Abnormal Uterine Bleeding Dr. Majda

Abnormal Uterine Bleeding Dr. Majda Komaikh; FRCOG, Reproductive Medicine Associate Professor, Obstetrics & Gynaecology Faculty of Medicine

Abnormal Uterine Bleeding

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Common gynaeological symptom, accounting for 25% of gynaecological surgeries.

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Before menarche

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Childbearing age

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Postmenopausal women

Before Menarche:

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Trauma

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Sexual abuse

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Malignancy

Childbearing Age: 

Pregnancy-related conditions:

Ectopic pregnancy, miscarriage, trophoblastic disease 

Iatrogenic:

Medications, herbal, HRT, OCP, IUCD 

Systemic disorders:

CAH, Cushing, coagulopathy, thrombocytopenia

--------------------------------------------------------------------------------------- Pituitary-ovarian axis: Hyperprolactinemia, PCOS 

Genital tract pathology:

Infection, neoplasm, trauma 

Dysfunctional uterine bleeding (DUB)

Postmenopausal Age:

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HRT

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Atrophic Vaginitis

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Malignancy

Terms Used to Describe Abnormal Uterine Bleeding Oligomenorrhea: Bleeding occurs at intervals of > 35 days and usually is caused by a prolonged follicular phase.

Menorrhagia: Bleeding occurs at normal intervals (21 to 35 days) but with heavy flow ( ≥ 80 mL) or duration ( ≥ 7 days

Menometrorrhagia: Bleeding occurs at irregular, noncyclic intervals and with heavy flow ( ≥ 80 mL) or duration ( ≥ 7 days).

Polymenorrhea: Bleeding occurs at intervals of < 21 days and may be caused by a luteal-phase Defect

Amenorrhea: Bleeding is absent for 6 months or more in a nonmenopausal woman

Postmenopausal bleeding : Bleeding recurs in a menopausal woman at least 1 year after cessation of cycles

Dysfunctional uterine bleeding: This ovulatory or anovulatory bleeding is diagnosed after the exclusion of pregnancy or pregnancy-related disorders, medications, iatrogenic causes, obvious genital tract pathology, and systemic conditions.

Differential Diagnosis of Abnormal Uterine Bleeding Medications and iatrogenic causes Anticoagulants Antipsychotics Hormone replacement Intrauterine devices Oral contraceptive pills, including progestin-only pills Tamoxifen Genital tract pathology •Infections: cervicitis, endometritis, myometritis, salpingitis •Benign anatomic abnormalities: adenomyosis, leiomyomata, polyps of the cervix or endometrium •Premalignant lesions: cervical dysplasia, endometrial Hyperplasia •Malignant lesions: cervical squamous cell carcinoma, endometrial adenocarcinoma, estrogen-producing ovarian tumors, testosterone-producing ovarian tumors, leiomyosarcoma •Trauma: foreign body, abrasions, lacerations, sexual abuse or assault

Pregnancy and pregnancy-related conditions Ectopic pregnancy Miscarriage Trophoblastic disease

Systemic conditions Adrenal hyperplasia and Cushing’s dx Blood dyscrasias : leukemia/ thrombocytopeni Coagulopathies Hepatic disease Hypothalamic suppression (from stress, weight loss, excessive exercise) Pituitary adenoma or Hyperprolactinemia Polycystic ovary syndrome Renal disease Thyroid disease

Dysfunctional uterine bleeding (diagnosis of exclusion)

Ovarian Cause PCOS •Obesity, acne, oligomenorrhea/secondary amenorrhea •Unopposed E stimulation, elevated androgen, insulin resistance •Anovulation •Treatment: ovulation induction, progestogens

Pituitary Cause Hyperprolactinemia Symptoms: galactorrhea, olig- ,amenorrhea Treatment: Bromocriptine, Cabergoline

Hypothalamic Hypothalamic disorders: • Eating disorders • Stress • Exercise-induced

Genital Tract

•Uterine causes: Fibroid uterus Endometrial polyp •Cervical causes: Endometrial polyp Cervical cancer

Evaluation of Abnormal Uterine Bleeding: Diagnostic step

Pertinent signs, Conditions symptoms, and tests

History

Pelvic

pain Nausea, vomiting, Wt gain, cold intolerance Easy bruising, tendency to bleed Jaundice, hepatitis Hirsutism, acne,obesity Postcoital bleeding Galactorrhea,headache, visual disturbances

Abortion,

Physical examination

Thyroid

enlargment Hepatomegaalt, Bruises Enlarged uterus Adnexal mass

Hypothyroidism

BhCG

Pregnancy

CBC

Anemia

LFT

Liver

TSH,prolctin,

Hypothyroidism,

Pap

Cervical

Laboratory Tests

smear Endometrial biopsy Ultrasound scan 

ectopic Pregnancy Hypothyroidism Coagulopathy Liver dx PCOS Cervical causes Hyperprolactinemia

Liver

diseases uterus

Fibroid PCOS

Dx

hyperprolactnemia dysplasia Endometrial causes Fibroids, polyps

Genital Tract Genital Tract Pathology Fibroid

Menorrhagia

Treatment : Myomectomy

Endometrial polyp

Gross App.

Hysteroscopic Resection

Hysteroscopic Appearance.

Cervical Polyp Postcoital bleeding, Intermenstrual bleeding

Cervical Cancer

Postcoital bleeding, Intermenstrual bleeding

Dysfunctional Uterine Bleeding (DUB):

• Diagnosis of exclusion

Management •Medical Treatment •Minimal invasive surgery •Surgical treatment

Medical treatment •OCP •Progestogens: anovulatory cycles •Mefenamic acid , Tranxamic acid: Menorrhagia •Mirena IUCD

Menorrhagia Mirena releases a low amount of progestin levonorgestrel continuously over a 5-year period

Endometrial Ablation or Endometrial resection •Indications •Procedure •Complications

Hysterectomy •Completed her family •Age •Seek definite treatment •Other pathology