Abnormal Uterine Bleeding,DUB AND UX MYOMA.pptx

Aub

1. Abnormal Uterine Bleeding (AUB) and Dysfunctional Uterine Bleeding (DUB) 1

2. Abnormal Uterine Bleeding (AUB) AUB Is defined as bleeding from the genital tract that is out of the normal menstrual cycle in terms of Duration of stay Frequency Amount Quality The normal menstrual cycle results from a complex feedback system involving the hypothalamus, pituitary, ovary, and uterus The normal menstrual cycle length may be defined as varying Comes 24 to 35 days Stays from 2 to 7 days F lowing less than 80 mL per cycle (average normal amount of menstrual blood loss is 30 to 40 mL per cycle ) 2

3. CONT…  The normal menstrual cycle is a tightly coordinated cycle of stimulatory and inhibitory effects that results in the release of a single mature oocyte from a pool of hundreds of thousands of primordial oocytes The first day of menses represents the first day of the cycle (day 1 ) The cycle is then divided into two phases, follicular and luteal The follicular phase begins with the onset of menses and ends on the day of the luteinizing hormone (LH) surge The luteal phase begins on the day of the LH surge and ends at the onset of the next menses 14 to 21 days are in the follicular phase and 14 days in the luteal phase  3

4. CONT… Menorrhagia refers to excessive or prolonged menstrual bleeding It is technically defined as blood loss greater than 80 mL per cycle and/or menstrual periods lasting longer than seven days In ovulatory women, menorrhagia is typically due to an anatomic lesion ( eg , fibroid) Anovulation is also a common cause of menorrhagia Metrorrhagia and menometrorrhagia   Metrorrhagia refers to light bleeding from the uterus at irregular intervals Menometrorrhagia refers to heavy bleeding from the uterus at irregular intervals ( Menorrhagia + Metrorrhagia) 4

5. CONT… Polymenorrhea  R efers to regular bleeding that occurs at an interval less than 24 days Oligommenorrhea Refers When menstruation comes in greater than 35 days Hypomenorrhea ( cryptomenorrhea ) Small bleeding (bleeding less than 2 days) Intermenstrual bleeding R efers to bleeding that occurs between menses or between expected hormone withdrawal bleeds in women using some forms of hormonal contraception or postmenopausal hormone therapy 5

6. CONT… Premenstrual spotting    Refers to light bleeding preceding regular menses Amenorrhea  Refers to absence of bleeding for at least three usual cycle lengths Postcoital bleeding  (Contact bleeding) R efers to vaginal bleeding that is noted within 24 hours of vaginal intercourse 6

7. CONT… Causes of AUB The causes of abnormal uterine bleeding can be divided into Structural causes – Ovulatory bleeding Level of sex hormones and gonadotropins are normal Mensus is cyclic 7

8. CONT… Hormonal causes – Anovulatory bleeding Sex steroids are produced, but not cyclically so bleeding is irregular Chronic estrogen production unopposed by adequate progesterone production allows continued proliferation of the endometrium which leads to breakthrough bleeding 8

9. CONT…   Causes of ovulatory bleeding A. Pregnancy associated complications B. Anatomic uterine lesions     Neoplasm - Lieomayoma, endometrial cancer cervical cancer      Infection - STI Mechanical causes - intrauterine device, perforation         Partial outflow obstruction - congenital müllerian defect, Asherman syndrome 9

10. Dysfunctional uterine bleeding (DUB) It is abnormal uterine bleeding with out any structural abnormality in the genital tract Excessive noncyclic endometrial bleeding unrelated to anatomical lesions of the uterus or to systemic disease So the cause is said to be hormonal abnormality It is more useful to think of dysfunctional uterine bleeding as anovulatory bleeding 80-90% is due to dysfunction of the H-P-O axis 10

11. Patho physiology no ovulation ↓ no corpus luteum ↓ no progesterone secretion ↓ unopposed estrogen stimulation of endometrium ↓ endometrium become out of phase and start to shade 11

12. Evaluation and Diagnosis of AUB History Physical examination Laboratory studies Pregnancy test Complete blood count Thyroid-stimulating hormone (TSH) and prolactin Coagulation profile 12

13. P/E focus on V/s HEENT( anemia) Abdomen Mass and enlarged irregular uterus suggests myoma Symmetrically enlarged ux is more typical of adenomyosis or endometrial CA GUS Consistency and surface of CX Any mass on the CX or VX Adenexal mass 13

