Dysfunctional uterine bleeding

DYSFUNCTIONAL UTERINE BLEEDING- Adolescent age group

SUBAIR SALAM T A

2006 MBBS

ABNORMAL & DYSFUNCTIONAL

UTERINE BLEEDING -ADOLESCENT AGE

GROUP

AIMIN BABYP1 UNIT

NORMAL MENSTRUATION

AVERAGE CYCLE LENGTH : 28 DAYS (RANGE FROM 21-35)

NO OF BLEEDING DAYS : 2-6

UPPER LIMIT OF BLOOD LOSS : 80 ml

ANY BLEEDING OUTSIDE THE ABOVE SPECIFIED NORMAL LIMIT IS TERMED AUB …

CAUSES OF ABNORMAL UTERINE BLEEDING :

DUB

PELVIC PATHOLOGIES :o FIBROID

o ADENOMYOSIS

o ENDOMETRIAL POLYPS

o ENDOMETRIOSIS

o PELVIC INFECTION

o CA ENDOMETIUM , CA CERVIX , CIN

o ATROPHIC VAGINITIS , ENDOMETRITIS

o FEMINISING OVARIAN TUMOURS

o AV MALFORMATIONS

PREGNANCY RELATED PROBLEMS :

o ECTOPIC PREGNANCY

o MISCARRIAGE OR ABORTION

o HYDATIDIFORM MOLE

o IMPLANTATION BLEEDING

COAGULATION AND HEMATOLOGICAL PROBLEMS :

o VON WILEBRAND’S DISEASE

o ITP

o LEUKAEMIAS

o THROBASTHENIAS

MEDICAL PROBLEMS :o HYPOTHYROIDISM AND HYPERTHYROIDISM

(INITIALLY)

o CUSHINGS DISEASE

o LIVER DISEASE

o RENAL PROBLEMS

IATROGENIC :o IUCD RELATED BLEEDING

o HORMONAL CONTRACEPTION

CLINICAL TYPES OF AUB :

MENORRHAGIA

HYPOMENORRHOEA

POLYMENORRHOEA

OLIGOMENORRHOEA

METRORRHAGIA

MENORRHAGIA :

o CYCLICAL REGULAR BLEEDING WHICH IS EXCESSIVE IN AMOUNT OR DURATION..

o CONDTIONS AFFECTING UTERUS AND ITS VASCULARITY RATHER THAN DISTURBANCE IN HPO AXIS..

o EG : INCREASE IN UTERINE SURFACE AREA (FIBROIDS , ADENOMYOSIS , ENDOMETRIAL HYPERPLASIA , UTERINE POLYPS)

o INCREASED UTERINE VASCULARITY (CHRONIC PELVIC INFLAMMATORY DISEASE , PELVIC ENDOMETRIOSIS)

o OTHER CAUSES : (IUCD , HEMATOLOGICAL PROBLEMS , THYROID DYSFUNCTION)

HYPOMENORRHOEA :

o CYCLICAL REGULAR BLEEDING WITH SCANTY AMOUNT OF BLOOD LOSS..

o MAY LASTS ONLY FOR 1 -2 DAYS..

o MAINLY UTERINE END ORGAN DAMAGE (NORMAL HPO AXIS)

EG : (GENITAL TUBERCULOSIS , ASHERMANS SYND)

OTHER CAUSE (ORAL COMBINED PILLS)

POLYMENNORHOEA :

o SHORTENED CYCLES (LESS THAN 21 DAYS)

o MAY BE DUE TO HPO AXIS DYSFUNCTION..

o MORE FREQUENT IN ADOLESCENT GIRLS AND IN PERIMENOPAUSAL WOMEN..

o FOLLICULAR PHASE IS ACCELERATED AND OVARIES BECOME HEMORRHAGIC AND HYPEREMIC..(WITH MYOHYPERPLASIA AND ENDOMETRIAL THICKENING)

o FREQUENTLY SEEN WHEN WOMEN RESUME MENSTRUAL ACTIVITY AFTER A DELIVERY..(PERSISTENT ANT PITUITARY AXIS ACTIVITY, EXCESSIVE GnRH STIMULATION)

o MOST COMMMON ASSOSCIATIONS = PID , ENDOMETRIOSIS (INCREASED UTERINE VASCULARITY)..

