DUB ppt

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Nadya Al-FaraidyNadya Al-Faraidy9824001598240015

21 October 200321 October 2003

DysfunctionalDysfunctional

Uterine Uterine

BleedingBleeding

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DefinitionDefinition

DUB is abnormal uterine DUB is abnormal uterine bleeding with no pathological or bleeding with no pathological or congenital cause.congenital cause.

diagnosis of exclusiondiagnosis of exclusion Can be:Can be: w/in the period: menorrhagia w/in the period: menorrhagia intermenstrual bleeding intermenstrual bleeding

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TerminologyTerminology Primary Amenorrhea:Primary Amenorrhea: no menstruation by age of 14 in absence no menstruation by age of 14 in absence

of secondary sexual characteristics OR of secondary sexual characteristics OR before 16 yrs in presence of secondary before 16 yrs in presence of secondary sexual characteristicssexual characteristics

Secondary Amenorrhea:Secondary Amenorrhea: cessation of menstruation or 6 months cessation of menstruation or 6 months

or more in a patient who was or more in a patient who was menstruating regularly or 12 months in menstruating regularly or 12 months in a patient who had a history of a patient who had a history of oligomenorrhea oligomenorrhea

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Menorrhagia:Menorrhagia: excessive &/or prolonged regular menstruationexcessive &/or prolonged regular menstruation Polymenorrhea:Polymenorrhea: frequent regular menses at intervals <21 daysfrequent regular menses at intervals <21 days

Polymenorrhagia:Polymenorrhagia: frequent but w/ prolonged &/or excessive frequent but w/ prolonged &/or excessive

bleedingbleeding Metrorrhagia:Metrorrhagia: irregular periods of uterine bleeding irregular periods of uterine bleeding

OligomenorrheaOligomenorrhea: : Episodes of bleeding, which occurs at intervals Episodes of bleeding, which occurs at intervals

of more than 35 days.of more than 35 days.

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PathophysiologyPathophysiology DUB is most common near the beginning and end of a DUB is most common near the beginning and end of a

woman's reproductive life, but may occur at any time. woman's reproductive life, but may occur at any time. first 18 months after menarchefirst 18 months after menarche: immature : immature

hypothalamin-pituitary axis obese women: non-ovarian hypothalamin-pituitary axis obese women: non-ovarian endogenous estrogen production may upset the normal endogenous estrogen production may upset the normal menstrual cycle. menstrual cycle.

Menopause:Menopause: anovulatory DUB. anovulatory DUB. anovulatory cyclesanovulatory cycles resulting in menometrorrhagia resulting in menometrorrhagia luteal phase deficiencyluteal phase deficiency cause the loss of LH surge, may cause the loss of LH surge, may

be especially prominent in amenorrheic athletes. be especially prominent in amenorrheic athletes. >>40 years:40 years: number and quality of ovarian follicles. number and quality of ovarian follicles. (OCPs),(OCPs), Endocrine disordersEndocrine disorders . Hyperprolactinemia Polycystic . Hyperprolactinemia Polycystic

ovary disease Hypothyroidism, hyperthyroidism, and ovary disease Hypothyroidism, hyperthyroidism, and Cushing's disease, premature ovarian failure Cushing's disease, premature ovarian failure

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Causes Causes Pregnancy complications Pregnancy complications Abortion Abortion Ectopic pregnancy.Ectopic pregnancy. Molar disease.Molar disease. Infection e.g. endometritis in post Infection e.g. endometritis in post

partum.partum.

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Causes Causes Vulvar lesions: Vulvar lesions:

Trauma.Trauma. Infection.Infection. Ulcer.Ulcer. Inflammatory lesion.Inflammatory lesion. Condylomata.Condylomata. Vulvar tumors (very rare).Vulvar tumors (very rare).

