOMENORRHEA Regularly timed but scanty episodes of

bleeding.

DYSMENORRHEA Painful cramping pain accompanying

menstruation.

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NORMAL AND ABNORMAL MENSTRUATION

MALINI

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HYPOTHALAMO-PITUITARY OVARIAN AXIS

+ FSH ESTROGEN

- GnRH +

LH PROGESTRONE -(Hypothalamus) (pituitary) (ovary)

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PHASES OF MENSTRUATION

PHASES :

1. MENSTRUATION 1–4 DAYS

2. PROLIFERATIVE PHASE 5–13 DAYS

3. PHASE OF OVULATION 14th DAY

4. SECRETORY PHASE 15–28 DAYS

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PROLIFERATIVE PHASE

• This phase is due to estrogen• Corresponds to proliferative phase or

estrogenic phase of ovarian cycle • Starts when regeneration of

endometrium is complete lasts until the 14th day of 28 days cycle

• At the end of menstruation the endometrium is represented by basal layer and its thickness is about 1mm

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• The uterine glands are short,straight,simple tubular glands.

• Uterine glands grow in length and about the 10th day the glands become slightly sinous and their columnar epithelium becomes taller than before.

• Epithelial cells also increase in number by mitosis and stromal blood vessels of the endometrium also grow with increase in number of coils.

Before ovulation the endometrial thickness becomes 5-6mm.

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OVULATION

• Occurs at the 14th day.• Due to action of LH,the graffian

follicle ruptures and ovulates forming CORPUS LUTEUM.

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LUTEAL PHASE

• Due to the action of progesterone• Begins on the 15th day until the onset of

menstruationCHANGES :1. Development of subnuclear vacuolation - Day

172. Uterine glands become tortuous (cock screw)

and glycogen appears in the glandular lumenEndometrial thickness : 8-10mm Day 19

3. Stromal edema-Day 21.

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• Perivascular cuffing – Day 23• Coiled arteries becoming more

closely wound,lymphocyte infilteration occur –Day 25

MENSTRUAL PHASE

• Lasts for 3-5 days• Superficial endometrium becomes

ischemic due to vasoconstriction and blood stasis

• Tissue sloughs off and blood vessels open up

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• Perivascular cuffing – Day 23• Coiled arteries becoming more

closely wound,lymphocyte infilteration occur –Day 25

MENSTRUAL PHASE

• Lasts for 3-5 days• Superficial endometrium becomes

ischemic due to vasoconstriction and blood stasis

• Tissue sloughs off and blood vessels open up

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HEMOSTASIS

Achieved in a normal menstruation by 2 mechanisms:

Formation of platelet plugConstriction of spiral arterioles

Vasoconstriction is brought about by means of prostaglandins

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DEFICIENT HEMOSTASIS

DUE TO:Disturbance in prostanoid metabolismIncreased fibrinolysis in endometrium

NORMAL:• In proliferative phase the endometrium

synthesizes equal amount of PGE2 & PGF2α

• In luteal phase PGF2α increases due to estradiol & progesteronePGF2α : PGE2 =2:1

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Endometrium – PGF2α, PGE2 & PGD2

Myometrium – PGE2 from arachidonic acid & endoperoxidases.

Phospholipid

Free Arachidonic Acid

Endoperoxides

PGE2 PGF2 α

PGI2

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1. First, PGF2 α produces vasoconstriction

2. Endoperoxides from endometrium are deviated to the myometrium which produces PGI2

3. This then diffuses back into endometrium which causes vasodilation followed by vasoconstriction of spiral arterioles preceding menstruation

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WITHDRAWAL OF PROGESTERONE

BREAKDOWN OF LYSOSOMES

RELEASE OF PHOSPHOLIPASE A2

PROSTANOID CASCADE

PREDOMINATION OF VASOCONSTRICTOR PROSTANOIDS

ORDERLY BLEEDING

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ABNORMAL HEMOSTASIS IN DUB

Failure in vasoconstriction due to excessive secretion of PGE2 & increase in PGE2 :PGF2α.

Failure in formation of adequate thrombotic plugs due to PGI2 excess.