OLIGOMENORRHOEA :

o LONG CYCLES (MORE THAN 35 DAYS OR LESS THAN 6 CYCLES PER YEAR)..

o OFTEN IN EXTREMES OF REPRODUCTIVE LIFE AND IN SOME LACTATING WOMEN..

o COMMON CAUSES ARE HORMONAL (PCOS , HYPERPROLACTINEMIA , HYPOTHYROIDISM)..

o MANY OF THESE WOMEN ARE OBESE , HIRSUTE , WITH POORLY DEVELOPED SECONDARY SEXUAL CHARACTERISTICS , GENITAL HYPOPLASIA AND OVARIAN SUBFUNCTION ..

METRORRHAGIA :

o ACYCLIC , INTERMENSTRUAL BLEEDING..

o SUPERIMPOSED ON A NORMAL MENSTRUAL CYCLE..( CONTINOUS OR INTERMITTENT )

o MAY BE PHYSIOLOGICAL (AT OVULATION) AND COMPLAINTS OF MID MENSTRUAL BLEEDING LASTING FROM FEW HOURS TO ONE DAY, A PROFUSE STICKY DISCHARGE AND INTERMITTENT CRAMPING PAIN OF SHORT DURATION

o COMMON CAUSES : CA CERVIX , CIN , CERVICAL POLYPS , EROSIONS , ENDOMETRIAL POLYPS, SUBMUCOUS FIBROIDS etc..

o IF INCREASED MENSTRUAL FLOW = MENOMETRORRHAGIA..(SUBMUCOUS FIBROIDS)

o BREAKTHROUGH BLEEDING = METRORRHAGIA ACCOMPANYING HORMONE THERAPY (OC PILL)

DUB :

AUB IN THE ABSENCE OF AN ORGANIC DISEASE (PELVIC OR SYSTEMIC DISORDERS)..

IS A CAUSE OF AUB..

60 % AUB..

MORE COMMON IN ADOLESCENT AND PERIMENOPAUSAL AGE GROUP..

DD

DIAGNOSIS BY EXCLUSION..

DUB

-AUB from the

endometrium in the

absence of organic d/s of genital

tract

2 types

Anovulatory

(80%)Ovulatory

(20%)

ANOVULATORY DUB : IRREGULAR CYCLES / SHORT CYCLES WITH

SCANTY FLOW / PERIODS OF AMENNORHOEA FOLLOWED BY PROLONGED AND IRREGULAR BLEEDING..

USUALLY DUE TO ALTERNATION IN HPO AXIS..

MORE COMMON IN EXTREMES OF REPRODUCTIVE LIFE AND PCOS..

UNOPPOSED OESTROGEN STIMULATION OF ENDOMETRIUM → PERSISTENT PROLIFERATIVE OR HYPERPLASTIC PATTERN..

Consequently there is increase of vasodilator prostaglandins,PGE2,

prostacyclins -- painless prolonged heavy bleeding..

Due to absence of Progesterone , endometrium can’t produce PGF2

alpha & Thromboxane..

NO OVULATION , HENCE ONLY FOLLICULAR PHASE NO LUTEAL PHASE..

NO PROGESTERONE , SO ENDOMETRIUM CANNOT ORGANISE OR STABILISE ,

INSTEAD BECOMES EXCESSIVELY VASCULAR WITHOUT STROMAL SUPPORT , BECOMES FRAGILE AND BLEED..

NORMAL MENSTRUAL BLEEDING WITHDRAWAL OF BOTH OESTROGEN AND PROGESTERONE

OESTROGEN WITHDRAWAL BLEEDING = PAINLESS , IRREGULAR AND PROLONGED..