14. CONT… Diagnostic procedures Ultrasonography Cytologic Examination Endometrial biopsy Hysteroscopy 14

15. CONT… Cytologic Examination Cervical and endometrial cancers can cause AUB Pap smear (for cervical ca ) Depending on the pap smear results, colposcopy or endometrial biopsy or both may be indicated  A special instrument called a colposcope lighted , highly magnified view of the tissue of the cervix , vagina, and vulva. The colposcope is placed close to the body, but it does not enter the body 15

16. CONT… ULTRASONOGRAPHY In post menopausal mothers endometrial thickness <4mm excludes endometrial ca in 95-97% Endometrial thicknesses >5 mm warrant additional evaluation with hysteroscopy, or endometrial biopsy Endometrial thickness of > 15mm independent of cycle in premenopausal mother endometrial ca should be rulled out by endometrial biopsy 16

17. CONT… Normal endometrial cancer thickness premenopausal During menstruation: 2-4 mm  Early proliferative phase (day 6-14): 5-7 mm late proliferative / preovulatory phase: up to 11 mm S ecretory phase: 7-16 mm 17

18. CONT… Saline-Infusion Sonography This simple, minimally invasive, and effective sonographic procedure can be used to accurately evaluate the myometrium, endometrium, and endometrial cavity To perform SIS, a small catheter is squeeze through the cervical os into the endometrial cavity Through this catheter, sterile saline is infused, and the uterus is distended Sonography is then performed using a transvaginal technique This method allows visualization of common masses associated with abnormal uterine bleeding such as endometrial polyps, submucosal myomas , and intracavitary blood clots 18

19. CONT… Endometrial Biopsy AUB in a woman above 35 years AUB not responding to conservative measures 19

20. CONT… Hysteroscopy This procedure involves inserting an optic endoscope, usually 3 to 5 mm in diameter, into the endometrial cavity The uterine cavity is then distended with saline or another medium for visualization In addition to inspection, biopsy of the endometrium allows histologic diagnosis of visually abnormal areas and has been shown to be a safe and accurate means to identify pathology The main advantage of hysteroscopy is to detect intracavitary lesions such as leiomyomas that might be missed using transvaginal sonography or endometrial sampling 20

21. Treatment of Abnormal Uterine Bleeding The cause of the abnormal bleeding should determine the treatment options available to the patient Hormonal or medical conditions causing the bleeding should be addressed Structural causes are often addressed surgically 21

22. CONT… Management of DUB The management of DUB has several goals Maintenance of hemodynamic stability Correction of acute or chronic anemia Return to a pattern of normal menstrual cycles Prevention of recurrence Prevention of long-term consequences of anovulation 22

23. CONT… Management for mild DUB Management of mild DUB consists of observation and reassurance They should follow-up in three to six months Although hemoglobin concentration is usually normal (>12 mg/ dL ) in mild DUB iron should be given 23

24. CONT… Mx of moderate DUB 1 ) Not in Active bleeding Managed in the outpatient setting Combined OCP Progesterone only pills Medroxyprogestrone 10 mg po /d from in the last 10days of the cycle 24

25. CONT… 2) Currently bleeding - a combination of estrogen and progestin rather than to progestin-only preparations, as estrogen provides hemostasis 1tab TID until the bleeding stops 1tab BID for 5 days 1tab daily to complete 21 days course If the bleeding persist despite 3month hormonal RX other causes should be ruled out 25

26. CONT… MX of sever DUB Hospitalization Stabilization Blood transfusion Hormone RX 26

27. CONT… Combined ocp (high dose estrogen ) 1tab qid for 4 day 1tab tid for 3 day 1tab bid for 21 day Give antiemetic 1hr before 27

28. CONT… Surgical methods Are last options in a lady who doesn’t respond to hormonal therapy D&C Endometrial destructive procedures Hysterectomy 28

29. CONT… Endometrial ablation Surgical destruction of the endometrium. The endometrium must be destroyed or resected to the level of the basalis , which is approximately 4 to 6 mm deep, depending upon the stage of the menstrual cycle Endometrial ablation is performed with a disposable device which is inserted into the uterine cavity and delivers energy (radiofrequency) to uniformly destroy the uterine lining Or endometrial ablation or resection performed under hysteroscopic visualization with electrosurgical instruments 29

30. CONT… Endometrial ablation is contraindicated in women with the following conditions or characteristics Pregnancy Known or suspected endometrial cancer Desire to preserve fertility Active pelvic infection Intrauterine device in place Previous transmyometrial uterine surgery After resection or ablation, 70 to 80% of women experience significantly decreased bleeding 30