Increased fibrinolysis due to increase in the tissue plasminogen activator.

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Increased endometrial lysosomal enzymes with excessive prostanoid formation.

Failure in vascular endothelial proliferation due to relaxin.

Delay in endometrial regeneration.

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TYPES OF DYSFUNCTIONAL UTERINE BLEEDING

• JAYAPRABHA

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DUB

ANOVULATORY OVULATORY(80%) (20%)

• PUBERTY MENORRHAGIA OVULATORY POLYMENORRHOEA• REPRODUCTIVE AGE OVULATORY OLIOMENORRHOEA

GROUP MENORRHAGIA• METROPATHIA HEMORRHAGICA OVULATORY MENORRHAGIA

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ANOVULATORY

PUBERTY MENORRHAGIA :-

Few cycles following menarche are anovulatory

Immature hypothalamo – pituitary – ovarian axis

Underactivity of ovarian function

Immature follicles & no ovulation

Only oestrogen secretion

Oestrogen level reaches critical threshold level

Hormone withdrawal

Shedding of endometrium (Breakthrough bleeding)

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• REPRODUCTIVE AGE GROUP MENORRHAGIA :-

Following pregnancy & abortion

Disturbed hypothalamo – pituitary – ovarian axis

Hormonal imbalance

Bleeding

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METROPATHIA HAEMORRHAGICA :-

Exact cause is not known

Disturbance in Hypothalamus or Anterier pituitary

FSH is continuously secreted without LH surge

Mature follicle

Increased level of oestrogen

Short period of amenorrhoea

Withdrawal of oestrogen

Continues bleeding

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BLEEDING IN METROPATHIA HAEMORRHAGICA

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• MICROSCOPIC FEATURES :-

Cystic glandular hyperplasia (Swiss cheese pattern)

Absence of secretory hypertrophy

Areas of necrosis are scattered over superficial layers of endometrium

OVARY :-

Cysts are present

Corpus luteum absent

Diffuse polyp in the endometrium

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Pic. 1 in MH

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Pic. 2 in MH

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Pic. 3 in MH

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OVULATORY

OVULATORY OLIGOMENORRHOEA :-

Prolonged proliferative phase with normal secretory phase

Infrequent cycles are present

Occurs in adolescence & preceding menopause

Endometrium normal

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• OVULATORY POLYMENORRHOEA:-

Ovary is normally functioning but matures quickly affecting follicular phase than

luteal phase

Short proliferative phase

Menstrual bleeding occurs every 2-3 weeks

Normal Endometrium

Occurs in few cycles following menarche, abortion & delivery

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CORPUS LUTEAL ABNORMALITY :-

D/T Irregular Ripening,

Deficient corpus luteum

Decreased progesterone secretion

Endometrial support of progesterone is inadequate

Breakthrough bleeding before actual date of menstruation

(Spotting / brownish discharge premenstrually)

ENDOMETRIUM:-

Contains both proliferative & secretory phases

Changes are seen in superficial zone of endometrium

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IRREGULAR SHEDDING:- (HALBAN’S DISEASE)

Persistent corpus luteum even after menstruation

Menstruation comes on time but prolonged

ENDOMETRIUM:-

Curettage on 2nd / 3rd day of menstruation shows secretory edomentrium

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DIAGNOSIS AND INVESTIGATIONS

MONICA

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Diagnosis of DUB depends on the process of exclusion of organic causes for menorrhagia.

It is based on

1. History

2. Examination

3. Investigations

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HISTORY1. Age, parity and fertility of the patient

2. Uterine bleeding – onset,duration,amount,pattern,character,cyclical features.

MENSTRUAL CALENDAR can be maintained.

It is a day to day record of amount of blood loss for 2-3 months

Useful when pattern and amount of blood loss are uncertain.

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3. Antecedent cause – IUCD, recent delivery/abortion, drug intake, sterilisation operation.

4. Any symptoms suggestive of bleeding disorders or hypothyroidism.

CLINICAL EXAMINATION

1.Degree of anaemia2.Associated thyroid problems 3.Abdomen and bimanual pelvic

examination

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INVESTIGATIONS

1. Assessment of amount of menstrual blood loss by

• Direct method - weighing napkins before and after use

• Indirect method - amount of clot passage degree of anaemia

2. Complete haemogramHb%, coagulation profile, blood grouping and typing.

3. Thyroid profile4. Hormonal profile

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5. ULTRASOUND

• Transvaginal US preferred over transabdominal.