3 TYPES :

1. METROPATHICA HEMORRHAGICA

2. THRESHOLD BLEEDING

3. PUBERTY MENORRHAGIA

METROPATHICA HEMORRHAGICA :

ANOVULATORY DUB CHARACTERISED BY PERIODS OF AMENORRHOEA FOLLOWED BY PROLONGED AND HEAVY BLEEDING..

TYPICAL SYMPTOMS : WOMEN PRESENTING WITH CONTINOUS PAINLESS VAGINAL BLEEDING AT ONSET OF MENSUS OR PRECEEDED BY 6 – 8 WEEKS OF AMENORRHOEA..

SEEN IN WOMEN BETWEEN 40 TO 45 YEARS..

DUE TO HYPEROESTROGENISM..

ASSOSCIATED GLANDULAR HYPERPLASIA OF ENDOMETRIUM (BULKY UTERUS) AND OVARIES MAY SHOW MULTICYSTIC PICTURE (FOLLICULAR CYSTS)

IT SIMULATE ABORTION OR ECTOPIC PREGNANCY BUT PAIN IS CONSPICUOSLY ABSENT..

THRESHOLD BLEEDING :

ANOVULATORY DUB USUALLY ASSOSCIATED WITH VERY LOW OESTROGEN LEVELS AND AN ATROPHIC ENDOMETRIUM..

SEEN NEARING OR AFTER MENOPAUSE , ALSO IN LACTATION..

OTHER CAUSES : CONSEQUENCE OF PROLONGED BLEEDING (WHEN PROGESTERONE FAILS TO STOP BLEEDING) , USE OF DEPOT PROVERA..

OESTROGEN IS NECESSARY TO ARREST HEMORRHAGE IN THRESHOLD BLEEDING..

PUBERTY MENORRHAGIA : (DUB IN ADOLESCENT ) COMMONEST CAUSE IS DUB (95%)

IMMATURE HPO AXIS..

INITIAL PERIODS AFTER MENARCHE = USUALLY OESTROGEN WITHDRAWAL BLEEDS

IT TAKES SOME TIME FOR POSITIVE FEEDBACK AND LH SURGE

THEREFORE IN EARLIER 1-5 YEARS – ANOVULATION DUE TO ABSENCE OF LH SURGE AND ENDOMETRIAL HYPERPLASIA DUE TO UNOPPOSED OESTROGEN..

AS GIRL MATURES , NORMAL MENSTRUAL CYCLES ARE ESTABLISHED..

OTHER CAUSES , MANAGEMENT ETC.. (LATER)

OVULATORY OR IDIOPATHIC DUB :

ONLY 20 % DUB..

MECHANISM : NOT CLEAR , PROBABLY IN ENDOMETRIUM ITSELF..

SHIFT IN ENDOMETRIAL CONVERSION FROM VC PGF2 ALPHA TO VD PGE2 AND PROSTACYCLINS..

ALSO REDUCED ENDOTHELINS (VC)..

CAUSES :

1. IRREGULAR RIPENING

2. IRREGULAR SHEDDING

3. IUCD INSERTION

4. FOLLOWING STERILISATION OPERATION

IRREGULAR RIPENING :

OVULATORY DUB DUE TO DEFECTIVE FUNCTIONING OF CORPUS LUTEUM..

DIMINISHED PROGESTERONE WITH LOW , NORMAL OR HIGH OESTROGEN..

PREMENSTRUAL SPOTTING OR BROWNISH DISCHARGE..

RX = PROGESTERONE DURING LATE LUTEAL PHASE..

IRREGULAR SHEDDING :

OVULATORY DUB DUE TO PERSISITENCE OF CORPUS LUTEUM..

PROLONGED PROGESTERONE SECRETION WITH DIMINISHED POTENCY OF OESTROGEN..

RARE AND SELF LIMITED..