31. CONT… Hysterectomy Removal of the uterus is obviously the most effective treatment for bleeding and overall patient satisfaction rates approximate 85% Disadvantages to hysterectomy include more frequent and severe intraoperative and postoperative complications compared with either conservative medical or ablation procedures Operating time, hospitalization, recovery times, and costs are also greater 31

32. Thank You! 32

33. Uterine Myoma By Helen.S (MSc in CM) 33

34. Uterine Myoma Uterine leiomyomas (fibroids or myomas ) are the most common pelvic tumor in women They are benign tumors arising from the smooth muscle cells of the myometrium They arise in reproductive age women and typically present with symptoms of abnormal uterine bleeding or pelvic  pain/pressure Uterine fibroids may also have reproductive effects ( eg , infertility, adverse pregnancy outcomes ) 34

35. CONT… TERMINOLOGY AND LOCATION  Fibroids are often described according to their location in the uterus, although many fibroids have more than one location designation 1) Intramural myomas These leiomyomas develop from within the uterine wall They may enlarge sufficiently to distort the uterine cavity or serosal surface Some fibroids can be transmural and extend from the serosal to the mucosal surface 2) Submucosal myomas T hese leiomyomas derive from myometrial cells just below the endometrium These neoplasms often protrude into the uterine cavity 35

36. CONT… The extent of this protrusion is classified A type 0 fibroid is completely intracavitary , type I has less than 50% of its volume in the uterine wall, whereas a type II has 50 % or more of its volume in the uterine wall Types 0 and I are hysteroscopically resectable , although significant hysteroscopic expertise may be needed to resect type I masses 3) Subserosal myomas – These leiomyomas originate from the myometrium at the serosal surface of the uterus. They can have a broad or pedunculated base and may be intraligamentary ( ie , extending between the folds of the broad ligament ) 4) Cervical myomas – These leiomyomas are located in the cervix, rather than the uterine corpus 36

37. Location of Myoma

38. Multiple fibroids

39. CONT… RISK FACTORS Race  — The incidence rates of fibroids are typically found to be two- to three-fold greater in black women than in white women  Early menarche (<10 years old ) Parity (having one or more pregnancies extending beyond 20 weeks) decreases the chance of fibroid formation It has been seen that the postpartum remodeling of the uterus may have the effect of clearing smaller fibroids E arly age at first birth decreases risk and a longer interval since last birth increases risk Hormonal contraception    — Use of low dose contraceptives (OCs) does not cause fibroids to grow, therefore administration of these drugs is not contraindicated in women with fibroids 40

40. CONT… Obesity  Diet and alcohol use  Smoking  — Smoking decreases the risk of having fibroids through an unknown mechanism Hypertension is associated with an increased leiomyoma risk 41

41. CONT… Clinical Manifestations  Symptoms attributable to uterine myomas can generally be classified into three distinct categories: Abnormal uterine bleeding Pelvic pressure and pain Reproductive dysfunction 42

42. CONT… Abnormal uterine bleeding   Abnormal uterine bleeding is the most common symptom Heavy  and/or prolonged menses is the typical bleeding pattern with myomas Intermenstrual bleeding and postmenopausal bleeding are  NOT  characteristic of myomas and should be investigated to exclude endometrial pathology 43

43. CONT… The presence and degree of uterine bleeding are determined by the location of the fibroid and size Submucosal myomas that protrude into the uterine cavity are most frequently related to significant menorrhagia women with intramural myomas also commonly experience heavy or prolonged menstrual bleeding 44

44. CONT… Pelvic pressure and pain Bulk-related symptoms   — The myomatous uterus is irregularly shaped, in contrast to the pregnant uterus, and can cause specific symptoms due to pressure from myomas at particular locations As examples, urinary frequency, difficulty emptying the bladder, and, rarely, urinary obstruction can all occur with fibroids symptoms sometimes arise when an anterior fibroid presses directly on the bladder or a posterior fibroid pushes the entire uterus forward Fibroids that place pressure on the rectum can result in constipation Back pain may be related to the presence of myomas 45

45. CONT… Dysmenorrhea  Dysmenorrhea is also reported by many women with fibroids. This pain in many women appears to be correlated with heavy menstrual flow and/or passage of clots Dyspareunia  among women with fibroids, anterior or fundal fibroids are the most likely to be associated with deep dyspareunia Number and size of fibroids do not appear to influence the incidence or intensity of dyspareunia 46

46. CONT… Effects on reproduction  —  Leiomyomas that distort the uterine cavity result in difficulty conceiving a pregnancy and an increased risk of miscarriage leiomyomas have been associated with adverse pregnancy outcomes ( eg , placental abruption, fetal growth restriction, and preterm labor and birth ) 47

