dysfunctional uterine bleeding
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DYSFUNCTIONAL UTERINE BLEEDING
I unit OG,2k6 Batch MMC,madurai
DYSFUNCTIONALUTERINE BLEEDING
INTRODUCTION
M.NITHYA I UNIT
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.
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”
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
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.
INCIDENCE 10-15 %
PREVALENCE Varies widely
AGE GROUP It can ocurr at any age group ,quite
frequently in the middle reproductive age group .
CRITERIA FOR NORMAL MENSTRUATION
cycle length duration of bleeding amount of blood loss
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.
DURATION OF BLEEDING
Normal range: 2-7 days
Normal mean:5 days
AMOUNT OF BLOOD LOSS
Normal range:50-80ml
Normal mean:around 40ml
MENSTRUAL CYCLE IRREGULARITIES
AMENORRHEA OLIGOMENORRHEA POLYMENORRHEA HYPOMENORRHEA DYSMENORRHEA MENORRHAGIA METRORRHAGIA MENOMETRORRHAGIA
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.
MENORRHAGIA Regularly timed episodes of
bleeding that are excessive in amount [>80 ml] and/or duration of flow [>5 days].
METRORRHAGIA Irregularly timed episodes of
bleeding superimposed on normal cyclical bleeding.
MENOMETRORRHAGIA Excessive prolonged bleeding that
occurs at irregularly timed and frequent intervals.
HYPOMENORRHEA Regularly timed but scanty episodes of
bleeding.
DYSMENORRHEA Painful cramping pain accompanying
menstruation.
NORMAL AND ABNORMAL MENSTRUATION
MALINI
HYPOTHALAMO-PITUITARY OVARIAN AXIS
+ FSH ESTROGEN
- GnRH +
LH PROGESTRONE -(Hypothalamus) (pituitary) (ovary)
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
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
• 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.
OVULATION
• Occurs at the 14th day.• Due to action of LH,the graffian
follicle ruptures and ovulates forming CORPUS LUTEUM.
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.
• 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
• 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
HEMOSTASIS
Achieved in a normal menstruation by 2 mechanisms:
Formation of platelet plugConstriction of spiral arterioles
Vasoconstriction is brought about by means of prostaglandins
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
Endometrium – PGF2α, PGE2 & PGD2
Myometrium – PGE2 from arachidonic acid & endoperoxidases.
Phospholipid
Free Arachidonic Acid
Endoperoxides
PGE2 PGF2 α
PGI2
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
WITHDRAWAL OF PROGESTERONE
BREAKDOWN OF LYSOSOMES
RELEASE OF PHOSPHOLIPASE A2
PROSTANOID CASCADE
PREDOMINATION OF VASOCONSTRICTOR PROSTANOIDS
ORDERLY BLEEDING
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.
Increased endometrial lysosomal enzymes with excessive prostanoid formation.
Failure in vascular endothelial proliferation due to relaxin.
Delay in endometrial regeneration.
TYPES OF DYSFUNCTIONAL UTERINE BLEEDING
• JAYAPRABHA
DUB
ANOVULATORY OVULATORY(80%) (20%)
• PUBERTY MENORRHAGIA OVULATORY POLYMENORRHOEA• REPRODUCTIVE AGE OVULATORY OLIOMENORRHOEA
GROUP MENORRHAGIA• METROPATHIA HEMORRHAGICA OVULATORY MENORRHAGIA
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)
• REPRODUCTIVE AGE GROUP MENORRHAGIA :-
Following pregnancy & abortion
Disturbed hypothalamo – pituitary – ovarian axis
Hormonal imbalance
Bleeding
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
BLEEDING IN METROPATHIA HAEMORRHAGICA
• 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
Pic. 1 in MH
Pic. 2 in MH
Pic. 3 in MH
OVULATORY
OVULATORY OLIGOMENORRHOEA :-
Prolonged proliferative phase with normal secretory phase
Infrequent cycles are present
Occurs in adolescence & preceding menopause
Endometrium normal
• 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
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
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
DIAGNOSIS AND INVESTIGATIONS
MONICA
Diagnosis of DUB depends on the process of exclusion of organic causes for menorrhagia.
It is based on
1. History
2. Examination
3. Investigations
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.
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
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
5. ULTRASOUND
• Transvaginal US preferred over transabdominal.