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USE:Exclude organic causes of abnormal bleedingEndometrial thickness and texture accurately

measured.thickness>12mm – risk of disease and is an indication for biopsythickness<5mm – biopsy unnecessary.

ADVANTAGE:Safepainless convenient non-invasive procedure avoids unnecessary biopsy

DISADVANTAGE:Variation of endometrial thickness with menstrual

cycle hence less useful in pre-menopausal women.

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6. DILATATION OF CERVIX AND CURETTAGE

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Consider the age groupPeri-menopausal – mandatory without

delayReproductive – abnormal USG and

biopsy - failed medical therapy

Pubertal – LAST RESORT - severe persistent bleeding

- non-responsive to medical therapy

CONTRAINDICATION:• Any infection

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USE:

Esentially DIAGNOSTIC but also THERAPEUTIC

only 60% diagnosed 30-40% cured

Excludes intrauterine - removes intrauterine path

-removes structurally diseased fragile endometriumFunctional state of endometrium det. Restores

normal haemostasis

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HISTOPATHOLOGICAL PICTURE OF ENDOMETRIUM

Normal endometrium - 54%Endometrial hyperplasia - 31%Irregular shedding - 6%Irregular ripening - 3%Atrophic endometrium - 3%

COMPLICATIONS:• Haemorrhage• Infection• Uterine perforation

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DILATATION AND CURETTAGE

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7. HYSTEROSCOPYEndoscopic technique of

directly visualizing interior of uterine cavity.

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USES AND ADVANTAGE:

Identification of intrauterine pathology even small lesions identified.

Identification of endometrial atrophy and bleeding from ruptured venules.

HYSTEROSCOPY GUIDED BIOPSY – Gold standard investigation of choice.

DISADVANTAGE:

ExpensiveNeeds skill and experience

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8. UTERINE ASPIRATION CYTOLOGY

Vibra aspirator, Gravlee’s jet washer, Isaac’s aspirator & Pipelle aspirator.

ADVANTAGE:Very simple OP procedureAvoids anaesthesia

DISADVANTAGE:Less diagnosticNot curative

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9. SONOHYSTEROGRAPHY

• Involves transvaginal ultrasound• Injection of sterile saline

improves visualization.

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10. MRI

11. PELVIC ANGIOGRAPHY AND VENOGRAPHY; COLOUR DOPPLER

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Medical Management of DUB :Objective :

To retrieve the natural controlling influence that are missing in the endometrium.

Management : depends up on

age of the patient

her fertility

her desire for children

degree of anaemia

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Medical Management

Harmonal Non harmonal

Progesterone NSAIDS

Estrogen Antifibrinolytics

Contraceptive pills Miscellenous

Danazol Ethamsylates

GnRH analogue

Androgens

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Hormonal therapy :

Aim : To stop bleeding To control the cycle To improve the quality of period

PROGESTERONE :

In puberty DUB anovulotory endometrium - proliferative stage No progesterone to start the secretory phase.

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Mode of action :Causes secretory changes in the

endometriumDecrease the ER in the endometriumEstradiol - estrone sulphateEnhancement of stromal matrix Heals superficial breaks

It is available as

a) Oral pills – nor ethisterone, MPA

b) Depot formulation – MPA

c) Progesterone containing IUD

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a)ORAL PILLS

Dose and Administration :

5 mg tds, until bleeding stops,

Dose tapered to 5 mg bd for next 2 weeks

5 mg od for 1 week

Withdrawal bleeding occurs in 48 hours

Then for the next 3-6 cycles patient is put on

Whole cycle Rx Luteal phase Rx

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Whole Cycle Treatment :

5mg / day from day 5 to day 25

withdrawal bleeding follows after the stoppage of drug

Luteal phase Treatment :

5mg / day from day 15 – day 25 of the cycle.

mainly used in ovulatory bleeding

Medical curettage :

Proliferative endometrium secretory endometrium normal shedding

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Advantage :Decrease in 80% of blood loss

Side effects : GIT symptoms - nausea, vomiting Symptoms of pseudopregnancy state

Weight gain and depression Increased LDL – atherosclerosis

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b) DEPOT FORMULATIONS :Depot MPA : 50 mg i.m at 3 months

intervalNorethindrone : 200 mg i.m at 2

months interval

Disadvantage : Bleeding - heavy Systemic side effects more.

