Abnormal Uterine Bleeding

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Abnormal Uterine Bleeding

• Dr. Mashael Shebaili
• Asst. Prof. Consultant
• Ob/Gyne Department

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Normal menstruation

• Rhythm regular from 21-35 days
• Duration 3-7 days
• Amount between 30-50 mls
• Flow non clotted fluid blood

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Disorders in rhythm, amount or duration

• Menorrhagia
• Polymenorrhea
• Oligomenorrhea
• Metrorrhagia

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Causes of Menorrhagia

• DUB
• Pelvic pathology
• Medical
• Clotting defect

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Dysfunctional uterine bleeding

• Definition uterine bleeding in the absence of an
  organic disease
• Incidence 10-20 usually at extremes of
  reproductive life.

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Diagnosis (by exclusion)

• History
• General examination
• Abdomino-pelvic examination
• Investigations (mainly to exclude organic causes)

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Treatment

• Medical treatment
• Non-steroidal anti-inflammatory drugs
• Mechanism of action inhibit cyclo-oxygenase
  enzyme and the production of prostaglandins
• Phospholipids phospholipase A2 arachidonic acid
  cyclo-oxygenase prostaglandins

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Possible Pathophysiology

1. Shift in the endometrium conversion of the
   endoperoxide from vaso-constrictor PGF2a
2. Increase in the level and activity of the
   endometrium fibrinolytic system
3. Effect of other endometrial derived factors as
   cytokines, growth factors and endothelins.

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Effectiveness

1. Decrease measured menstrual loss by 40 in 75 of
   patients
2. Relief dysmenorrhoea
3. Little effect on regularity of cycle or duration
   of bleeding

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Side effects

• Mainly mild gastrointestinal tract irritation
• The treatment should start immediately with the
  start of bleeding.

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Antifibrinolytic agents

• Mechanism of action
• Prevent conversion of plasminogen into plasmin
  which dissolve the fibrin clots occluding the
  blood vessels.

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• Effectiveness
• Reduce measured loss by 40-50. The effect is
  dose related. It should be given with the start
  of menstruation and continue for 3-4 days.

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• Comparative studies suggested that tranexemic
  acid is more effective than PG synthetase
  inhibitors (Milsom et al.1991 Bonnar and Shepard
  1996).

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Side effects

1. Mild gastrointestinal tract irritation
2. Serious adverse effect has been documented
   (intracranial thrombosis central venous stasis
   retinopathy) but they are extremely rare.

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1. No such complications occurred in Scandinavia
   over 19 years (1st line of treatment there
2. Should not prescribed for women with history of
   thrombo-embolism.

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Hormonal treatment

• Oral contraceptive pills
• One of the most effective treatments available
  for both menorrhagia and dysmenorrhoea
• Can be used safely in women over 40 years if they
  are of low risk category

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• Mechanism of action
• Mainly locally by inducing endometrial
  atrophy with reduction in both PG synthesis and
  fibrinolysis.
• Side effects
• That of oral contraceptive pills in general
• Socially unaccepted in single unmarried women.

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• Progestogens
• Norethisterone medroxy-progesterone acitate.
• Are the most commonly prescribed preparations in
  UK because it was wrongly thought that the
  majority of women with DUB are anovulatory

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• Mechanism of action
• In anovulatory cycle it induce secretory changes
  but in ovulatory cycle it produce minimal changes
• Norethisterone is given as 5mg t.d.s. for 21 days
  while Provera is given as 10 mg for 10-14 days
  during luteal phase.

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• Effectiveness
• If given in high dose for 21 days especially in
  anovulatory cycle it reduce menstrual loss by 80
  (Irvin et al., 1998)
• In anovulatory cycle it convert irregular,
  unpredictable bleeding into regular controlled
  one which is an attractive feature for many women.

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• Side effects
• Usually minimal as abdominal bloating and
  weight gain

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Progesterone releasing devices

• Produce marked reduction in menstrual blood loss
  up to 80
• Mechanism of action mainly locally leading to
  atrophic endometrium with very minimal systemic
  effect

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• Effectiveness Scandinavian study (milson et
  al.,1991) showed decreased menstrual loss by 90.
• Side effects irregular bleeding is common
  especially in the in the early months.

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Danazol

• Is an extremely effective drug for treatment of
  menstrual problems but its use is limited by its
  high androgenic side effects

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Gonadotrophin releasing hormone agonist

• Mechanism of action produce down regulation of
  pituitary gland that decrease gonadotrophins and
  ovarian steroids
• Effectiveness relief amenorrhoea in 90 of
  cases. Also relief PMS

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• Side effects
• Hypo-estrogenic state and osteoporosis (add
  estrogen and progesterone if used for long
  period)
• Unless used to prepare the patient for
  endometrial ablation it is not accepted by most
  patients for long term.