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.
6. DILATATION OF CERVIX AND CURETTAGE
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
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
HISTOPATHOLOGICAL PICTURE OF ENDOMETRIUM
Normal endometrium - 54%Endometrial hyperplasia - 31%Irregular shedding - 6%Irregular ripening - 3%Atrophic endometrium - 3%
COMPLICATIONS:• Haemorrhage• Infection• Uterine perforation
DILATATION AND CURETTAGE
7. HYSTEROSCOPYEndoscopic technique of
directly visualizing interior of uterine cavity.
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
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
9. SONOHYSTEROGRAPHY
• Involves transvaginal ultrasound• Injection of sterile saline
improves visualization.
10. MRI
11. PELVIC ANGIOGRAPHY AND VENOGRAPHY; COLOUR DOPPLER
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
Medical Management
Harmonal Non harmonal
Progesterone NSAIDS
Estrogen Antifibrinolytics
Contraceptive pills Miscellenous
Danazol Ethamsylates
GnRH analogue
Androgens
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.
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
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
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
Advantage :Decrease in 80% of blood loss
Side effects : GIT symptoms - nausea, vomiting Symptoms of pseudopregnancy state
Weight gain and depression Increased LDL – atherosclerosis
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.
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
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.
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
Benefits
Contraception
Reduces the incidence of benign breast neoplasia, ovarian cyst, uterine malignancy, PID, ectopic pregnancy.
Advantage :
50% reduction in menstrual blood loss
Contraindications : coronary, cerebral vascular disease Thrombo embolism Genital carcinoma Liver disease DM, HT, Smokers
Adverse effects : Gall stones Hepatoma Genital Carcinoma Thromboembolic disorder
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
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.
Mode of action :
GnRH agonist
Down regulation of pituitary
Decrease FSH, LH
Ovarian function depressed
Hypoestrogenism
Regression of endometrial tissue
Side effects :
Hot flushes,
Vaginal dryness,
Osteporosis,
menopausal symptoms
Prior to endometrial ablation - reduces the thickening of endometrium, pseudo decidual reaction.
5. CLOMIPHENE CITRATE :
SERM
Anovulatory cycles with infertility
6.DANAZOL
Synthetic androgen
Indications :
When OCP are contraindicated
When progestrogens produce side effects
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
Side effects : Complete amenorrhoea acne, hirsutism, breast atrophy,
deepening of voice Weight gain
Main use of danazol – preop
adjunct
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
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.
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
NON-STEROIDAL ANTI INFLAMMATORY DRUGSANTI-FIBRINOLYTICS
TREATMENT OF ANEMIA
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.
• DOSE:• Mefenamic acid 500mg TDS• Flurbiprofen 100mg TDS• Naproxen 500mg BD• Indomethacin 25mg QID Taken during Menstruation
USE
1.Ovulatory DUB2.IUCD DUB
SIDE EFFECTS
• GIT Symtoms.• Bleeding Time is increased.• Pruritus, Rashes , Edema.• Abnormal Renal funtion tests, increased Liver
Enzymes.
CONTRA INDICATIONS
• Hypersensitivity, Bleeding disorders.• Compromised Renal function.• Active Ulceration.• Chronic inflammation of GIT.
ADVANTAGE & DISADVANTAGE
• ADVANTAGE:• Beneficial effects on Dysmenorrhea.• Low cost.DISADVANTAGE:• Limited Efficacy.• Failure to cure DUB.• Side effects.• Poor Acceptability for long term use.
ANTI-FIBRINOLYTICS
• MECHANISM OF ACTION:• Prevents Plasminogen activation & Fibrinolysis
& Dissolution of Clot.
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
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.
TREATMENT OF ANEMIA
• Blood Transfusion.• Iron Supplementation.
