Abnormal UT bleeding

Abnormal uterine bleeding

It is an descriptive term applied to any alteration in the normal pattern of menstrual flow and it is the uterine bleeding that is abnormal in amount, duration or timing. The abnormalities of menstruation are only symptoms and do not describe pathological entities.

definitionsmenorrhagia

The average menstrual period lasts for 3-7 days, with a mean blood loss of 35 mL.
Menorrhagia ('heavy periods') is defined as a heavy,prolonged regular blood loss of greater than 80 mL per period.
This definition
is rather arbitrary, but represents the level of blood
loss at which a fall in haemoglobin and haematocrit
concentration commonly occurs

Polymenorrhoea

: is a frequent menstruation as menses occurring at < 21 days interval associated with a shortened follicular phase or inadequate luteal phase
Metrorrhagia -irregular intervals with excessive flow and duration

Intermenstrual bleeding –

Uterine bleeding of variable amounts occurring between regular menstrual periods.
*Midcycle spotting :
is scanty intermenstrual discharge occurring just before ovulation that is associated with a decrease in estrogen at midcycle.


*Postcoital bleeding:
is non-menstrual bleeding that occurs immediately after sexual intercourse.
*With drawl bleeding:
bleeding occurred after stopping oestrogen and progestrone use or progestrone use.
*Postmenopausal bleeding
- Recurrence of bleeding in a menopausal woman at least 6 months to 1 year after cessation of cycles.

Prevalence

Menorrhagia is extremely common. Indeed, each
year, 5 per cent of women between the ages
of 30 and 49 consult their general practitioner with
this complaint. Menorrhagia is the single leading
cause of referral to hospital gynaecology clinics.

Classification

Menorrhagia can be classified as:
• idiopathic, where no organic pathology can be
found: idiopathic menorrhagia is otherwise
known as dysfunctional uterine bleeding-(DUB).
The majority of women who present with
menorrhagia will have DUB,
• secondary to an organic cause, such as fibroids.


Aetiology
A. Organic causes:
1. Local disorders:
Uterine fibroids.
Endometrial/ Endocervical polyp.
Adenomyosis.
Pelvic endometriosis.
Intrauterine device (IUD).

Cervicitis

pco
Pelvic inflammatory disease (PID).
Oestrogen-secreting ovarian tumour.(granulosa or theca cell tumour).
Cervical carcinoma.
Uterine body carcinoma.
Trauma of lower genital tract
Urethral caruncle.

2. Systemic disorders:

Menorrhagia is a feature of a number of organic conditions,
which should be considered in the differential
diagnosis.
These include


1.Endocrine disorders may interfere with normal feedback mechanisms that regulate secretion of gonadotrophin- releasing hormone (GnRH), gonadotrophin, sex steroid.
A. Thyroid disorder (Hypothyroidism or hyperthyroidism).
B. Diabetes mellitus.
E. Prolactin disorders

3. Haemostasis disorder:

A. Von Willebrand's disease.
B. Idiopathic Thrombocytopenic purpura (ITP).

4. Liver disorder

5. Renal disease
6. Medications as steroid hormones, anticoagulants and cytotoxic agents, contraceptive method

7.Psychological and emotional cause, Excessive exercise, stress, and weight changes. All these can cause hypothalamic suppression leading to abnormal uterine bleeding due to disruption along the hypothalamus-pituitary-ovarian pathway
8. Pregnancy
Should be considered in women of reproductive life in any patient presenting with abnormal uterine bleeding

B. Non –organic cause (Dysfunctional uterine bleeding (DUB)

no specific organic cause can
be found


is defined as abnormal uterine bleeding in the absence of organic disease.
It is the most common cause of abnormal vaginal bleeding during a woman's reproductive years.
bleeding is most common at the extreme ages of a woman's reproductive years, either at the beginning or near the end, but it may occur at any time during her reproductive life.
It is a diagnosis of exclusion

Aetiology

Despite extensive research, the aetiology of
DUB remains unclear. Disordered endometrial
prostaglandin production has been implicated in the
aetiology of this condition, as have abnormalities of
endometrial vascular development