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Surgical treatment

• Suitable for older patients who have no further
  wish to conceive.
• Endometrial ablation/resection
• To remove or destroy the endometrium producing
  changes similar to Ashermans syndrome (Laser
  electrocautary - roller ball - diathermy
  microwave- hot balloon).

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• Advantage over hysterectomy
• Short hospital stay and return to work
• 50 of patients were amenorrhoeic, 30-40
  experienced marked reduction in menstrual loss
• 70 or more were satisfied

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• Disadvantages
• Needs experience
• Recurrence of about 20
• Operative complications as perforation
• Post operative pain

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Hysterectomy

• Definitive cure for menorrhagia (Abdominal,
  vaginal or laparoscopic) (total or subtotal)
• Disadvantages
• Mortality of 6/10000 procedures
• Injury of ureter, bladder or bowel.

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POSTMENOPAUSAL BLEEDING
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• POSTMENOPAUSAL BLEEDING
• It is bleeding from the genital tract occurring 6
  months or more after cessation of menstruation in
  a woman above the age of 40.
• It is a serious symptom because in about 25 of
  cases, it is due to a malignant lesion in the
  genital tract
• Prevalence
• About 7 per 1000 postmenopausal women.

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• Aetiology

• (A) General Causes
• Oestrogen therapy (25). Oestrogen given for
  menopausal symptoms may lead to withdrawal
  bleeding.
• hypertension.
• blood diseases as leukemia.
• anticoagulant therapy.

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• (B)Local Causes
• Vulva. Malignant tumour, fissured leucoplakia,
  urethral caruncle, and direct trauma.
• Vagina. Malignant tumour, senile vaginitis,
  trophic ulcer in prolapse, and retained foreign
  body or pessary in the vagina.
• Cervix. Malignant tumour, erosion and ulcers.
• Uterus. Malignant tumour, senile endometritis,
  tuberculous eiidometritis, fibroid.

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• F.tube carcinoma. This leads to a watery vaginal
  discharge which finally becomes blood stained
• Ovary. Carcinoma with metastases in the
  endometrium and oestrogenic ovarian tumours.
• (C) In about 15 of cases no cause is found after
  physical examination and uterine curettage which
  shows atrophic endometrium

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Diagnosis

• A. History
• Personal history
• (a) Age The commonest age incidence for
  carcinoma of uterus is 55-70 years while that for
  carcinoma of the vulva is 60-70 years.
• (b) parity some tumours are more common among
  nulliparae e.g. endometrial and ovarian
  carcinoma.
• Present history
• Ask about the amount, character and duration of
  bleeding, duration of menopause, and the presence
  of other symptoms as pain and foul discharge,
  urinary and gastrointestinal symptoms (malignant
  invasion of bladder or bowel).

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• Past history
• Oestrogen therapy.
• diseases as diabetes mellitus, hypertension and
  blood diseases as leukemia.
• Endometrial carcinoma is more common in
  diabetic hypertensive patients.
• Family history
• Carcinoma of the body of the uterus and ovary
  have a familial tendency

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• B. General Examination
• (I) Signs of anaemia.
• (2) signs of bleeding disorders.
• (3) presence of cachexia.
• (4) examination of heart and chest for
  secondaries.
• (5) estimation of blood pressure

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• C Abdominal Examination
• For a pelvi-abdominal mass and ascites which is
  common with ovarian malignancy.
• D.Pelvic Examination
• To detect a local cause for bleeding. The urethra
  and anal canal are excluded as being the source
  of bleeding.

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• E. Special Investigations
• Transvaginal sonography. It excludes the presence
  of an ovarian tumour or alesion in the uterus as
  endometrial carcinoma.
• Cervical smear. Taken in absence of bleeding to
  detect the presence of malignantcells which may
  come from the cervix, endometrium, tubes, or
  ovaries.

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• Endometrial biopsy. It must be done in every case
  of postmenopausal bleeding, asit is the only
  sure method to exclude endometrial carcinoma.
• Endometrial biopsy is taken by one of three
  methods
• Fractional uterine curettage,
• Endometrial aspiration, or
• Hysteroscopy.

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• 4. Biopsy is taken from any suspected lesion in
  the vulva, vagina, or cervix.
• 5. Laboratory tests. These are done according to
  the clinical findings and include
• a. Complete blood count.
• b. Platelet count, bleeding time,
  coagulation time, estimation of
  clotting factors if a bleeding disorder is
  suspected.

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Treatment

• It is treatment of the cause.
• If no cause can be detected the patient should be
  followed up.
• If bleeding recurs it is better to do
  hysterectomy and bilateral salpingo-oophorectomy
  which may reveal a missed early carcinoma of
  uterus or tube.

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Thank you