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Causes Causes Vaginal lesions:Vaginal lesions:

Vaginitis.Vaginitis. Atrophic vaginitis (common in post Atrophic vaginitis (common in post

menopausal women).menopausal women). Foreign bodies e.g. forgotten Foreign bodies e.g. forgotten

tampons.tampons. Traumas and lacerations.Traumas and lacerations. Vaginal tumors (very rare).Vaginal tumors (very rare). Disorders of pelvic support (pelvic Disorders of pelvic support (pelvic

relaxation).relaxation).

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Causes Causes Cervical lesions:Cervical lesions:

Polyps.Polyps. Cervicitis.Cervicitis. Cervical condyloma.Cervical condyloma. Cervical tumors.Cervical tumors.

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CausesCausesUterine lesions:Uterine lesions:

Fibroid.Fibroid. Adenomyosis and endometriosis.Adenomyosis and endometriosis. Endometrial Polyps.Endometrial Polyps. Endometrial hyperplasiaEndometrial hyperplasia Endometritis.Endometritis. Uterine malformation: if severe, Uterine malformation: if severe,

menorrhagiamenorrhagia Precocious puberty.Precocious puberty. IUCD.IUCD. Endometrial ca.Endometrial ca.

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Causes Causes Ovarian lesions:Ovarian lesions:

Salpingo-oopheritis (PID).Salpingo-oopheritis (PID). Endometriosis.Endometriosis. Ovarian cyst.Ovarian cyst. Ovarian tumors.Ovarian tumors.

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Causes Causes GU and GI lesions:GU and GI lesions:

Hematuria.Hematuria. Hemorrhoids.Hemorrhoids. Fissures.Fissures. Rectal cancer.Rectal cancer. Colon cancer.Colon cancer.

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CausesCausesGeneral disease:General disease:

Coagulation disorders.Coagulation disorders. Liver disease.Liver disease. Renal diseaseRenal disease Thyroid disease.Thyroid disease. Adrenal disease.Adrenal disease. Pituitary disease.Pituitary disease.

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Causes Causes Blood Dyscariasis:Blood Dyscariasis:

ITPITP Von-Willibrand disease Von-Willibrand disease Leukemia Leukemia Anemias Anemias SCA SCA ThalassemiaThalassemia

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Causes Causes Medications:Medications:

Exogenous hormones eg Hormone Exogenous hormones eg Hormone Replacement TherapyReplacement Therapy

Oral contraceptives.Oral contraceptives. Aspirin.Aspirin. Anticoagulant therapy.Anticoagulant therapy. Digitalis.Digitalis. Corticosteroids.Corticosteroids. Others.Others.

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IncidenceIncidence . One of the most common symptoms in . One of the most common symptoms in

gynecology.gynecology. . Most frequently at the extremes of age:. Most frequently at the extremes of age: an-ovulation or Imbalance.an-ovulation or Imbalance. 6months – 1 year after menarche and 6months – 1 year after menarche and

post menopause.post menopause. Menorrhagia affects approximately 22% Menorrhagia affects approximately 22%

of healthy women. of healthy women. In the United States, approximately 7.6 In the United States, approximately 7.6

million pre-menopausal women aged million pre-menopausal women aged between 30 and 55 perceive their between 30 and 55 perceive their menstrual bleeding to be excessive. menstrual bleeding to be excessive.

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EvaluationEvaluationHistoryHistory

ageage Menstrual history.Menstrual history. Amount of bleeding.Amount of bleeding. Duration of the loss.Duration of the loss. Interval between Interval between

episodes.episodes. Associated Associated

symptoms.symptoms. Drugs ingested esp Drugs ingested esp

use of hormones or use of hormones or contraceptives.contraceptives.

Variation in weather, Variation in weather, diet and exercise.diet and exercise.

