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DD
YSFUNCTIONYSFUNCTION
ALAL UUTERINETERINE
BBLEEDINGLEEDING
S. Pattanasuttinont M.D.S. Pattanasuttinont M.D.
Department of OB & GYNDepartment of OB & GYN
Faculty of MedicineFaculty of Medicine
Srinakharinwirot UniversitySrinakharinwirot University
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DEFINITION
Excessive uterine bleeding with no organic cause
Most commonly caused by anovulationA diagnosis of exclusion
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CAUSE OF ABNORMAL UTERINE
BLEEDING
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NORMAL WITHDRAWAL
BLEEDING
Withdrawal of E/P
-Vasomotor events ( PGF2 , Endothelin-1)-Apoptosis (Lysosomal enzymes, Metallo-proteinases)
-Tissue loss and menstruation
Shrinkage of tissue height Spiral arteriole vasomotor response
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NORMAL WITHDRAWAL
BLEEDING
Early control of blood loss
-Formation of thrombin plugs Late control of blood loss
-Generalized vasoconstrictive hemostasis
-Healing effects of estrogen
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NORMAL MENSTRUAL BLEEDING
Tissue and vascular breakdown (upper 2/3)
Focal
breakthrough bleeding Diffuse withdrawal bleeding
Endometrium (balance)
Paracrine
Angiogenesis
Vasoactive
Hemostatic substances
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NORMAL VAGINAL BLEEDING :
MENSES
Interval 28 + 7 days
Duration 3 - 5 days Amount < 80 ml
Color dark- red
Clot no or small amount
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PATHOPHYSIOLOGY
Hormonal disturbances
Anovulation Ovulatory bleeding
Abnormal folliculogenesis
Corpus luteum insufficiency
Abnormal PGs production
Abnormal fibrinolytic activity
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MECHANISM
Hyperestrogenic or progestogenic state
Abnormal neovascularization Increased enzymatic tissue/ vascular breakdown
Impaired hemostatic mechanism
Uterine bleeding
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MECHANISM OF BLEEDING IN DUB
PatternPattern MechanismMechanismMenorrhagia abn.PG production, abn.fibrinolysis
Metrorrhagia E or P breakthrough bleeding
Polymenorrhea short FP or short LP
Oligomenorrhea anovulation
Midcycle bleeding E withdrawal bleeding
Premenstrual spotting corpus luteal dysfunction
Postmenstrual spotting abn. folliculogenesis
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Characteristic anovulatoryDUB
ovulatoryDUB
Bleeding pattern
Age
Dysmenorrhea
PMS
metrorrhagia
short period ofamenorrhea followed
by excessive bleeding
teenage, climacteric
no
no
menorrhagia
pre or post menstrualspotting
reproductive year
yes
yes
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Diagnostic approach
Pt. with vaginal bleeding
uterineextrauterine
urethra
rectum
genital:
vaginacervix
preg.related:
- abortion- ectopic- molar
non-preg:-uterine pathology-systemic dz.-drug/hormone-Infection
-DUB
false vg bleedingtrue vg bleeding
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APPROACHDifferential
Dx.pregnancy
relatedpelvic
pathologyinfection systemic
dz.contraception drug DUB
Hx
PE
PV & PR
Obtain Hx taking according to differential Dx and complete PE
Initial Dx could be made in most cases
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History :
- age- present abnormal bleeding- menstrual pattern, OB Hx
- previous abnormal bleeding- method of contraception- physical-psychological stress
- systemic review
Physical exam:
- vital signs- general appearance- abdominal exam- PV (indicated cases)
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APPROACHDifferential
Dx.pregnancy
relatedpelvic
pathologyinfection systemic
dz.Contra
ception
drug DUB
Hx
PE
PV & PR
Investigation pregnancytest
U/S
Pap smearbiopsy
D&C
U/Shysteroscopylaparoscopy
culture
laparoscopy
CBC
TFT
LFT
renal fncoag.
- - investigatecause ofanovulation
Obtain Hx taking according to differential Dx and complete PE
Initial Dx could be made in most cases
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Goal of managementGoal of management
Control the immediate bleedingDetermine the cause
Prevent similar episodes
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MEDICAL TREATMENTAnti PGs agents
Mefenamic acid
NaproxenHormone
Estrogen
Progesterone
Combine OCs
Danazol
GnRH agonist
GestrinoneFibrinolytic inhibitor
Tranxenamic acid
Epsilon amino caproic acid
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ESTROGEN RXAtrophic or thin endometrium
On progestin medication
POP
DMPA
Progesterone IUD
Long term use of COCs
CEE 1.25 mg/d for 7-10 daysCEE 1.25 mg/d for 7-10 days
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PROGESTERONE RXAnovulatory bleeding
Stop bleeding Maintenance for cyclic withdrawal bleeding
Ovulatory bleeding
(cyclic P is less effective for ovulatory bleeding,Continuous P D5-D25)
MPA or NETA10 mg/d for 12-14 days per cycle
MPA or NETA10 mg/d for 12-14 days per cycle
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COMBINED E-P RXAnovulatory bleeding
Stop bleeding Maintenance in women with androgenic symptom
Need contraception
Ovulatory bleeding
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bleeding Mechanism Treatment
Menorrhagia
Metrorrhagia
Polymenorrhea
Oligomenorrhea
Midcycle bleeding
Premenstrualspotting
Postmenstrual
spotting
Treatment of Bleeding in DUB
abn.PGS production,abn.fibrinolysis
E or P breakthroughbleeding
short FP or short LP
anovulation
E withdrawal bleeding
corpus luteal dysfunction
abn.folliculogenesis
anti PGS, fibrinolytic inh.
cyclic P, E, COCs
cyclic P, COCs
late FP E, COCs
cyclic P, COCs
early FP E, COCs
COCs, cyclic P
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SURGICAL TREATMENT D & C
Endometrial ablation
Selective embolization
Hysterectomy
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