Nadya Al-Faraidy 98240015 21 October 2003 Dysfunctional Uterine Bleeding Definition DUB is abnormal uterine bleeding with no pathological

al or congenital cause. diagnosis of exclusion Can be: w/in the period: menorrhagia intermenstrual bleeding Terminology Primary Amenorrhea: no menstruation by age of 14 in absence of secondary sexual characteristics OR before 16 yrs in presence of secondary sexual characteristics Secondary Amenorrhea: cessation of menstruation or 6 months or more in a patient who was menstruating regularly or 12 months in a patient who had a history of oligomenorrhea Menorrhagia: excessive &/or prolonged regular menstruation

Polymenorrhea: frequent regular menses at intervals <21 days Polymenorrhagia: frequent but w/ prolonged &/or excessive bleeding

 Metrorrhagia: irregular periods of uterine bleeding Oligomenorrhea: Episodes of bleeding, which occurs at intervals of more than 35 days. Pathophysiology DUB is most common near the beginning and end of a woman's reproductive life, but may occur at any time. first 18 months after menarche: immature hypothalamin-pituitary axis obese women: nonovarian endogenous estrogen production may upset the normal menstrual cycle. Menopause: anovulatory DUB. anovulatory cycles resulting in menometrorrhagia

luteal phase deficiency cause the loss of LH surge, may be especially prominent in amenorrheic athletes. >40 years: number and quality of ovarian follicles. (OCPs),

Endocrine disorders . Hyperprolactinemia Polycystic ovary disease Hypothyroidism, hyperthyroidism, and Cushing's disease, premature ovarian failure Causes Pregnancy complications Abortion Ectopic pregnancy. Molar disease. Infection e.g. endometritis in post partum. Causes Vulvar lesions: Trauma. Infection. Ulcer.

 Inflammatory lesion. Condylomata. Vulvar tumors (very rare). Causes Vaginal lesions: Vaginitis. Atrophic vaginitis (common in post menopausal women). Foreign bodies e.g. forgotten tampons. Traumas and lacerations. Vaginal tumors (very rare). Disorders of pelvic support (pelvic relaxation). Causes Cervical lesions: Polyps. Cervicitis. Cervical condyloma. Cervical tumors. Causes Uterine lesions: Fibroid. Adenomyosis and endometriosis. Endometrial Polyps. Endometrial hyperplasia Endometritis. Uterine malformation: if severe, menorrhagia Precocious puberty. IUCD.

 Endometrial ca. Causes Ovarian lesions: Salpingo-oopheritis (PID). Endometriosis. Ovarian cyst. Ovarian tumors. Causes GU and GI lesions: Hematuria. Hemorrhoids. Fissures. Rectal cancer. Colon cancer. Causes General disease: Coagulation disorders. Liver disease. Renal disease Thyroid disease. Adrenal disease. Pituitary disease. Causes Blood Dyscariasis: ITP Von-Willibrand disease Leukemia

 Anemias SCA Thalassemia Causes Medications: Exogenous hormones eg Hormone Replacement Therapy Oral contraceptives. Aspirin. Anticoagulant therapy. Digitalis. Corticosteroids. Others. Incidence . One of the most common symptoms in gynecology. . Most frequently at the extremes of age: an-ovulation or Imbalance. 6months 1 year after menarche and post menopause. Menorrhagia affects approximately 22% of healthy women.

In the United States, approximately 7.6 million pre-menopausal women aged between 30 and 55 perceive their menstrual bleeding to be excessive. Evaluation History age Menstrual history. Amount of bleeding. Duration of the loss. Interval between episodes.

 Associated symptoms. Drugs ingested esp use of hormones or contraceptives. Variation in weather, diet and exercise. Evaluation Physical Examination Examination of all symptoms. Basal temperature charting Pelvic examination & speculum examination Recto-vaginal examination in young children or single women in which you cant do pelvic examination. Evaluation Lab Investigations CBC: Hb and Hct + WBCs for infection ESR Serum HCG to rule out pregnancy. Urinalysis Pelvic U.S. Hysterosalpingography (HSG). Endometrial biopsy. Hysteroscopy. Dilatation and curettage (D & C) Diagnostic and therapeutic. # Most of the time we dont need all these investigation, Hb and HCG will be enough. Management Medical Combined contraceptive pill: transforms uterus into pseudo-secretory state short secretory & short proliferative & then shedding occurs Progesterone: for 21 days if uterus hyperplastic PGSI- PG Synthase Inhibitor:

 Rationale: during DUB, there is excessive PG esp PGE2 which cause excessive bleeding Eg indomethacin, mefenamic acid (Ponstan) Rx 50-70% of DUB Side effect: diarrhea ECA: Fibrinolytic Causes thrombosis of spiral uterine blood vessels causes decreased bleeding > side effects How successful is HRT at preventing menstrual bleeding? Continuous combined hormone replacement usually results in amenorrhea after about 3 months of use intermittent bleeding during the first 3 months is common.