AgeAge Most common cause of bleedingMost common cause of bleeding

New bornNew born Maternal estrogenMaternal estrogen

ChildhoodChildhood Foreign body, cancerForeign body, cancer

AdolescenceAdolescence due to hormonal imbalancedue to hormonal imbalance

PerimenopausaPerimenopausall

Due to weaning of ovarian functionDue to weaning of ovarian function

reproductivereproductive -Pregnancy and its complications.Pregnancy and its complications.-Anovulation due to:Anovulation due to:

1.1.polycystic ovarian disease polycystic ovarian disease

2.2.idiopathic idiopathic

3.3.stress stress

4.4.hypothyroidism hypothyroidism

5.5.hyperprolactinemia b/c of:hyperprolactinemia b/c of:

a.a.pituitary adenoma pituitary adenoma

b.b.pituitary microadenoma pituitary microadenoma

galactorrheagalactorrhea

Post Post menopausemenopause

Hormone replacement cancerHormone replacement cancer

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EvaluationEvaluationPhysical ExaminationPhysical Examination

Examination of all symptoms. Examination of all symptoms. Basal temperature chartingBasal temperature charting

Pelvic examination & speculum Pelvic examination & speculum examinationexamination

Recto-vaginal examination in Recto-vaginal examination in young children or single women young children or single women in which you can’t do pelvic in which you can’t do pelvic examination.examination.

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EvaluationEvaluationLab InvestigationsLab Investigations

CBC: Hb and Hct + CBC: Hb and Hct + WBCs for infectionWBCs for infection

ESRESR Serum HCG to rule out Serum HCG to rule out

pregnancy.pregnancy. Urinalysis Urinalysis Pelvic U.S.Pelvic U.S. Hysterosalpingography Hysterosalpingography

(HSG).(HSG). Endometrial biopsy.Endometrial biopsy. Hysteroscopy.Hysteroscopy. Dilatation and curettage Dilatation and curettage

(D & C) (D & C) Diagnostic Diagnostic and therapeutic.and therapeutic.

# Most of the time we # Most of the time we don’t need all these don’t need all these investigation, Hb and investigation, Hb and HCG will be enough.HCG will be enough.

Test Test Indication Indication urine pregnancy urine pregnancy test test CBC  CBC  PT/PTT  PT/PTT  Pap smear*  Pap smear*  FSH  FSH  liver function tests  liver function tests 

TSH  TSH  prolactin level  prolactin level 

Serum Serum progesteroneprogesterone

pregnancy pregnancy anemia  anemia  coagulpathy (especially in adolescents  coagulpathy (especially in adolescents  cervical cancer  cervical cancer  > 40IU/L suggests ovarian failure  > 40IU/L suggests ovarian failure  liver disease  liver disease  thyroid disease  thyroid disease  pituitary adenoma (with breast pituitary adenoma (with breast discharge)  discharge) 

Ovulation luteal phaseOvulation luteal phase

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ManagementManagementMedicalMedical

Combined contraceptive pill: transforms uterus into Combined contraceptive pill: transforms uterus into pseudo-secretory state “short secretory & short pseudo-secretory state “short secretory & short proliferative & then shedding occurs proliferative & then shedding occurs

Progesterone: for 21 days if uterus hyperplastic Progesterone: for 21 days if uterus hyperplastic PGSI- PG Synthase Inhibitor:PGSI- PG Synthase Inhibitor:

Rationale: during DUB, there is excessive PG esp PGE2 Rationale: during DUB, there is excessive PG esp PGE2 which cause excessive bleeding which cause excessive bleeding

Eg indomethacin, mefenamic acid (Ponstan)Eg indomethacin, mefenamic acid (Ponstan) Rx 50-70% of DUBRx 50-70% of DUB Side effect: diarrheaSide effect: diarrhea

ECA:ECA: Fibrinolytic Fibrinolytic Causes thrombosis of spiral uterine blood vessels causes Causes thrombosis of spiral uterine blood vessels causes

decreased bleeding decreased bleeding > side effects> side effects

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How successful is HRT at How successful is HRT at preventing menstrual preventing menstrual

bleeding?bleeding? Continuous combined hormone replacement Continuous combined hormone replacement

usually results in amenorrhea after about 3 usually results in amenorrhea after about 3 months of use months of use

intermittent bleeding during the first 3 months intermittent bleeding during the first 3 months is common. is common.

