Abnormal Uterine Bleeding

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Abnormal Uterine Bleeding
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Phases of menstrual cycle
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(No Transcript)
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Sequential morphologic changes in endometrium
throughout the menstrual cycle
PROLIFERATIVE PHASE

• Tortuous endometrial glands
• Tall columnar epithelium
• Mitotic figures in the endometrial glands
• Pseudostratified nuclei
• Compact stroma

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Sequential morphologic changes in endometrium
throughout the menstrual cycle
PROLIFERATIVE PHASE

• Tortuous endometrial glands
• Tall columnar epithelium
• Mitotic figures in the endometrial glands
• Pseudostratified nuclei
• Compact stroma

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Sequential morphologic changes in endometrium
throughout the menstrual cycle
PROLIFERATIVE PHASE

• Tortuous endometrial glands
• Tall columnar epithelium
• Mitotic figures in the endometrial glands
• Pseudostratified nuclei
• Compact stroma

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Sequential morphologic changes in endometrium
throughout the menstrual cycle
PROLIFERATIVE PHASE

• Tortuous endometrial glands
• Tall columnar epithelium
• Mitotic figures in the endometrial glands
• Pseudostratified nuclei
• Compact stroma

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Sequential morphologic changes in endometrium
throughout the menstrual cycle
POST-OVULATORY DAY 1 (INTERVAL ENDOMETRIUM)

• Coiled endometrial glands
• Mitotic figures in endometrial glands
• Subnuclear vacuoles in lt50 of glands

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Sequential morphologic changes in endometrium
throughout the menstrual cycle
POST-OVULATORY DAY 2

• Frequent mitotic figures
• Subnuclear vacuoles in gt50 of glands

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Sequential morphologic changes in endometrium
throughout the menstrual cycle
POST-OVULATORY DAY 6

• Prominent glandular secretion
• Infrequent cytoplasmic glandular vacuoles
• Irregular hazy luminal border
• Dilated glandular lumina
• Naked stromal nuclei

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Sequential morphologic changes in endometrium
throughout the menstrual cycle
POST-OVULATORY DAY 14

• Initial evidence of stromal hemorrhage
•   Prominent stromal granulocytes
• Focal thrombosis in endometrial vessels
•  Prominent apoptosis in endometrial glands

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Sequential morphologic changes in endometrium
throughout the menstrual cycle
MENSTRUAL ENDOMETRIUM

• Crumbling stroma
• Prominent stromal granulocytes
• Thrombosis in endometrial vessels
• Prominent apoptosis in endometrial glands
•   Prominent hemorrahge
•   Regenerative changes

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Abnormal Uterine Bleeding

• Amenorrhea Lack of menstrual bleeding
• Hypomenorrhea Regular uterine bleeding that is
  decreased in amount
• Oligomenorrhea Infrequent, irregular episodes
  of bleeding usually with intervals of more than
  40 days
• Polymenorrhea Frequent but regular episodes of
  bleeding, usually with intervals of 21 days or
  less
• Menorrhagia Bleeding excessive in both amount
  and (Hypermenorrhea) duration of flow, occurring
  at regular intervals
• Metrorrhagia Bleeding (usually not excessive)
  occurring at irregular intervals
• Metrometrorrhagia Bleeding, usually excessive
  and prolonged occurring at frequent and irregular
  intervals

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Types of Uterine Bleeding

• Normal menstrual bleeding
• Bleeding not exceeding 5 days in an ovulatory
  cycle
• Abnormal uterine bleeding
• Organic cause
• Non-organic cause (DUB)
• Ovulatory cycle
• Anovulatory cycle

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Types of Uterine Bleeding
Normal menstrual bleeding Timing There is no
standard definition of "normal" menstrual cycles,
but in general, normal cycles are those in which
the first day of each bleeding episode occurs
every 28 days /- 7 days, lasting 4-5 days /-
4-5 days. So, a woman with 1-2 days of bleeding
every 35 days is normal, as is one with 10
day-long cycles every 26 days. Slight changes in
menstrual cyclicity have no significance, and
most patients can be reassured about such
changes. In practice, patients with AUB/
irregular cycles are usually markedly irregular
(menses every 3-4 months, or very erratic). Flow
"Normal" menstrual blood loss is the equivalent
of 30-60 mL of blood, and over 80 is considered
excessive. Clinically, it is usually impossible
to objectively measure blood loss from the
history, and the patient's impression is
frequently misleading.
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Types of Uterine Bleeding
Uterine bleeding due to an organic cause

• Complications of pregnancyIntrauterine
  pregnancyEctopic pregnancySpontaneous
  abortionGestational trophoblastic
  diseasePlacenta previa

Medications/iatrogenic Intrauterine device
Hormones (oral contraceptives, estrogen,
progesterone) Anovulatory cycles Hypothyroidism
Hyperprolactinemia Cushing's disease
Polycystic ovarian syndrome Adrenal
dysfunction/tumor Stress (emotional, excessive
exercise)
Benign pelvic pathology Cervical
polypEndometrial polypLeiomyoma Adenomyosis
Systemic disease Hepatic disease Renal disease
Coagulopathy Thrombocytopenia von Willebrand's
disease Leukemia
Malignant neoplasm Cervical Endometrial Ovarian

