Dr ShaimaaKadhim Al-Khafajy

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1 Dr ShaimaaKadhim Al-Khafajy
Abnormal Uterine Bleeding By Dr ShaimaaKadhim Al-Khafajy

2 Normal menstrual cycle:
Mean duration of menstrual cycle: 28 days. Range days Average duration of menses: 2-7 days. Average blood loss is 80 ml. Abnormal uterine bleeding: any disturbance in regularity duration, amount of menstrual loss.

3 Terms used to describe various forms of AUB:
Heavy menstrual bleeding (menorrhagia) (hypermenorrhea): excessive uterine bleeding in amount (loss of more than 80 ml)and for prolonged days of bleeding at regular intervals. Hypomenorrhea: decreased uterine menstrual bleeding in days or amount at regular intervals. Polymenorrhea: episodic menstrual flow at intervals less than 21 days (frequent menstrual flow). Oligomenorrhea: episodic menstrual flow at intervals more than 35 days (infrequent menstrual flow). Metrorrhagia: uterine bleeding at irregular intervals. Combination of these terms may be used as metromenorrhagia which means excessive bleeding at irregular intervals.

4 Heavy menstrual bleeding: (HMB)
The presentation of HMB is common, e.g. each year in UK, 5% of women between years of age consult their doctors with this complaint. Etiology: fibroids. Endometrial polyps. Coagulation disorders: 10-20% of women with HMB have a systemic disorder of coagulation. The most common inherited disorder is Von Willebrand’s disease which is found in 13% of female with HMB. Acquired disorders include severe thrombocytopenia. Pelvic inflammatory disease: data do exist to support an association between chronic infection and HMB e.g. Chlamydia trachomatis infection.

5 5. Thyroid disease: untreated hypothyroidism leads to anovulation that typically present with amenorrhea, but this endocrine disorder may be also associated with HMB. 6. Malignancy: both endometrial and cervical cancer are potential causes for HMB and postcoital bleeding. 7. Iatrogenic causes: include drugs like warfarin, drugs that affect ovulation by disruption of the hypothalamic-pituitary ovarian axis like tricyclic antidepressants and phenothiazine. IUCD may be associated with HMB and the effect is thought to be due to local inflammatory process. 8. Arteriovenous malformation: is congenital or acquired localized collection of abnormally connected arteries and veins, when they are in the uterus they can be associated with attacks of excessive bleeding.

6 9. Bleeding of endometrial origin: (BEO)
Despite appropriate investigations, often no pathology can be identified, BEO is a diagnosis of exclusion. BEO replaces the older term (dysfunctional uterine bleeding DUB). The cause is thought to be disordered endometrial prostaglandin production, as well as abnormalities of endometrial vascular development. The exact cause is still an area of research. Control of menstrual blood loss in a major part is by vasoconstriction, factors regulating vascular tone thus play an important role and include prostaglandins, endothelins and nitric oxide. For example: reduced endometrial expression of endothelin (a vasoconstrictor) has been described in women with HMB. Also studies showed increased level of total prostaglandins in the endometrium of women with HMB. Therefore administration of Cox inhibitors is a first line treatment during menses for women with HMB.

7 Hemostasis in the endometrium differs from hemostasis elsewhere in the body. Platelets in the endometrial cavity are deactivated. The endometrium is a rich source of plasminogen activators but coagulation is rapidly reversed by marked fibrinolysis, because the menstrual loss is mainly controlled by vasoconstriction. There is a lesser need for coagulation. Women with HMB are reported to have increased fibrinolytic activity, therefore antifibrinolytic commonly prescribed for complaint of HMB, they reduce blood loss by 40-50%.

8 History and examination:
Useful questions to ask: How often does the patient need to change soaked sanitary napkins. Does she notice passing clots, is the bleeding so heavy leading to flooding (it spills over clothes, bedding??). Does she need to take anytime off work and need to be confined to her house? (i.e. we want to determine the impact of HMB on the quality of life).