By 6 months, about 2/3's of women will not By 6 months, about 2/3's of women will not have bleeding have bleeding

at 1 year 80-85% will be without bleeding. at 1 year 80-85% will be without bleeding. Increasing the estrogen dose as well as the Increasing the estrogen dose as well as the

progestin dose may help stop some of the progestin dose may help stop some of the bleeding. bleeding.

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ManagementManagementSurgicalSurgical

Removal of the endometriumRemoval of the endometrium If hormone therapy is not effective, If hormone therapy is not effective, the endometrium may be removed. the endometrium may be removed.

Endometrial ablationEndometrial ablation is usually the is usually the method of choice, although some method of choice, although some patients choose a patients choose a hysterectomyhysterectomy or or D & CD & C. .

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Endometrial ablationEndometrial ablation

YAG LASERYAG LASER Thermal balloonThermal balloon HydrothermablatorHydrothermablator ResectoscopeResectoscope

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YAG LASERYAG LASERAdvantagesAdvantages

15 and 30 minutes.15 and 30 minutes. discharged two or three hours. discharged two or three hours. The patient should be The patient should be

reassured that discharge is reassured that discharge is normal normal

80% successful in reducing 80% successful in reducing heavy periods and may heavy periods and may eliminate menstruation eliminate menstruation altogether. altogether.

Advantages of the procedure Advantages of the procedure over hysterectomyover hysterectomy

it is safer, less invasive, and it is safer, less invasive, and does not require a surgical does not require a surgical incision incision

it is less expensive it is less expensive it requires a shorter hospital it requires a shorter hospital

stay stay women can resume normal women can resume normal

activity within days, compared activity within days, compared to 4 to 6 weeks to 4 to 6 weeks

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YAGYAGDisadvantagesDisadvantages

o fluid overload fluid overload o hyponatremia, hyponatremia, o perforation of the uterus or adjacent perforation of the uterus or adjacent

organs,organs,o uterine rupture, uterine rupture, o infection or haemorrhage. Overall, infection or haemorrhage. Overall,

endometrial ablation has a endometrial ablation has a o morbidity rate of 3%. morbidity rate of 3%. o sterilitysterility

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The Novasure SystemThe Novasure System

Another new Another new device, the device, the Novasure System™ Novasure System™ , is now available, , is now available, and has a number and has a number of advantages over of advantages over other systems.  It other systems.  It only takes a few only takes a few minutes and has an minutes and has an excellent safety excellent safety recordrecord

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Thermal balloonThermal balloon

two components - a balloon catheter for heating and a two components - a balloon catheter for heating and a controller controller

local anaesthesia local anaesthesia 87 degrees Celsius, for eight minutes. 87 degrees Celsius, for eight minutes. outpatient procedure equal it to inserting an intrauterine outpatient procedure equal it to inserting an intrauterine

device (IUD). device (IUD). SE: pressure or cramping sensation (NSAID) suppository SE: pressure or cramping sensation (NSAID) suppository

administered 45 minutes prior to the procedure.administered 45 minutes prior to the procedure. might experience vaginal discharge or spotting, which might experience vaginal discharge or spotting, which

normally changes to a watery discharge, between 10 and normally changes to a watery discharge, between 10 and 30 days. it is normal.30 days. it is normal.

intended for use by women who have already completed intended for use by women who have already completed their families. their families.