By 6 months, about 2/3's of women will not have bleeding at 1 year 80-85% will be without bleeding.

Increasing the estrogen dose as well as the progestin dose may help stop some of the bleeding. Management Surgical Removal of the endometrium If hormone therapy is not effective, the endometrium may be removed. Endometrial ablation is usually the method of choice, although some patients choose a hysterectomy or D & C. Endometrial ablation YAG LASER Thermal balloon Hydrothermablator Resectoscope

 YAG LASER Advantages 15 and 30 minutes. discharged two or three hours. The patient should be reassured that discharge is normal 80% successful in reducing heavy periods and may eliminate menstruation altogether. Advantages of the procedure over hysterectomy it is safer, less invasive, and does not require a surgical incision it is less expensive it requires a shorter hospital stay women can resume normal activity within days, compared to 4 to 6 weeks YAG Disadvantages o o o o o o o fluid overload hyponatremia, perforation of the uterus or adjacent organs, uterine rupture, infection or haemorrhage. Overall, endometrial ablation has a morbidity rate of 3%. sterility

The Novasure System Another new device, the Novasure System , is now available, and has a number of advantages over other systems. It only takes a few minutes and has an excellent safety record Thermal balloon two components - a balloon catheter for heating and a controller

local anaesthesia 87 degrees Celsius, for eight minutes.

outpatient procedure equal it to inserting an intrauterine device (IUD). SE: pressure or cramping sensation (NSAID) suppository administered 45 minutes prior to the procedure.

might experience vaginal discharge or spotting, which normally changes to a watery discharge, between 10 and 30 days. it is normal. intended for use by women who have already completed their families. HTA Hydrothermablator hot water, but allows it to circulate freely in the endometrial cavity. It is done under direct vision through a hysteroscope 10 minutes Who should consider endometrial ablation? menstrual bleeding that is impacting life, with no other problems that require a hysterectomy >80ml per cycle, >8 days Activity is limited b/c of periods anemic and tired

Bleeding limits intimate time with partner Failure of drug therapy Exclusion of other causes NO desire to retain fertility

Who shouldn't have an endometrial ablation? endometrial ablation is not for anyone who desires to keep her fertility. malignancy or pre-malignant condition of the uterus severe pelvic pain, unless the pain is coming from an intracavitary myoma Although pregnancy is unlikely after ablation, serious complications could arise. It is essential for to use reliable contraception after an endometrial ablation. Who can help me decide if an endometrial ablation is for me?

gynecologist

A physician who does not do endometrial ablation on a regular basis is unlikely to have the experience to help you make the best decision. The physician should be expert at vaginal-probe ultrasound and at diagnostic hysteroscopy, and should consider non-surgical treatments, as well as discussing the advantages and disadvantages of all the options available. While the physician can provide you with information, the decision is ultimately yours.

How successful is endometrial ablation at stopping uterine bleeding problems? The various techniques used for endometrial ablation may have slightly different outcomes in general about 1/3 to 1/2 of women are completely without any bleeding afterwards (amenorrheic) about 15-20% still have bleeding problems severe enough to warrant further surgery . The overall satisfaction rate of endometrial ablation is about 65%

Other Surgical Options Hysteroscopy

Resectoscopy

Hysterectomy

D&C

Is hysterectomy a better treatment than endometrial ablation for bleeding problems? The two procedures are somewhat difficult to compare. outpatient vs. inpatient

1 week vs. 6 weeks 4 year study:

 36% of the women having endometrial ablation and 24% of the women having hysterectomy required more sx Satisfaction rates 80% in the ablation group and 89% in the hysterectomy group. (retreatment, PMS) Endometrial ablation allows about 75% of women to avoid hysterectomy Hysterectomy was more successful in the long run in treating the bleeding problems as well as premenstrual symptoms