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c) IUD :

Progesterone IUD include

Progestasert : 38 mg of progesterone releasing 65 ug of daily should be replaced every year.

Mirena : 52 mg of levonorgestrol releasing 20 ug / day Can be left in place for 5 years

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Disadvantage of mirena : Ectopic pregnancy Amenorrhoea

LNG – IUD monthly used, menstrual blood loss decreases by 21-44% after first 2 months and by 82-96% after 3-12 months after insertion.

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2. OCP Contains both estrogen and progesterone

Mode of action

Suppresses FSH & LH

Atrophic changes in the endometriumDose :

2 tablets od until bleeding stops 20 – 30 ug ofethinyl estradiol + 0.5 mg

of norgestrol

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Benefits

Contraception

Reduces the incidence of benign breast neoplasia, ovarian cyst, uterine malignancy, PID, ectopic pregnancy.

Advantage :

50% reduction in menstrual blood loss

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Contraindications : coronary, cerebral vascular disease Thrombo embolism Genital carcinoma Liver disease DM, HT, Smokers

Adverse effects : Gall stones Hepatoma Genital Carcinoma Thromboembolic disorder

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3. ORMELOXIFENE

Mode of action :

ER - Uterus

suppress endometrial proliferation

Dose :

60 mg twice weekly for 3 months - 60 mg weekly for another 3 months

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Side effects :

Nausea, headache

Fluid retension

Weight gain

Increased BP

4. GnRH ANALOGUE : Last drug when others fail

Depot injection 3.6 mg monthly for 3 months

Therapeutic dose – amenorrhoea.

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Mode of action :

GnRH agonist

Down regulation of pituitary

Decrease FSH, LH

Ovarian function depressed

Hypoestrogenism

Regression of endometrial tissue

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Side effects :

Hot flushes,

Vaginal dryness,

Osteporosis,

menopausal symptoms

Prior to endometrial ablation - reduces the thickening of endometrium, pseudo decidual reaction.

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5. CLOMIPHENE CITRATE :

SERM

Anovulatory cycles with infertility

6.DANAZOL

Synthetic androgen

Indications :

When OCP are contraindicated

When progestrogens produce side effects

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Mode of action :

Binds to androgen receptor

Androgen specific MRNA production

Suppression of Gn secretion

Inhibition of ovarian functionDose :

200 mg daily for 4-6 months

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Side effects : Complete amenorrhoea acne, hirsutism, breast atrophy,

deepening of voice Weight gain

Main use of danazol – preop

adjunct

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7. ESTROGEN THERAPY :Used in atropic endometrium

Mode of action : Increase the threshold level in serum Build up the basal endometrium Drugs :

Estradiol valerate 4 mg / dayEthinyl estradiol 0.05 mg / dayPremarin 25 mg IV

Disadvantages : CVS risk, Malignancy of breast and endometrium

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8.NEWER DRUGS :

GESTRINONE : A derivative of 19-nortestosterone Dose : 2.5 mg orally twice weekly or

5 mg vaginal tablet thrice weekly for 6 months

SEASONALE Combined estrogen and progestogen Daily for 84 days and a gap of 6 days is

given in a 3 monthly treatment.

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SUMMARYEndometrial

HistologyTreatment

Proliferative Acute : High dose progestrogenChronic : progestogens

Normal Acute : AntifibrinolyticsChronic : Low dose oc and or NSAIDs

Atrophic Emergency : Premarin 25 mgAcute : unopposed estrogen 21 days, then OCChronic : Estrogen dominant OC

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NON-STEROIDAL ANTI INFLAMMATORY DRUGSANTI-FIBRINOLYTICS

TREATMENT OF ANEMIA

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NSAID

• MECHANISM OF ACTION:• Inhibits Cyclo-oxygenase pathway, imparing the

production of vaso dialator PGE2, PGI2.• Inhibits binding of PGE2 to its specific receptor in

Uterine Myometrium.• Improve Platelet aggregation, degranulation & vaso

constriction.