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HTA Hydrothermablator HTA Hydrothermablator

hot water, but allows it to circulate hot water, but allows it to circulate freely in the endometrial cavity.  It is freely in the endometrial cavity.  It is done under direct vision through a done under direct vision through a hysteroscope hysteroscope

10 minutes 10 minutes

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Who should consider Who should consider endometrial ablation?endometrial ablation?

menstrual bleeding that is impacting menstrual bleeding that is impacting life, with no other problems that life, with no other problems that require a hysterectomy >80ml per require a hysterectomy >80ml per cycle, >8 dayscycle, >8 days

Activity is limited b/c of periodsActivity is limited b/c of periods anemic and tiredanemic and tired Bleeding limits intimate time with Bleeding limits intimate time with

partnerpartner Failure of drug therapyFailure of drug therapy Exclusion of other causesExclusion of other causes NO desire to retain fertilityNO desire to retain fertility

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Who shouldn't have an Who shouldn't have an endometrial ablation?endometrial ablation?

endometrial ablation is not for anyone endometrial ablation is not for anyone who desires to keep her fertility.who desires to keep her fertility.   

malignancy or pre-malignant condition of malignancy or pre-malignant condition of the uterus  the uterus  

severe pelvic pain, unless the pain is severe pelvic pain, unless the pain is coming from an intracavitary myoma  coming from an intracavitary myoma 

Although pregnancy is unlikely after Although pregnancy is unlikely after ablation, serious complications could arise.  ablation, serious complications could arise.  It is essential for to use reliable It is essential for to use reliable contraception after an endometrial ablation.contraception after an endometrial ablation.

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Who can help me decide if Who can help me decide if an endometrial ablation is an endometrial ablation is

for me?for me? gynecologist gynecologist A physician who does not do endometrial A physician who does not do endometrial

ablation on a regular basis is unlikely to ablation on a regular basis is unlikely to have the experience to help you make the have the experience to help you make the best decision. best decision. 

The physician should be expert at vaginal-probe The physician should be expert at vaginal-probe ultrasound and at diagnostic hysteroscopy, and ultrasound and at diagnostic hysteroscopy, and should consider non-surgical treatments, as well should consider non-surgical treatments, as well as discussing the advantages and disadvantages as discussing the advantages and disadvantages of all the options available.  While the physician of all the options available.  While the physician can provide you with information, the decision is can provide you with information, the decision is ultimately yours.ultimately yours.

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How successful is endometrial How successful is endometrial ablation at stopping uterine ablation at stopping uterine

bleeding problems?bleeding problems?

The various techniques used for endometrial The various techniques used for endometrial ablation may have slightly different outcomes ablation may have slightly different outcomes

in general about 1/3 to 1/2 of women are in general about 1/3 to 1/2 of women are completely without any bleeding afterwards completely without any bleeding afterwards (amenorrheic) (amenorrheic)

about 15-20% still have bleeding problems about 15-20% still have bleeding problems severe enough to warrant further surgery . severe enough to warrant further surgery .

The overall satisfaction rate of endometrial The overall satisfaction rate of endometrial ablation is about 65% ablation is about 65%

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Other Surgical OptionsOther Surgical Options

HysteroscopyHysteroscopy

ResectoscopyResectoscopy

HysterectomyHysterectomy

D & CD & C

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Is hysterectomy a better treatment Is hysterectomy a better treatment than endometrial ablation for bleeding than endometrial ablation for bleeding

problems?problems? The two procedures are somewhat difficult to The two procedures are somewhat difficult to

compare. compare. outpatient vs. inpatientoutpatient vs. inpatient 1 week vs. 6 weeks1 week vs. 6 weeks 4 year study:4 year study: 36% of the women having endometrial ablation 36% of the women having endometrial ablation

and 24% of the women having hysterectomy and 24% of the women having hysterectomy required more sxrequired more sx

Satisfaction rates 80% in the ablation group and Satisfaction rates 80% in the ablation group and 89% in the hysterectomy group. (retreatment, 89% in the hysterectomy group. (retreatment, PMS)PMS)

Endometrial ablation allows about 75% of women Endometrial ablation allows about 75% of women to avoid hysterectomy to avoid hysterectomy

Hysterectomy was more successful in the long run Hysterectomy was more successful in the long run in treating the bleeding problems as well as in treating the bleeding problems as well as premenstrual symptomspremenstrual symptoms