Abnormal Uterine Bleeding Dr. Mashael Shebaili Asst. Prof. & Consultant Ob/Gyne Department

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

Disorders in rhythm, amount or duration Menorrhagia Polymenorrhea Oligomenorrhea Metrorrhagia

Causes of Menorrhagia DUB Pelvic pathology Medical Clotting defect

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

Diagnosis (by exclusion) History General examination Abdomino-pelvic examination Investigations (mainly to exclude organic causes)

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

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

Effectiveness: Decrease measured menstrual loss by 40% in 75% of patients Relief dysmenorrhoea Little effect on regularity of cycle or duration of bleeding

Side effects: Mainly mild gastrointestinal tract irritation The treatment should start immediately with the start of bleeding.

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

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.

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

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

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

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

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.

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

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.

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.

Side effects: Usually minimal as abdominal bloating and weight gain

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

Effectiveness: Scandinavian study (milson et al 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.

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

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

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.

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 Asherman’s syndrome (Laser – electrocautary - roller ball - diathermy – microwave- hot balloon).

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

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

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

POSTMENOPAUSAL BLEEDING

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.

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

(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 .

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

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).

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

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

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.

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

Endometrial biopsy is taken by one of three methods; Endometrial biopsy. It must be done in every case of postmenopausal bleeding, as it 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.

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.

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.

Thank you