MINIMAL INVASIVE
PROCEDUREA.KAVITHA
• Hystrectomy-100% success rate• Disadvantages the diseased organ is only
endometrium
• Long term complications – urinary dysfunction, cvs problems
• So better choice is MIS
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
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
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
• Under HYSTEROSCOPE
• Distension medium-irrigate1stGeneration
OBJECIVE of Ablation is to cause thermal damage to the basalis layer of endmetrium
ABLATION BY Nd-YAG LASER
• Distension-saline• 5mm destroyed• SUCCESS RATE-95%• ADVANTAGE
– More precise– Lesser complication
ELECTROSURGERY
TCRE•‘U’ shaped loop
•3-5mm myometrium resected•SUCCESS RATE
50%Amenorrhoea
96%Hypomenorrhea
• ADVANTAGE
Cheap,sampling,low failure
rate
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
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
2ndGeneration
•No hysteroscope
•No distention media
•Risk of 1st generation tech minimised
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
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
NOVASURE
3rdGeneration
No HYSTROSCOPE
Even no distention media
Only probe is used
MICROWAVE ENDOMETRIAL ABLATION
• Magnetic energy-9.2GHz• 8mm applicator• Temp 80 deg -3min• 6mm destroyed• ADVANTAGE
–No bleed,no fluid load
OTHER PROCEDURES
• CRYOABLATION• RADIOFREQUENCY INDUCED
THERMAL ABLATION• HYDROTHERMAL• ELITT-Endmetrial LASER
Intrauterine Thermotherapy
POST OPERATIVELY
• Rapid recovery• Normal diet• May be bleeding slighty-serosanguinus
discharge-profuse watery discharge
SURGICAL MANAGEMENT OF DYSFUNCTIONAL UTERINE
BLEEDING
K.KABILAN
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
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)
SURGICAL MODALITY
Hysterectomy Abdominal Vaginal Laproscopic Laproscopic assisted vaginal hysterectomyOvaries must be preserved in patients age
below 50yrs
Indications
• Failure of medical line of management and MIS.
• Family history of uterine malignancy.• Premalignant endometrial pathologies.
ABDOMINAL HYSTERACTOMY
Abdominal hysterectomy is preferred when extensive adhesions are anticipated
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.
Disadvantages:• Patient recovery prolonged.• Prolonged hospitalisation.• Incisional pain.• P.Op wound infection.• Uretral injury.• Risk of developing hernia.
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”
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
Disadvantages:• Pelvic infection• Vesical injury, fistula• Vaginal shortening and stenosis • Recurrent cystocele, rectocele, entrocele• Vault prolapse• P.Op bleeding Haemorrhagic shock
LAPROSCOPIC HYSTERECTOMY&
LAVH
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
K NAVANEETHARANI UNIT OG
DYSFUNCTIONAL UTERINE BLEEDING
Management at Pubertal Age Group
• MAJOR
MINOR
Immature hypothalamo-pituitary axis• excess/unopposed estrogen • absent progesterone in
anovulatory cycles
o coagulation disorderso blood dyscrasiaso hypothyroidism
ETIOLOGY
FACTORS DETERMINING THE CHOICE OF TREATMENT
◦Age
◦Parity
◦Histopathological changes in Endometrium
◦Need for contraception
◦Availability of treatment option
3
2
1Early control of excessive bleeding
Normalizing cyclical rhythms
Prevention of recurrence
TREATMENTOBJECTIVES
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%)
MILD PUBERTAL MENORRHAGIA
◦Reassurance
◦Maintenance of menstrual calendar, pictorial bleeding assessment chart & assessment of menstrual blood loss
◦Iron & Vitamin Supplementation
◦Periodic re-evaluation
MILD (..contd)• No Specific treatment required• Normal menstrual pattern occurs spontaneously
within 1 or 2 years
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
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
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
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
• DILATATION AND CURETTAGE (D&C)
– Last resort
– To rule out Tuberculous Endometritis (4% of cases)
MANAGEMENT OF DUB IN REPRODUCTIVE & PERI MENOPAUSAL WOMEN
By D.MANOJ
Reprodutive age group ( 20-39 years)
Exclude pregnancy disturbances and conditions like Fibroid uterus, Endometriosis,PID,Functioning ovarian tumour
Dilatation & Curettage- 60% therapeutic
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
OCP ANTI-FIBRINOLYTIC
PROGESTOGEN GnRH analogues
Surgical Management -Conservative: MIS techniques like
Hysteroscopic endometrial ablation, Non-hysteroscopic endometrial ablation
- Definitive: Hysterectomy
PERIMENOPAUSAL AGE GROUP( > 40 YEARS)
Exclude Malignancy Fractional curretage –
Mandatory Hysterectomy- Treatment of
choice