DYSFUNCTIONAL UTERINE BLEEDING Gem Ashby MD OB/GYN

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DYSFUNCTIONAL UTERINE BLEEDING DUB Bleeding is heavier (passing large clots, soaking through a sanitary pad or tampon every hour for hours in a row) Bleeding is heavier (passing large clots, soaking through a sanitary pad or tampon every hour for hours in a row) Bleeding or spotting that occurs between periods Bleeding or spotting that occurs between periods Time between menstrual periods changes with each cycle Time between menstrual periods changes with each cycle Bleeding lasts for more days than normal Bleeding lasts for more days than normal

CAUSES OF DUB GYN cancers GYN cancers Anovulation Anovulation Fibroids Fibroids Polyps Polyps Systemic illness Systemic illness

WORK UP FOR DUB History and exam History and exam Blood work/PAP smear Blood work/PAP smear Pelvic US Pelvic US Endometrial biopsy Endometrial biopsy D&C, hysteroscopy D&C, hysteroscopy

A: Cervical cancer B: Endometrial(Uterine) cancer C: Ovarian cancer Which two cause DUB? Which one has been linked to a viral infection? Which one is often diagnosed at a very late stage?

CERVICAL CANCER

Cervical cancer is the second most frequent cancer in women in the world Cervical cancer is the second most frequent cancer in women in the world Third greatest cause of death from cancer in women Third greatest cause of death from cancer in women 90% of cervical cancer is cause by HPV 90% of cervical cancer is cause by HPV Of the estimated more than deaths from cervical cancer every year, more than 85% occur in developing countries Of the estimated more than deaths from cervical cancer every year, more than 85% occur in developing countries Stats from WHO

CERVICAL CANCER AND DUB Early cervical cancer is frequently asymptomatic Early cervical cancer is frequently asymptomatic The most common symptoms at presentation are: The most common symptoms at presentation are: Abnormal bleeding Abnormal bleeding Postcoital bleeding Postcoital bleeding Vaginal discharge that may be watery, mucoid, or purulent and malodorous Vaginal discharge that may be watery, mucoid, or purulent and malodorous

TREATMENT OF CERVICAL Surgery to remove the cancer Radiation therapy, which uses high-dose X-rays or implants in the vaginal cavity to kill cancer cells. It is used for certain stages of cervical cancer. It is often used in combination with surgery Chemotherapy, which uses medicines to kill cancer cells. Chemotherapy may be used to treat advanced cervical cancer

ENDOMETRIAL CANCER

Endometrial cancer is cancer of the lining of the uterus Endometrial cancer is cancer of the lining of the uterus

ENDOMETRIAL CANCER Endometrial cancer is rare in women under the age of 45 The average chance of a woman being diagnosed is about one in 37 This cancer is slightly more common in white women, but black women are more likely to die from it

RISK FACTORS FOR ENDOMETRIAL CANCER Being obese. Fat cells make extra estrogen, but the body doesn't make extra progesterone to balance it out Being obese. Fat cells make extra estrogen, but the body doesn't make extra progesterone to balance it out Taking estrogen without taking a progestin Taking estrogen without taking a progestin Polycystic ovary syndrome. This can cause you to produce too much estrogen and not enough progesterone Polycystic ovary syndrome. This can cause you to produce too much estrogen and not enough progesterone Having type 2 diabetes Having type 2 diabetes Never having been pregnant Never having been pregnant

ENDOMETRIAL CANCER AND DUB The most common symptoms include: DUB DUB BLEEDING AFTER MENOPAUSE BLEEDING AFTER MENOPAUSE Pain during sex Pain during sex Pelvic pain Pelvic pain

TREATMENTS Surgery to remove the uterus (and cervix), ovaries, and fallopian tubes (hysterectomy with bilateral salpingo- oophorectomy) Surgery to remove the uterus (and cervix), ovaries, and fallopian tubes (hysterectomy with bilateral salpingo- oophorectomy) Surgery to remove lymph nodes Surgery to remove lymph nodes Radiation therapy to kill cancer cells Radiation therapy to kill cancer cells Progestin hormone therapy to block cancer growth Progestin hormone therapy to block cancer growth Chemotherapy to kill cancer cells Chemotherapy to kill cancer cells