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• DOSE:• Mefenamic acid 500mg TDS• Flurbiprofen 100mg TDS• Naproxen 500mg BD• Indomethacin 25mg QID Taken during Menstruation

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USE

1.Ovulatory DUB2.IUCD DUB

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SIDE EFFECTS

• GIT Symtoms.• Bleeding Time is increased.• Pruritus, Rashes , Edema.• Abnormal Renal funtion tests, increased Liver

Enzymes.

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CONTRA INDICATIONS

• Hypersensitivity, Bleeding disorders.• Compromised Renal function.• Active Ulceration.• Chronic inflammation of GIT.

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ADVANTAGE & DISADVANTAGE

• ADVANTAGE:• Beneficial effects on Dysmenorrhea.• Low cost.DISADVANTAGE:• Limited Efficacy.• Failure to cure DUB.• Side effects.• Poor Acceptability for long term use.

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ANTI-FIBRINOLYTICS

• MECHANISM OF ACTION:• Prevents Plasminogen activation & Fibrinolysis

& Dissolution of Clot.

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DOSE

• Tranexamic Acid 1-1.5g orally 3-4 times a day for three to four days.

• SIDE EFFECTS: • GI symptoms.• Thrombotic events.CONTRAINDICATION:• Renal failure

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MISCELLANEOUS-ETHAMSYLATE

• MECHANISM OF ACTION:• Inhibits capillary fragility.DOSE:• 500mg QID From 5th day prior to anticipated

start of menses to 10 days after.It has very less side effects.

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TREATMENT OF ANEMIA

• Blood Transfusion.• Iron Supplementation.

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MINIMAL INVASIVE

PROCEDUREA.KAVITHA

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• Hystrectomy-100% success rate• Disadvantages the diseased organ is only

endometrium

• Long term complications – urinary dysfunction, cvs problems

• So better choice is MIS

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MIS

• An alternative to hysterectomy when medical management fail

• The idea for this procedures evolved from pathology that happens in Ashermann syndrome leading to amenorrhea

• The basic principle is ablation of endometrium

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INDICATIONS

•Intractable uterine bleeding

•Coagulopathies-risk for hysterectomy

•Age >40yrs (completed family)

•Not willing for hysterectomy

CONTRAINDICAIONS

•Uterine size>12wks

•Any pathology in uterus

•Pregnancy

•Acute pelvic inflammation

•Scarred uterus

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PREREQUISITE• preoperative thinning of endometrium – danazol 200 mg tds -6 wks, Gnrh analogues 3 months• Immediate Post menstrual period – endometrial thickness < 3 cm

PRE OPERATIVE PREPARATION:• Evaluate completely and rule out CI

INTRA OPERATIVE:• Anaesthesia – GA or regional• Position – dorsal lithotomy

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• Under HYSTEROSCOPE

• Distension medium-irrigate1stGeneration

OBJECIVE of Ablation is to cause thermal damage to the basalis layer of endmetrium

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ABLATION BY Nd-YAG LASER

• Distension-saline• 5mm destroyed• SUCCESS RATE-95%• ADVANTAGE

– More precise– Lesser complication

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ELECTROSURGERY

TCRE•‘U’ shaped loop

•3-5mm myometrium resected•SUCCESS RATE

50%Amenorrhoea

96%Hypomenorrhea

• ADVANTAGE

Cheap,sampling,low failure

rate

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ROLLER BALL ENDOMETRIAL

ABLATION

•2-4MM ball/barrel/ovoid•Uniform vapourisation•FAILURE RATE 5-10%•ADVANTAGE Low rate of perforation Short time

•2-4MM ball/barrel/ovoid•Uniform vapourisation•FAILURE RATE 5-10%•ADVANTAGE Low rate of perforation Short time