• Trauma Laceration abrasion Foreign body

• Infection Cervicitis Endometritis

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Dysfunctional Uterine Bleeding
DEFINITION Dysfunctional uterine bleeding (DUB)
is heavy or irregular menstrual bleeding that is
not caused by an underlying anatomical
abnormality, such as a fibroid, lesion, or tumor.
DUB is the most common type of abnormal uterine
bleeding.
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Dysfunctional Uterine Bleeding
OVULATORY CYCLE Most common after the adolescent
years and before the perimenopausal years, to as
many as 10 of ovulatory women. Menstrual
irregularity associated with corpus luteum
defects or midcycle staining is considered as
subgroup of DUB, but anovulatory DUB is most
widely accepted form of DUB.
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Dysfunctional Uterine Bleeding

• OVULATORY CYCLE
• Regular cycle length
• Presence of premenstrual symptoms
• Dysmenorrhea
• Breast tenderness
• Change in cervical mucus
• Mittleschmertz
• Biphasic temperature curve
• Positive result from use of luteinizing-hormone
  predictor kit

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Dysfunctional Uterine Bleeding
OVULATORY CYCLE Inadequate proliferative
phase Disparity between the endometrial phase and
date of menstrual cycle Inadequate secretory
phase (luteal phase defect) Disparity between the
endometrial phase and date of menstrual
cycle Irregular shedding Lag in shedding of
secretory endometrium leading to bleeding over 7
days
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Dysfunctional Uterine Bleeding

• OVULATORY CYCLE
• Unpredictable cycle length
• Unpredictable bleeding pattern
• Frequent spotting
• Infrequent heavy bleeding
• Monophasic temperature curve

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Dysfunctional Uterine Bleeding
ANOVULATORY CYCLE Any disruption to the cyclic
release of GnRH, FSH, LH can result in
anovulation. Due to immaturity of the HPO axis
in postmenarche, decreased sensitivity of the
ovary to gonadotropin stimulation in
perimenopausal women. Most anovulatory DUB is due
to estrogen withdrawal or estrogen breakthrough
bleeding
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Dysfunctional Uterine Bleeding

• ANOVULATORY CYCLE
• Disordered proliferative endometrium
  (proliferative endometrium during the secretory
  phase) to hyperplasia
• Hpyerplasia
• Simple
• Complex
• Atypical hyperplasia
• Simple
• Complex

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Types of Uterine Bleeding
Hyperplasia to Carcinoma
Microscopically, the well differentiated tumors
(upper left) appear as glands with the
morphologic feature of normal endometrial glands.
The glands are densely packed with little
intervening stroma or may exhibit a cribriform
appearance. The poorly differentiated tumors
(upper right) appear as sheets and rarely form
glandular structures. Some tumors may form
papillary structures (lower left), or may consist
of clear cells (lower right).
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Types of Uterine Bleeding

• ANOVULATORY CYCLE
• Thick endometrium
• Crowded glands with little stroma
• Fragile endometrium
• Hypervascular endometrium
• Spontaneous bleeding
• In absence of a controlled progesterone
  withdrawal there is
• No vasoconstriction
• No tight coiling of spiral vessels
• No orderly collapse to induce stasis
• Bleeding is long and heavy

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Abnormal Uterine Bleeding

• MEDICAL HISTORY
• Detailed information about the menstrual pattern
  
• List of medications and nonprescription drugs
• Sexual history (including pregnancy and
  contraception information)
• Symptoms of infection and disease (including
  gynecologic disorders)
• Recent surgery
• History of injury to the area
• Weight loss
• Eating disorders
• Stress
• Excessive exercise

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Abnormal Uterine Bleeding

• PHYSICAL AND PELVIC EXAMINATION
• Uterus
• Thyroid
• Breasts
• Liver
• Skin (ecchymoses)
• Hirsutism
• Obesity

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Abnormal Uterine Bleeding

• LABORATORY TESTS
• CBC (Hgb, Platelets)
• ß HCG pregnancy test
• PT, PTT, Bleeding time
• TSH
• GC test

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Abnormal Uterine Bleeding

• LABORATORY TESTS
• Chlamydia test
• Pap smear
• Imaging tests
• Pelvic ultrasound
• Transvaginal ultrasound
• Sonohysterograph
• Endometrial Biopsy

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Abnormal Uterine Bleeding

• MANAGEMENT
• Treatment of underlying disorder
• Induction of ovulation (Clomid)
• Hormone therapy
• Treatment with with progestin
• Treatment with OCP's

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Abnormal Uterine Bleeding

• MANAGEMENT
• Surgical intervention
• DC
• Endometrial ablation
• Myomectomy
• Hysterectomy

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Abnormal Uterine Bleeding

• MANAGEMENT
• Systemic disease or organic pathology
• Medical and surgical intervention

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Abnormal Uterine Bleeding

• MANAGEMENT
• Ovulatory DUB
• Prostaglandin
• Non-steroidal antiinflammatory drugs (NSAIDs)
• Progestin releasing IUD
• Low dose oral contraceptives

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Abnormal Uterine Bleeding

• MANAGEMENT
• Anovulatory DUB
• Acute, severe blood loss
• DC
• Mild to moderate blood loss
• High dose OCP (I QID, 7 days then QD for 1-3
  months)
• Provera (50-100 mg IM or 10 mg PO QDX 5-7 days)
• Chronic bleeding
• Oral contraceptive pills
• Cyclic estrogen/progesterone
• Provera on day 13-25 each months
• NSAIDs