47. CONT… DIAGNOSIS Pelvic examination   P elvic examination should be performed On bimanual pelvic examination, an enlarged, mobile uterus with an irregular contour is consistent with a leiomyomatous uterus The size, contour, and mobility of the uterus should be noted, along with any other findings ( eg , adnexal mass, cervical mass ) Infrequently, on speculum exam, a prolapsed submucosal fibroid may be visible at the external cervical os 48

48. CONT… Ultrasound    Transvaginal ultrasound has high sensitivity (95 to 100 % ) for detecting myomas in uteri less than 10 weeks' size B ut Localization of fibroids in larger uteri or when there are many tumors is limited This is the most widely used modality due to its availability and cost-effectiveness Saline infusion sonography ( sonohysterography ) improves characterization of the extent of protrusion into the endometrial cavity by submucous myomas and allows identification of some intracavitary lesions not seen on routine ultrasonography  49

49. CONT… Diagnostic hysteroscopy H ysteroscopy less accurately predicts the size of the myoma compared with ultrasound and sonohysterography 50

50. CONT… DIFFERENTIAL DIAGNOSIS  A normal nonpregnant uterus weighs approximately 70 g The differential diagnosis of an enlarged uterus includes both benign and malignant conditions: Uterine adenomyosis or adenomyoma Pregnancy Hematometra Endometrial carcinoma 51

51. CONT… One characteristic that may distinguish adenomyomas from leiomyomas is the presence of dysmenorrhea as a prominent symptom Adenomyomas are generally more difficult to excise than leiomyomas  Pregnancy is readily distinguishable from other uterine masses with measurement of a serum human chorionic gonadotropin and/or pelvic sonography Hematometra , a collection of blood within the uterine cavity, occurs most often following after an intrauterine procedure and/or in women with cervical stenosis and is diagnosed with pelvic imaging Endometrial carcinoma may also result in abnormal uterine bleeding and a uterine mass, However , the diagnosis is typically made with endometrial sampling and imaging usually shows a thickened endometrium 52

52. CONT… Hematometra , a collection of blood within the uterine cavity, occurs most often following after an intrauterine procedure and/or in women with cervical stenosis and is diagnosed with pelvic imaging Endometrial carcinoma may also result in abnormal uterine bleeding and a uterine mass, However, the diagnosis is typically made with endometrial sampling and imaging usually shows a thickened endometrium 53

53. CONT… Natural History Premenopausal women     With modern pelvic imaging, achieved an increased appreciation of the variability of growth and shrinkage of leiomyomas  among women of reproductive age Prospective studies have found that between 7 to 40 % of fibroids regress over six months to three years Postmenopausal women  Relief of menstrual bleeding symptoms related to fibroids occurs at the time of menopause, when menstrual cyclicity stops and steroid hormone levels decline Most women have shrinkage of leiomyomas at menopause 54

54. CONT… Postmenopausal Women on hormone therapy    Use of postmenopausal hormone therapy may cause some women with leiomyomas to continue to have symptoms after menopause The risk of symptoms may depend, on the location of the fibroid (higher if submucosal   ) 55

55. CONT… Treatment Expectant Management Medical Therapy Surgical 56

56. CONT… Expectant Management Women who have no symptoms from their fibroids A n initial imaging study (usually an ultrasound) to confirm that a pelvic mass is a fibroid and not an ovarian mass After an initial evaluation, perform annual pelvic exams and, in patients with anemia or menorrhagia, check a complete blood count If symptoms or uterine size are increasing, proceed with further evaluation and patient counseling 57

57. CONT… Medical Therapy M edical therapy provides adequate symptom relief in some women, primarily in situations where bleeding is the dominant Estrogen-progestin contraceptives   —  clinical experience suggests some women with heavy menstrual bleeding associated with leiomyomas respond to OC therapy Gonadotropin-releasing hormone agonists  - the most effective medical therapy for uterine myomas These drugs work by initially increasing the release of gonadotropins, followed by desensitization and downregulation to a hypogonadotropic , hypogonadal state that clinically resembles menopause 58

58. CONT… Surgical Indications for surgical therapy: Severe Abnormal uterine bleeding or bulk-related symptoms Infertility or recurrent pregnancy loss  I) Hysterectomy   women with acute hemorrhage who do not respond to other therapies (2 ) women who have completed childbearing  II) Myomectomy   I s an option for women who have not completed childbearing or otherwise wish to retain their uterus Although myomectomy is an effective therapy for menorrhagia and pelvic pressure, the disadvantage of this procedure is the risk that more leiomyomas will develop from new clones of abnormal myocytes 59

59. Thank you 60