POST MENSTRUAL SPOTTING OR PROLONGED MENSUS..

PROGESTERONE CAN SUPPRESS THE BLEEDING ,BUT NEEDS TO BE TAKEN ON TAPERING DOSE FOR 20 DAYS..(TO COMPLETE THE CYCLE)

ABNORMAL UTERINE BLEEDING :

1. ADOLESCENT AGE GROUP

2. REPRODUCTIVE AGE GROUP

3. PERIMENOPAUSAL AGE GROUP..

In adolescent age group 95% AUB is

due to DUB (hypothalamic pituitary axis is

immature)

initial periods after menarche are usually oestrogen withdrawal

bleeds as it takes sometime for positive

feedback & LH surge to be established.

AUB IN ADOLESCENT AGE GROUP : VERY COMMON (50%)

VARIES FROM MINOR LENGTH CHANGES TO SEVERE BLEEDING..

CAUSES OF AUB IN ADOLESCENTS :

1) DUB

2) HEMATOLOGICAL: VON WILLEBRANDS DISEASE , ITP , LEUKEMIAS etc..

3) MEDICAL PROBLEMS: HYPOTHYROIDISM , CUSHINGS SYNDROME,LIVER PROBLEMS..

4) PELVIC PATHOLOGY: GENITAL TUBERCULOSIS , FEMINISING OVARIAN TUMOURS (GRANULOSA CELL AND THECA CELL TUMOURS), POLYPS , FIBROID , TRAUMA , FOREIGN BODY etc..

“AS SEVERITY INCREASES THE CHANCE FOR OTHER PATHOLOGY INCREASES …

AS IN SEVERE BLEEDING REQUIRING TRANSFUSION 74 % WAS DUE TO DUB AND 19 % DUE TO HEMATOLOGICAL CAUSES AND 7% OTHERS

DIAGNOSIS :

DUB IS A DISEASE OF EXCLUSION ( ANATOMIC AND SYSTEMIC DISORDERS )

EXCLUSION FROM

1. HISTORY

2. GENERAL , ABDOMINAL AND PELVIC EXAMINATION

3. INVESTIGATIONS..

PROPER HISTORY :

ABNORMAL BLEEDING RIGHT FROM MENARCHE OCCURING CYCLICALLY = HEMATOLOGICAL DISORDERS..

CYCLICAL BLEEDING WITH INTERVAL IRREGULAR BLEEDING = LOCAL PATHOLOGY..

IRREGULAR PERIOD WITH PROLONGED EXCESSIVE FLOW = DUB ( COMMONEST PRESENTATION)..

MENSRTUAL HISTORY :

AGE OF MENARCHE

LENGTH OF CYCLE , REGULARITY , AMOUNT OF FLOW ( CLOTS , FLOODING ,NO OF PADS CHANGED )

COLOUR , SMELL ..

H/O MENORRHAGIA , DYSMENORRHOEA OR ANY MENSTRUAL IRREGULARITIES..

H/O OF INTERMENSTRUAL / POST COITAL BLEEDING..

LMP

HORMONE REPLACEMENT THERAPY

VASOMOTOR SYMPTOMS , DISTURBED SLEEP OR MOOD SWINGS IN PERI OR POST MENOPAUSAL AGE..

POSTMENOPAUSAL BLEEDING..

CLINICAL EXAMINATION : GENERAL EXAMINATION :

o PALLOR , ENDOCRINOPATHY , PREGNANCY ..

o BLEEDING GUMS , EASY BRUISABILITY = HEMATOLOGICAL DISORDERS (VON WILLEBRANDS DISEASE 1-2 % PREVALANCE)

o OBESITY AND OTHER SIGNS OF HYPERANDROGENISM = PCOS

o MAY HAVE THYROID ENLARGMENT = THYROID DISORDERS..

ABDOMINAL EXAMINATION : o LIVER , SPLEEN , PELVIC OR ABDOMINAL MASS

PELVIC EXAMINATION :

o ORIGIN OF BLEEDING , CAUSE ..

