DL 16-AUB.pptx

AUB

1. Abnormal uterine bleeding

2. SLO 1. Discuss about the definition, incidence, pathogenesis and PALM-COEIN classification of AUB. 2. Discuss the etiology , clinical features, investigations and treatment of puberty menorrhagia. 3. Discuss about the Metropathica hemorrhagica , irregular ripening and Halban’s disease.

3. Objectives Normal uterine bleeding Common terminologies Classification Pathogenesis Investigation Management

4. Normal uterine bleeding Normal duration – 3-7 days Normal cycle frequency – 21- 35 days Normal amount – 30- 80ml Normal control of menstrual bleeding Menstrual bleeding- Platelet aggregation forms clot Prostaglandin F2alpha- myometrial contraction, constricts Endometrial vessels

5. Common terminologies Menorrhagia – Cyclical bleeding Excessive In amount or duration . Polymenorrhea – frequent cycles <21 days . Epimenorrhagia- frequent cycles + excessive bleeding . Metrorrhagia – intermenstrual bleeding . Oligomenorrhea- cycles frequency > 35days Hypomenorrhea- Scanty bleeding, cycle duration less than 2 days . Menometrorrhagia- Bleeding irregular and excessive

6. Abnormal uterine bleeding Excessive bleeding forom the uterus through the gental tract with palpable pelvic organ pathology or macroscopic / microscopic pathology.

7. Menorrhagia- causes Pelvic Fibroid uterus Adenomyosis Endometriosis IUCD in utero Chronic tubo ovarian mass Tubercular endometritis Retroverted uterus Granulosa cell tumour

8. Continued…… Systemic Liver dysfunction . Congestive cardiac failure . Severe hypertension Endocrine hypothyroidism . Hyperthyroidism Hematological Idiopathic thrombocytopenic purpura . Leukemia . Von willebrand disease . Platelet deficiency

9. Polymenorrhea - causes Dysfunctional –during adolescence - preceding menopause - following delivery and abortion Ovarian hyperemia PID and ovarian endometriosis

10. Metrorrhagia - causes Causes of acyclic bleeding DUB Submucous fibroid Uterine polyp Carcinoma cervix causes of contact bleeding Ca cervix Mucous polyp of cervix Vascular ectopy of cervix Cervicitis Cervical endometriosis

11. Causes of Intermenstrual bleeding Urethral caruncle Decubitus ulcer Breakthrough bleeding Iucd in utero Ovular bleeding

12. Oligomenorrhea Causes Age related – adolescence and menopause Obesity Stress related and exercise related Endocrine – Pcos , hyperthyroidism, hyperprolactinemia Androgen producing tumours – ovarian , adrenal tumours Tubercular endometritis Drugs – phenothiazine, cimetidine, methyldopa

13. Hypomenorrhea Causes Uterine synechiae Tubercular endometritis- late cases Oral contraceptive Thyroid dysfunction Malnutrition

14. FIGO classification PALM COEIN Polyp Adenomyosis Leiomyoma Malignancies Coagulopathy Ovulatory dysfunction Endometrial causes Iatrogenic Not yet classified

15. Dysfunctional uterine bleeding Abnormal uterine bleeding without any palpable pelvic organ pathology either macroscopic or microscopic. Common during extremes of reproductive life, following pregnancy during lactation Immature hypothalamic pituitary ovarian axis- anovulatory cycle Types Anovulatory cycles- Ovulatory cycles

16. Pathogenesis PGE2 and PGI2- vasodilators antiplatelet aggregates PGF2alpha and Thromboxane A2- vasoconstriction and platelet aggregates Progesterone- secretes PGF2alpha Anovulatory cycles- absence of progesterone- reduced PGF2alpha-vasodilatation- menorrhagia Tissue plasminogen activator - fibrinolytic enzyme- increased- menorrhagia Low endothelin(vasoconstrictor)- vasodilatation- menorrhagia

17. Puberty menorrhagia Causes Hypothalamic pituitary ovarian dysfunction Blood dyscrasia- coagulation disorders, thrombocytopenic purpura, von willebrand disease, leukemia Hypothyroidism Genital tuberculosis Liver disorders Feminising ovarian tumour, adrenal hyperplasia

18. Clinical features Often Initial cycles regular Heavy regular cycles or Normal bleeding for several days Investigations Hb, bleeding time, clotting time, coagulation factors, blood film Xraychest - tb Thyroid function test Ultrasound D &C - tb endometrium

19. Management Treat cause, anemia Anovulatory cycles-acute - IV premarin 25mg 6-8hrly Estrogen for 21days Progesterone- for 10 days for 3-6cycles Chronic - oral combined pills or cyclical progesterone NSAIDs- mefenemic acid ,naproxen, ponstan, ibuprofen Mirena IUCD, Arterial embolisation, Uterine tamponade- foley catheter for 24hrs Anti tb treatment Iv tranexemic acid with oestrogen Desmopressin analogue of arginine vasopressin iv or nasal spray- von willebrand disease

20. Reproductive age Causes PALM COEIN classification PALM- structural abnormaties- studied by imaging and histopathological study COEIN- non structural- coagulation disorders and hormonal dysfunction

21. Investigation Ultrasound- polypus, adenomyosis, leiomyoma, malignancy Saline sonography- polypus Hysteroscopy- polypus Dilitaion and curettage Papsmear

22. Childbearing and premenopausal women Metropathia hemorrhagica Anovulatory AUB- 40-45years Continuous painless vaginal bleeding preceded by 6-8weeks of amenorrhoea Uterus slightly bulky Myohyperplasia- Uterine wall measurements upto 25mm Endometrium thick , polypoidal, thin slender polypi project into Uterine cavity Cystic glandular hyperplasia- Swiss cheese pattern

23. Investigation Hb, thyroid function test, coagulation profile Ultrasound Curettage, uterine aspiration, hysteroscopic biopsy Doppler ultrasound- endometrial vascularity Hysterosalpingography and saline salpingography

24. Treatment Correct anemia Treat the cause Combined oral contraceptives Progestogens Gestrinone Danazol GnRH analogues- 4weekly inj Tranexemic acid NSAIDs, ethamsylate , mirena iucd SERM- ormeloxifene, centchroman

25. Minimal invasive surgery Ablative techniques 1st generation- hysteroscopic ablation endometrium resectoscope, roller ball laser 2nd generation- radio frequency induced thermal ablation, balloon therapy, microwave ablation Uterine tamponade- Bilateral uterine artery embolisation If no response- hysterectomy

26. Thank you