There are clearer reasons why many more women

complain of menorrhagia now than they did a century
ago.
With decreasing family size, women now
experience many more menstrual cycles.
Additionally,
the changing role of women in society and more liberated
attitudes to the discussion of reproductive
health mean that women are now much less
likely to tolerate menstrual loss that they consider to
be excessive


clinical assessment
History:
*Age, parity, marital status (single, married, widow, divorced).
*Description of the pattern of abnormal menstrual bleeding and it's severity and it's duration and amount of blood loss.
*Presence of other cyclical symptoms as dysmenorrhoea, breast tenderness, psychological disturbance, fatigue, dizziness, and syncope.

perhaps greater relevance is to determine the

impact of the condition on the patient's lifestyle and
quality oflife For example, the patient whose menorrhagia
is so severe that she does not leave the house
during her period clearly has a much greater problem
(and may wish to pursue treatment further) than one
to whom menorrhagia is a minor inconvenience.

Ask about : Recent illness, psychological stress, excessive exercise, or weight change

*Past medical history:
Diabetes mellitus, Thyroid disease, Endocrine problems, pituitary tumors, Liver disease.
*Past surgical history.
*Drug history:
Medication usage, including exogenous hormones, anticoagulants, aspirin, anticonvulsants, and antibiotics


It is also important to determine the duration of
the current problem, and any other symptoms or factors of potential importance.
The following symptoms should be enquired about specifically, as they may suggest a diagnosis other than DUB:
*irregular,intermenstrual or postcoital bleeding,
*a sudden change in symptoms,
* pelvic pain or premenstrual pain,
* and excessive bleeding from other sites or in other situations (e.g. after tooth
extraction).

Clinical examination

Look for:
height and weight and body mass index (BMI).
signs of anemia or hypovolemia, vital signs.
General looking for stigmata of underlying systemic disease is important. hirsutism, striae, thyroid enlargement or nodularity, skin pigment changes.
Assessment for secondary sexual characteristic.
ecchymoses or petechiae (suggest coagulopathy).

it is important to perform a physical examination,

including an abdominal and bimanual pelvic examination,
in all women complaining of menorrhagia.
A cervical smear should be performed if one
is due.


investigations
Initial investi gations
Full blood count
A full blood count (FBC) is done to ascertain the need
for iron therapy.

B-hCG if any possibility of pregnancy exists.

In patients with suspected endocrine disorders, laboratory studies such as thyroid function tests and prolactin levels may be helpful
A mid-luteal progestrone level in regular cycle only (done in day 21 in 28 day cycle). level >30nmol/L is indicative of ovulation.
Serum androgen in some cases as it is elevated in poly cystic ovary syndrome (PCO), androgen producing tumour, adrenal condition.
Prolactin.

Coagulation screen and bleeding time is important to request if bleeding disorder is suspected.
Renal function tests and liver function tests should be requested if systemic condition or malignancy is suspected

Pelvic ultrasound.

It is useful to determine shape and size of uterus and adnexal structures.
It may determine the etiology of the bleeding such as a fibroid, endometrial thickening, poly cystic ovary, adenomyosis

Endometrial sampling

Endometrial biopsy is important step in evaluation abnormal uterine bleeding. It is indicated for the following patients with abnormal uterine bleeding :
1.Women older than 35 years.
2.Those with abnormal endometrial thickness (>12mm in perimenopausal women and >4mm in postmenopausal women).
3.Obese patients.
4.Women who have prolonged periods of unopposed estrogen stimulation
5. Women with chronic anovulation.


Endometrial biopsy can be done by
1. Hysteroscopically directed biobsy:
is the gold slandered procedure as it provides direct visualization of uterine cavity and allows to take biopsy from specific lesion. It is ideally done in proliferative phase of menstrual cycle when the endometrium is at it's thinnest.
2. Aspiration technique.
3.Curettage.

Treatments

There is a host of different treatments for menorrhagia,
all of which have different efficacies and side
effects.

Each treatment

option is associated with a different array of side
effects, which may be acceptable to some women but
not others. For these reasons, and since menorrhagia
is rarely life threatening but has an adverse impact on
the woman's quality of life, it is essential that the
treatment plan is determined in collaboration with
the patient.