INVESTIGATIONS :

COMPLETE BLOOD EXAMINATION ( Hb% , PLATELETS)

COAGULATION PROFILE ( BT , CT ,PT INR , APTT COAGULATION FACTORS ,VWF )

PELVIC ULTRASOUND ( PELVIC TUMOURS , PREGNANCY , PCOS )

THYROID FUNCTION TESTS

LIVER AND RENAL FUNCTION TESTS

IF MEDICAL TREATMET FAILS , DILATATION AND CURRETAGE ( ENDOMETRIAL TB )..

BETA HCG (PREGNANCY TEST) , PROLACTIN ,PAP SMEAR , HYSTEROSCOPY , ENDOMETRIAL BIOPSY ..

MANAGEMENT:

TREATMENT DEPENDS ON SEVERITY :

o MILD ( NORMAL HEMATOCRIT )

o MODERATE ( MAY BE ANAEMIC )

o SEVERE (REQUIRE HOSPITALISATION , Hb < 8 g % )

DUB IS MOST COMMON CAUSE (ANOVULATORY) THEREFORE HORMONES ARE MAINSTAY OF TREATMENT..

MILD CASES :

GENERAL MEASURES..

REASSURANCE AND EXPLANATION AS TO THE CAUSE..

REST

PROPER DIET

Fe SUPPLEMENTATION

VITAMIN SUPPLEMENTATION

MENSTRUAL CALENDAR

PERIODIC REVALUATION

MODERATE CASES :

FIRST LINE MX :

NSAIDS (MEFENAMIC ACID 500 MG TDS × 3–5 DAYS )..

ANTIFIBRINOLYTICS ( TRANAEXAMIC ACID 500 MG 3-4 TIMES PER DAY )..

ETHAMSYLATE 500 MG QID STARTING 5 DAYS BEFORE ANTICIPATED ONSET OF CYCLE AND CONTINUED FOR 10 DAYS..

SECOND LINE / HORMONAL MANAGEMENT :

ACUTE EPISODES : (FOR SEVERE CASES)

HIGH DOSE NOR ETHISTERONE (15 -30 MG IN DIVIDED DOSES) , ONCE BLEEDING STOPS CONTINUED FOT 1 WEEK AND TAPERED IN NEXT 2 WEEKS..

OR

INJ PREMARIN 25 MG TDS/QID × 2-3 DAYS..(CONTROLS BLEEDING)..

THEREAFTER , OESTROGEN × 21 DAYS WITH PROGESTERONE ADDED FOR 10 DAYS ( FOR 3-6 CYCLES TO REGULARISE THE CYCLE )..

CHRONIC MANAGEMENT :

CYCLICAL PROGESTERONE (MEDROXYPROGESTERONE ACETATE 10 DAYS EVERY MONTH )..TO SUPPRESS HPO AXIS AND PREVENT OVULATION..

ORAL COMBINED PILLS..

SEVERE CASES : HOSPITALISATION

BLOOD TRANSFUSION IF REQUIRED

ACUTE MANAGEMENT : SIMILAR , IF NOT CONTROLLED ;

I. ARTERIAL EMBOLISATION

II. UTERINE TAMPONADE USING FOLEYS CATHETER

III. THERMAL BALLOON THERAPY

CHRONIC MANAGEMENT : PROGESTERONE 21 DAYS IN A MONTH FOR 6 MONTHS OR COMBINED OCP CAN BE USED..

IF PROGESTERONE CAUSE SIDE EFFECTS , MIRENA IUCD FOR FEW MONTHS CAN CONTROL MENORRHAGIA..

DANAZOL (ANDROGENIC EFFECT)

GnRH THERAPY (EXPENSIVE , TAKES 4 WEEKS TO ACT , PROLONGED TREATMENT CAUSES OSTEOPOROSIS)

THANK YOU..