ANOVULATION Anovulation is the absents of ovulation

ANOVULATION Polycystic ovarian syndrome Peri-menopause Thyroid dysfunction (either hyperthyroidism or hypothyroidism) Extremely high levels of stress

ANOVULATION TREATMENT Hormonal manipulation OCP’sNuvaring Depo Provera Nexplanon Mirena IUD

FIBROIDS The most common pelvic tumor in women The most common pelvic tumor in women They are benign tumors arising from the smooth muscle cells of the myometrium They are benign tumors arising from the smooth muscle cells of the myometrium They can cause DUB, pain, voiding dysfunction and may also have reproductive effects (e.g, infertility, adverse pregnancy outcomes) They can cause DUB, pain, voiding dysfunction and may also have reproductive effects (e.g, infertility, adverse pregnancy outcomes)

FIBROID TREATMENTS There's no single best approach to uterine fibroid treatment; many treatment options exist

FIBROID TREATMENTS Hormonal Manipulation (OCP, Nuvaring, Depo Provera, Nexplanon, Mirena) Gonadotropin-releasing hormone (Gn-RH) agonists Medications called Gn-RH agonists (Lupron, Synarel, others) treat fibroids by putting you into a temporary postmenopausal state. With the decreased estrogen many fibroids tend to shrink

FIBROID TREATMENTS Uterine artery embolization Small particles (embolic agents) are injected into the arteries supplying the uterus, cutting off blood flow to fibroids, causing them to shrink and die SHOULD NOT BE DONE if the patient wants more children !!!

FIBROID TREATMENTS Laparoscopic, robotic or open myomectomy In a myomectomy, your surgeon removes the fibroids, leaving the uterus in place

FIBROID TREATMENTS Endometrial ablation and resection of submucosal fibroids A specialized instrument inserted into your uterus; uses heat, microwave energy, hot water or electric current to destroy the lining of your uterus, either ending menstruation or reducing your menstrual flow Ablations DO NOT remove the fibroids SHOULD NOT be done if the patient wants more children

ABLATION

FIBROID TREATMENTS HYSTERECTOMY Abdominal Vaginal Laparoscopic Robotic

FIBROID TREATMENTS HYSTERECTOMY A hysterectomy is an operation to remove a woman's uterus Definitions: In a supracervial or subtotal hysterectomy, a surgeon removes only the upper part of the uterus, keeping the cervix in place A total hysterectomy removes the whole uterus and cervix The ovaries may also be removed -- a procedure called oophorectomy -- or may be left in place

POLYPS Overgrowth of cells in the lining of the uterus (endometrium) Are usually noncancerous (benign), although some can be cancerous or can eventually turn into cancer (precancerous polyps)

POLYPS

TREATMENT FOR POLYPS Hormonal Manipulation (OCP, Nuvaring, Depo Provera, Nexplanon, Mirena) Surgical removal: D&C hysteroscopy A camera is used to look inside the uterus and then the polyp is scraped out An ablation can be done at the same time

AUB Causes GYN cancers GYN cancers Anovulation Anovulation Fibroids Fibroids Polyps Polyps Systemic illness Systemic illness Treatment Surgery Hormonal Contraception Lupron, Surgery/UAE Surgery Treatment based on affected organ system

THANK YOU Wright, Jason and Solange Wyatt. The Washington Manual Obstetrics and Gynecology Survival Guide. Lippincott Williams and Wilkins, ISBN X Wright, Jason and Solange Wyatt. The Washington Manual Obstetrics and Gynecology Survival Guide. Lippincott Williams and Wilkins, ISBN XISBN XISBN X Bravender T, Emans SJ (June 1999). "Menstrual disorders. Dysfunctional uterine bleeding". Pediatr. Clin. North Am. 46 (3): 545–53, viii. PMID Bravender T, Emans SJ (June 1999). "Menstrual disorders. Dysfunctional uterine bleeding". Pediatr. Clin. North Am. 46 (3): 545–53, viii. PMID PMID PMID ^ "Dysfunctional Uterine Bleeding". Retrieved ^ "Dysfunctional Uterine Bleeding". Retrieved ^"Dysfunctional Uterine Bleeding" ^"Dysfunctional Uterine Bleeding"