In treatment of abnormal uterine bleeding, Consider:
1.Age group.
2.Amount and pattern of bleeding.

Medical treatment

* Non hormonal therapy:
Non steroidal anti-inflammatory drugs
These medications may reduce blood loss by 20-50%. It is used only during menstruation as it is used with the onset of menses or just prior to its onset and continued throughout its duration. It is generally well tolerated

Their mode of action is probably in

restoring imbalanced endometrial prostaglandin synthesis.
An added benefit of these drugs is their painrelieving
properties; thus they are useful alone or in
combination for women who complain of both menorrhagia
and dysmenorrhoea

Antifibrinolytic therapy

Tranexamic acid
This agent is associated with a mean reduction in
MBL of about 50-100 mL. Its mode of action is by
inhibiting fibrinolysis (clot breakdown) in the
endometrium. In view of this, theoretical concerns
have been raised that tranexamic acid may be associated
with an increased risk of venous thrombosis.
This theoretical risk is not borne out by the studiesثhat have investigated it to date


HORMONAL THERAPY
First-line drugs:*Cyclical Combined oral contraceptive pills ((OCPs

Are effective in reducing menstrual bleeding, controlling cycle irregularities and relieving menstrual pain giving for women requiring contraception or for women whom hormonal agents are acceptable. It helps to prevent the risks associated with prolonged unopposed estrogen stimulation of the endometrium

Progestogen therapy 1-cyclic progestins

# Treatment with cyclic progestins is preferred when COCP use is contraindicated, such as in smokers over age 35 and women at risk for thromboembolism.
cyclical progestogens are effective for menorrhagia when given for 21days out of 28 and first choice for control of anovulatory dysfunctional bleeding.
withdrawal bleeding occured 3-5 days after completion of the course.

#Arrest bleeding.

Norethisterone acetate (primolut-N ) 20-30 mg daily until bleeding stops usually in 24-48 hours and for not more than 3days and may continued in lower dose for up to 21 days .
Once she stopped , withdrawal bleeding will occur in a few days later

Luteal phase treatment

#Luteal phase treatment in second half of cycle (from 15th to 26th day) indicated when corpus luteum insuffiency has been diagnosed particularly in premenstrual spotting. Treatment continued for 6-9 months.
Norethisterone acetate (primolut-N ) 5mg tid (three times a day)
Or
Medroxy progestrone acetate (Provera) 10 mg tid

2-Whole cycle treatment:

A-Whole cycle treatment: Throughout menstrual cycle (5th to 26th day)
Effective treatment for menorrhagia when given at high doses between days 5 and 26 of cycle. As luteal phase treatment is not so effective in treating menorrhagia. Treatment can be continued for 6-9 months.
Norethisterone acetate (primolut-N ) 5mg tid for 21days out of 28
Or Medroxy progestrone acetate (Provera) 10 mg tid
Side effects include weight gain, headache and bloatedness.


B-Long acting high dose progestogens (e.g. #Depo-Provera) may be used to induce amenorrhoea but limited by side effects.
#Progestogen-releasing intrauterine system:
Levonorgestrel-releasing intrauterine system (LNG-IUS) used to relief
Menorrhagia as it induce
progressive endometrial atrophy

Mean reductions in MBL of around 95 per cent

by 1 year after LNG-IUS insertion have been demonstrated.
These results are similar to those for the surgical
procedure endometrial resection, and the patient
satisfaction rates for the two treatments were found
to be similar in one stud

Estrogen therapy

Alone used rarely in DUB treatment. Used in atrophic endometrium and in cases of DUB secondary to depot progestogen.