ROLLER BALL

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COMPLICATION• Perforation• Haemorrhage• Gas embolism• Infection• Damage to vessels,bowels,urinary bladder• Fliud absorbtion-lead to

HT,Hyponatremia,neurological symptoms,haemolysis and even death

Hence,fluid input/output should be monitored

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2ndGeneration

•No hysteroscope

•No distention media

•Risk of 1st generation tech minimised

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THERMOCHOICE OR CAVARERM BALLOON THERAPHY

• Central computer system with disposable silicon balloon catheter 5mm• Insert• Inflate balloon- 5%dextrose+water

circulate• Heat-87deg for 8min and deflate• ADVANTAGE

– Low complications – No special skill

– Effective and safe 85% success rate

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NOVASURE/Impedense controled electrocoagulation

• Disposable 3D fan shaped fabric like expandable with metallic skeleton is used

• Outer sheath removed• With high frequency electro generator

electrocoagulation is done

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NOVASURE

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3rdGeneration

No HYSTROSCOPE

Even no distention media

Only probe is used

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MICROWAVE ENDOMETRIAL ABLATION

• Magnetic energy-9.2GHz• 8mm applicator• Temp 80 deg -3min• 6mm destroyed• ADVANTAGE

–No bleed,no fluid load

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OTHER PROCEDURES

• CRYOABLATION• RADIOFREQUENCY INDUCED

THERMAL ABLATION• HYDROTHERMAL• ELITT-Endmetrial LASER

Intrauterine Thermotherapy

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POST OPERATIVELY

• Rapid recovery• Normal diet• May be bleeding slighty-serosanguinus

discharge-profuse watery discharge

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SURGICAL MANAGEMENT OF DYSFUNCTIONAL UTERINE

BLEEDING

K.KABILAN

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SURGICAL MANAGEMENT OF DUB

• DUB is usually controlled by medical line of management

• The need for surgical management arises when there is a failure in medical line of management

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An overview of Management of Menorrhagia

Menorrhagia

Young women Older women

Pregnancy desired Pregnancy not desiredRule out uterine pathology and cancer

•Progestogens•Ethamsylate•NSAID•GnRH 3-4 months

•COC•Progestogens•Mirena

Effective Fails

Continue for 6-9 months and follow up

•MIS•Hysterectomy with conservation of ovaries

Normal uterus (DUB)

Uterine pathology

Surgery

•Medical theraphy•COC contraindicated over 40 years

No response

Hysterectomy with oopherectomy after 50 years (No MIS)

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SURGICAL MODALITY

Hysterectomy Abdominal Vaginal Laproscopic Laproscopic assisted vaginal hysterectomyOvaries must be preserved in patients age

below 50yrs

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Indications

• Failure of medical line of management and MIS.

• Family history of uterine malignancy.• Premalignant endometrial pathologies.

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ABDOMINAL HYSTERACTOMY

Abdominal hysterectomy is preferred when extensive adhesions are anticipated

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Advantages:• Good access and better visualisation.• Technically easy.• Less time consuming.• No need of advanced instrumentation as in

laproscopic procedure• P.Op bleeding and bladder injury are less in

compare to vaginal hysterectomy • Anatomical relations not altered.

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Disadvantages:• Patient recovery prolonged.• Prolonged hospitalisation.• Incisional pain.• P.Op wound infection.• Uretral injury.• Risk of developing hernia.

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VAGINAL HYSTERECTOMY

This approach preffered when extensive adhesions are not anticipated.

Pre-requesties:• Uterus size <12 cms.• Mobile uterus without

adhesions;vallsellum traction test positive.

