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Abnormal uterine bleeding prof jamiyah hassan
- 1. Powerpoint Templates Abnormal Uterine Bleeding Jamiyah Hassan UMMC
- 2. Powerpoint Templates Page 2 Causes FIGO Classification of Abnormal Uterine Bleeding (AUB) Investigations Management ◦ Medical ◦ Surgical ◦ Interventional
- 3. Powerpoint Templates Page 3 Uterine fibroids DUB Adenomyosis/endometriosis Uterine hyperplasia Uterine malignancies Genital infections Coagulation disorders Idiopathic Polyps
- 4. Powerpoint Templates Page 4 Term “DUB” discarded Menorrhagia replaced with heavy menstrual bleeding
- 5. Powerpoint Templates Page 5 New Classification of abnormal menstrual bleeding 2009
- 7. Powerpoint Templates Page 7 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
- 10. Powerpoint Templates Page 10 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
- 11. Powerpoint Templates Page 11 Blood tests ◦ FBC, thyroid, coagulation abnormalities Pap test Endometrial biopsy Ultrasound scan
- 12. Powerpoint Templates Page 12 Exclusion of malignant causes is vital i.e. endometrial cancer or hyperplasia. Benign organic causes of menorrhagia include endometrial polyps and sub mucous fibroids.
- 13. Powerpoint Templates Page 13 People with risk factors for endometrial cancer or hyperplasia. The following were found to be independently associated. 1. Obesity(>90kg); 2. Infertility 3. 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
- 14. Powerpoint Templates Page 14 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.
- 18. Powerpoint Templates Page 18 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
- 20. Powerpoint Templates Page 20 Overall health and the medical history Cause and severity of condition Tolerance of medications Future childbearing plans Effect of condition on lifestyle
- 21. Powerpoint Templates Page 21 Iron supplements Nonsteroidal anti-indflammatory drugs(NSAIDs) Transnexamic acid Oral contraceptives Oral progestogen Hormonal IUS (Mirena) Danazol GNRH
- 22. Powerpoint Templates Page 22 MIRENA – now is first line medical therapy
- 23. Powerpoint Templates Page 23 Days of cycle Ovulation Ovulation Menstruation
- 24. Powerpoint Templates Page 24 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
- 25. Powerpoint Templates Page 25 Mirena effectively reduces menstrual blood loss (MBL) 0 50 100 150 200 Before insertion 3 6 12 Months of Mirena use MedianMBL(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
- 26. Powerpoint Templates Page 26 126 128 130 132 134 136 138 140 0 1 2 3 4 5 6 7 8 9 10 11 12 Months of Mirena use Meanserum haemoglobin(g/L) **p<0.001# ##p<0.01
- 27. Powerpoint Templates Page 27 IUS 0 10 20 30 40 50 60 70 80 90 100 Mirena Control Proportionofwomen(%) *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
- 28. Powerpoint Templates Page 28 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
- 29. Powerpoint Templates Page 29 TCRE Roller-ball Laser Thermal balloon Heated free fluid Cryoablation Microwave endometrial ablation (MEA) Radiofrequency electricity (NovaSure)
- 30. Powerpoint Templates Page 30 Better mean reduction of blood loss Longer learning curve Higher complication rate Consider childbearing plan
- 31. Powerpoint Templates Page 31 Hysterectomy ◦ Vaginal ◦ Abdominal ◦ Laparoscopic Myomectomy
- 32. Powerpoint Templates Page 32 Hysterectomy ◦ Provides definitive cure ◦ More expensive ◦ O.1 -1.1 cases of mortality per 1000 procedures ◦ Morbidity rate up to 40%
- 34. Powerpoint Templates Page 34 Percutaneous femoral artery puncture with selective catheterisation of each uterine artery in turn
- 35. Powerpoint Templates Page 35 Small vessels are accessed using a microcatheter Once the catheter is in place, PVA particles are introduced until the blood flow stopped