Second line hormonal therapy

Gonadotropin-releasing hormone agonists(GnRH analogue)
They produce a profound hypoestrogenic state similar to menopause (They induce medical menopause by suppressing gonadotrophions). Side effects include menopausal symptoms and bone loss with long-term use so it should not prescribed for longer than 6 months because the risk of osteoporosis


danazole
l
Treatment with danazol for 2-3 months is associated
with a mean reduction in MBL in the order of 100 mL.
However, danazol is associated with androgenic side
effects such as weight gain, acne, hirsutism and voice
changes

Although the majority of these (with the

exception of voice changes) are reversible on cessation
of treatment, the fact that they can occur is
enough to prevent most women with menorrhagia
from opting for danazol treatment

gestrinone

Gestrinone is a 19-testosterone derivative which has anti-progestogenic, anti-oestrogenic and androgenic activity.it reduce menstrual blood loss in menorrhagia. However, it also has androgenic side effects

Surgical treatment

Surgical treatment is normally restricted to women
for whom medical treatments have failed. Women
contemplating surgical treatment for menorrhagia
should be certain that their family is complete. Whilst
this caveat is obvious for women contemplating hysterectomy,
in which the uterus will be removed, it also
applies to women contemplating endometrial ablation.
Women wishing to preserve their fertility for
future attempts at childbearing should therefore be
advised to have the LNG-IUS rather than endometrial
ablation or hysterectomy


Surgical method:
Dilatation and curettage (D&C)
Endometrial resection and ablation.
Hysterectomy

Dilatation and curettage (D&C):

Dilatation and curettage (D&C):
A D&C may be done for a woman with heavy bleeding used in acute situation (for diagnostic and therapeutic purpose).

Endometrial ablation

All endometrial destructive procedures employ the
principle that ablation of the endometrial lining of
the uterus to sufficient depth prevents regeneration of
the endometrium. During normal menstruation, the
upper functional layer of the endometrium is shed,
whilst the basal 3 mm of the endometrium is retained

At the end of menstruation and the

beginning of the next cycle, the upper functional layer
of the endometrium regenerates from the basal
endometrium. In endometrial ablation, the basal
endometrium is destroyed, and thus there is little or
no remaining endometrium from which functional
endometrium can regenerate.


There is a variety of methods by which endometrial
ablation can be achieved, including the following.
Methods performed under direct visualization at
hysteroscopy:
• Laser
• Diathermy
• Transcervical endometrial resection

Methods performed non-hysteroscopically (i.e.

without direct visualization of the endometrial
cavity at the time of the procedure)
• Thermal uterine balloon therapy
• Microwave ablation
• Heated saline

All the above operations are performed through

the uterine cervix. Most take around 30-45 minutes
to perform, and in the majority of cases the patient
can return home that evening. The mean reduction in
MBL associated with endometrial ablation is around
90 per cent


In many units, endometrial ablation is performed
using a single method and, in practice, patients may
not be able to choose a particular technique for this
procedure. This may not be important, as comparative
studies have shown that the complication rates

The complications associated with endometrial

ablation include
uterine perfo ration,
haemorrhage
and fluid overload.
Around 4 per cent of women have
some sort of immediate complication. In 1 per cent of
women, the complications arising during the procedure
are sufficiently serious to prompt either laparotomy
or another unplanned surgical p rocedure

Hysterectomy

Hysterectomy involves the removal of the uterus. It is
an extremely common surgical procedure,
20 per cent of women will have a hysterectomy
at some point in their lives.
Hysterectomy can be 'total', in which the uterine
cervix is also removed, or 'subtotal', in which the cervix
is retained. Hysterectomy is often accompanied by
bilateral oophorectomy (removal of both ovaries).


The
precise choice of operation should be determined after
detailed discussion between the doctor and patient.
In terms of the treatment of menorrhagia, it is removal
of the uterus that effects a cure, and '-thus removal of
the cervix and/ or ovaries is an 'optional extra'.

The main perceived advantage of oophorectomy is

a reduced risk of ovarian cancer. Additionally, women
with pelvic pain and/or severe premenstrual syndrome
in addition to their menorrhagia may find that
hysterectomy and bilateral salpingo-oophorectomy
is more effective at treating their symptoms than
hysterectomy alone.

These advantages have to be set

against the adverse effects of oestrogen loss
on bonedensity for women who do not take hormone replacement
therapy (HRT) after oophorectomy

Mode of hysterectomy

Total hysterectomy may be achieved using three main
techniques:
• abdominal hysterectomy
• vaginal hysterectomy
• laparoscopically assisted hysterectomy