abnormal uterine bleeding prof jamiyah hassan
DESCRIPTION
ikram husmTRANSCRIPT
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Causes
FIGO Classification of Abnormal Uterine Bleeding (AUB)
Investigations
Management◦ Medical
◦ Surgical
◦ Interventional
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Uterine fibroids
DUB
Adenomyosis/endometriosis
Uterine hyperplasia
Uterine malignancies
Genital infections
Coagulation disorders
Idiopathic
Polyps
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Term “DUB” discarded
Menorrhagia replaced with heavy menstrual bleeding
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New Classification of abnormal menstrual bleeding 2009
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Notation. A. In all cases, the presence or absence of each criterion is noted using
“0” if absent, “1” if present, and “?” if not yet assessed. Each of the cases shown has 1
abnormality identified. From the top: at least one submucosal leiomyoma (LSM);
adenomyosis (A)—focal and/or diffuse; endometrial polyps (P); and an absence of any
abnormality, leaving endometrial causes (E) as a diagnosis of exclusion. B. Each of the cases
shown has more than 1 positive category. From the top: submucosal leiomyoma and
atypical endometrial hyperplasia (M), as diagnosed by endometrial sampling; endometrial
polyps and adenomyosis; endometrial polyps and subserosal leiomyoma (LO); and
adenomyosis, subserosal leiomyoma and coagulopathy (C), as determined by positive
screening test and subsequent biochemical confirmation of von Willebrand dis
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General assessment
◦ Full blood count
Determine ovulatory status
◦ Detail structured history
◦ Progesterone assessment mid luteal
Screening for systemic hemostasis
◦ Bleeding disorders
◦ Von Willebrand factor
Evaluation endometrium
◦ Adequate endometrial sampling
Evaluation endometrial cavity
◦ Transvaginal ultrasound
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Blood tests◦ FBC, thyroid, coagulation abnormalities
Pap test
Endometrial biopsy
Ultrasound scan
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Exclusion of malignant causes is vital i.e. endometrial cancer or hyperplasia.
Benign organic causes of menorrhagia include endometrial polyps and sub mucous fibroids.
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People with risk factors for endometrial cancer or hyperplasia. The following were found to be independently associated.
1. Obesity(>90kg);2. Infertility3. Nulliparity;4. Age >45 yrs; ( At 40 yrs 5/100,000, 45 yrs
13/100000, 55 yrs 32/100000)5. Family history of colon cancer
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D&C is not performed as an initial work up. Should be performed in conjunction with hysteroscopy to evaluate endometrial cavity.
Pipelle endometrial biopsy appears at least as accurate as D&C, has high levels of patient acceptability, lower complication rates and do not require inpatient admission or GA.
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No tissue found◦ Most likely endometrium is atrophic and
requires estrogen Simple proliferative
◦ This is normal and does not require treatment Endometrial hyperplasia
◦ Except atypical adenomatous requires progestins regimens
◦ Atypical adenomatous hyperplasia, hysterectomy advised
Endometrial carcinoma◦ Refer onco team
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Overall health and the medical history
Cause and severity of condition
Tolerance of medications
Future childbearing plans
Effect of condition on lifestyle
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Iron supplements Nonsteroidal anti-indflammatory
drugs(NSAIDs) Transnexamic acid Oral contraceptives Oral progestogen Hormonal IUS (Mirena) Danazol GNRH
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MIRENA – now is first line medical therapy
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Days of cycle
Ovulation
Ovulation
Menstruation
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Bleeding patterns of LNG-containing intrauterine systems (Mirena®):
-3 -2 -1 1 2 3 4 5 6 7 8 9 10 11
In the first 3-6 months irregular bleeding and spotting
shorter, lighter and less painful periods
about 20% of women may have no bleeding after 1 year
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Mirena effectively reduces menstrual blood loss (MBL)
0
50
100
150
200
Before
insertion
3 6 12
Months of Mirena use
Media
n M
BL (
mL)
* * *
* p<0.001
─86%─97%─91%
%
Reduction
(80mL MBL = menorrhagia)
Andersson JK, Rybo G. Levonorgestrel-releasing intrauterine device in the
treatment of menorrhagia. Br J Obstet Gynaecol. 1990; 97: 690-4
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126
128
130
132
134
136
138
140
0 1 2 3 4 5 6 7 8 9 10 11 12
Months of Mirena use
Mean s
eru
m
haem
oglo
bin
(g/L
) **p<0.001###p<0.01
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IUS
0
10
20
30
40
50
60
70
80
90
100
Mirena Control
Pro
po
rtio
n o
f w
om
en
(%
) *p<0.001; between groups
. Lähteenmäki P, Haukkamaa M, Puolakka J, et al. Open randomised study of use of
levonorgestrel releasing intrauterine system as an alternative to hysterectomy. BMJ
1998; 316: 1122-6
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Compared to endometrial ablation◦ Slightly less mean reduction of blood loss but
equal patient satisfaction
◦ Similarly equal satisfaction to hysterectomy
◦ Higher continuation rate
◦ More cost effective
◦ Should be considered in women who failed medical therapy
◦ Added advantage of reliable contraception
◦ Risk of expulsion 10-20%
◦ Need trained staff for insertion
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TCRE
Roller-ball
Laser
Thermal balloon
Heated free fluid
Cryoablation
Microwave endometrial ablation (MEA)
Radiofrequency electricity (NovaSure)
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Better mean reduction of blood loss
Longer learning curve
Higher complication rate
Consider childbearing plan
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Hysterectomy◦ Vaginal
◦ Abdominal
◦ Laparoscopic
Myomectomy
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Hysterectomy◦ Provides definitive cure
◦ More expensive
◦ O.1 -1.1 cases of mortality per 1000 procedures
◦ Morbidity rate up to 40%
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Percutaneous femoral artery puncture with selective catheterisation of each uterine artery in turn
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Small vessels are accessed using a microcatheterOnce the catheter is in place, PVA particles are introduced until the blood flow stopped