• No adnexal tumour or pathology

“Gynaecologist route”

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Advantages:• Faster recovery• Reduced hospital stay• No risk of developing hernia• Peritoneum minimally opened, no bowel

handling hence less post operative illness• Bowel function returns soon• Quick ambulation• Less post-operative infection• Least invasive route

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Disadvantages:• Pelvic infection• Vesical injury, fistula• Vaginal shortening and stenosis • Recurrent cystocele, rectocele, entrocele• Vault prolapse• P.Op bleeding Haemorrhagic shock

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LAPROSCOPIC HYSTERECTOMY&

LAVH

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Advantages:• Faster patient recovery• Reduced hospital stay• Less post operative pain• Less wound infection• Provides better visualization and access to

abdomen and pelvisDisadvantages:• Time consuming• Expensive• Require better surgical skills

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K NAVANEETHARANI UNIT OG

DYSFUNCTIONAL UTERINE BLEEDING

Management at Pubertal Age Group

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• MAJOR

MINOR

Immature hypothalamo-pituitary axis• excess/unopposed estrogen • absent progesterone in

anovulatory cycles

o coagulation disorderso blood dyscrasiaso hypothyroidism

ETIOLOGY

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FACTORS DETERMINING THE CHOICE OF TREATMENT

◦Age

◦Parity

◦Histopathological changes in Endometrium

◦Need for contraception

◦Availability of treatment option

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3

2

1Early control of excessive bleeding

Normalizing cyclical rhythms

Prevention of recurrence

TREATMENTOBJECTIVES

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Management

Assessment• ASSESS THE SEVERITY

- Hb %, hematocrit -Menstrual history (last menstrual period, frequency,

duration, flow, pain) CATEGORIZED AS

• MILD (Hb >10g%)

• MODERATE (Hb = 8 to 10g%)

• SEVERE (Hb < 5g%)

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MILD PUBERTAL MENORRHAGIA

◦Reassurance

◦Maintenance of menstrual calendar, pictorial bleeding assessment chart & assessment of menstrual blood loss

◦Iron & Vitamin Supplementation

◦Periodic re-evaluation

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MILD (..contd)• No Specific treatment required• Normal menstrual pattern occurs spontaneously

within 1 or 2 years

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MODERATE PUBERTAL MENORRHAGIA

oHigh dose progestogenoNorethisterone acetate

o 1st 48hrs 5-10mg tdso Next 2 weeks 5-10mg bdo Next 1 week 5-10mg odo Then stop the drug

Progestogen – Cyclical / Luteal Phase Administered for 3-6 months 10mg/day for 10 days/month

Re-evaluation after stopping the drug

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SEVERE PUBERTAL MENORRHAGIA

o ADMISSION OF THE PATIENTo Blood Transfusiono RULE OUT

Hypothyroidism-thyroid profile

Bleeding diathesis - FBC, platelet count, bleeding time, PTT,vwf antigen

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oTo Achieve HemostasisoHigh dose progestogeno Norethisterone acetate

o 1st 48hrs 5-10mg tdso Next 2 weeks 5-10mg bdo Next 1 week 5-10mg odo Then stop the drug

oTo Regularise Menstrual CyclesoCyclical progestogen for 6 months or longer

oRe-evaluation upto 12 months or longer if necessary

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OCP-20-30 microgram tabs

mefenemic acid 500 mg tds for 6 days

OTHER DRUGS

tranexemic acid 500-1000 mg 8 hourly

GnRH-leuprolide -3.75 mg im monthly for 6 months

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• DILATATION AND CURETTAGE (D&C)

– Last resort

– To rule out Tuberculous Endometritis (4% of cases)

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MANAGEMENT OF DUB IN REPRODUCTIVE & PERI MENOPAUSAL WOMEN

By D.MANOJ

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Reprodutive age group ( 20-39 years)

Exclude pregnancy disturbances and conditions like Fibroid uterus, Endometriosis,PID,Functioning ovarian tumour

Dilatation & Curettage- 60% therapeutic

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Medical treatment - Oral contraceptive pills - NSAIDS-Mephenamic

acid -Anti-Fibrinolytics -Hormones Progestogens:

Oral/Parenteral/

Intra-uterine devices

Danazol DUB associated with infertility 1. Clomiphene 2. GnRH agonists

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OCP ANTI-FIBRINOLYTIC

PROGESTOGEN GnRH analogues

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Surgical Management -Conservative: MIS techniques like

Hysteroscopic endometrial ablation, Non-hysteroscopic endometrial ablation

- Definitive: Hysterectomy

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PERIMENOPAUSAL AGE GROUP( > 40 YEARS)

Exclude Malignancy Fractional curretage –

Mandatory Hysterectomy- Treatment of

choice