9 Suggestive of: Associated symptoms
Endometrial or cervical polyp Irregular bleeding Intermenstrual bleeding Postcoital bleeding Coagulation disorder (coagulation disorders will be present in 20% of those presenting with ‘unexplained’ heavy menstrual bleeding.) Excessive bruising/bleeding from other sites History of postpartum haemorrhage (PPH) Excessive postoperative bleeding Excessive bleeding with dental extractions Family history of bleeding problems Pelvic inflammatory disease Unusual vaginal discharge Pressure from fibroids Urinary symptoms Thyroid disease Weight change, skin changes, fatigue Symptoms which can be associated with HMB and related pathologies

10 Examination: General examination for signs of anemia, systemic coagulation disorders (bruising and petechiae), thyroid disease (goiter). Abdominal and pelvic examination to assess for any mass. Speculum examination to visualize the cervix for polyps, carcinoma, discharge suggesting infection. Swabs can be taken if pelvic infection is suspected, smear to be taken if one is due. Bimanual examination should be performed to elicit uterine enlargement.

11 Investigations: Full blood count: in all women with HMB, to ascertain the need for iron therapy and sometimes blood transfusion. TFT: when history is suggestive of thyroid disease. Endocervical/high vaginal swabs: when unusual vaginal discharge is reported or observed on examination, or there are risk factors for PID. Coagulation screen: if history and examination are suggestive of coagulation disorder with referral to hematological opinion. Colposcopic examination: suspicion of cervical malignancy.

12 Evaluation of the uterus and its cavity by pelvic US including saline infusion sonography and outpatient hysteroscopy, done when: Pelvic mass is palpated on examination e.g. fibroid. When there is intermenstrual or postcoital bleeding suggestive of endometrial polyp. When drug therapy for HMB is unsuccessful. When there is irregular HMB. MRI should be considered when uterine conservation is desired in females with fibroids and US is unsuccessful in determining the depth of myometrial involvement of a fibroid. The MRI precision in the localization of submucosal fibroid can be obviate the need for hysterectomy and permit hysteroscopic resection of the fibroid.

13 7) Histological assessment of the endometrium i. e
7) Histological assessment of the endometrium i.e. endometrial biopsy should be performed in: Those aged > 45 years. Younger women when medical treatment has failed. If irregular or intermenstrual bleeding. All women prior to surgical intervention. There are many methods for taking endometrial sample: A. Pipelle endometrial biopsy can be performed in the outpatient setting.

14 B. Outpatient hysteroscopy is indicated if:
1. Pipelle biopsy attempt fails. 2. Pipelle biopsy is insufficient for histopathological assessment. 3. There is abnormality in US suggesting polyp or submucous fibroid. 4. Patient is known to poorly tolerate speculum examination.

15 C. If the patient fails to tolerate an outpatient procedure or the cervix need to be dilated to enter the cavity, then hysteroscopy and endometrial biopsy under GA may be required. When hysteroscopy is not available then dilatation and curettage to get endometrial biopsy under GA is done.

16 of Heavy Menstrual Bleeding
Management of Heavy Menstrual Bleeding

17 For some women demonstrating that their blood loss in fact is ‘normal’ may be sufficient to reassure them, and make further treatment unnecessary. When treatment is required, it is important to consider and discuss the following points in order to choose the most suitable treatment options: Patient’s preference of treatment. Risk/benefit of each option. Contraceptive requirement (family complete, current contraceptive).

18 Past medical history: Any contraindication to medical therapies for HMB. Suitability for anesthesia, previous surgical history.

19 Medical Treatment Non-hormonal treatment:
If a woman is wishing to conceive, hormonal treatment and most surgical interventions are unacceptable. Prostaglandin synthetase inhibitors: as NSAIDs. Mefenamic acid is the most frequently used agent, and is associated with a reduction in mean menstrual loss of 20-25%.

20 Benefits: analgesia, hence helps when there is also dysmenorrhea.
Disadvantage: contraindicated with a history of duodenal ulcer or severe asthma. There are also isolated reports of NSAIDs-associated reversible female infertility, probably due to non rupture of mature follicle. Recommended dose: is 500mg PO tds during menstruation.

21 Antifibrinolytic: such as tranexamic acid
Antifibrinolytic: such as tranexamic acid. It reduces blood loss by up to 50%. Benefits: need to be taken on days when bleeding is particularly heavy. It is compatible with ongoing attempts at conception. Disadvantage: gastrointestinal symptoms. Concerns that it may increase risk of venous thrombosis, but this has not been proved by the studies that have investigated it to date. Dose: 1g PO qds when heavy menstruating.

22 Hormonal treatment: A. COCP: Combined oral contraceptive pills Benefit: effective in management of HMB, and offer contraceptive effect especially when taken properly. Disadvantage: Contraindicated in patients who have risk factors for thromboembolism. Unsuitable for patients > 35 years old who smoke. Unsuitable if there is personal or family history of CA breast. Unsuitable for patients who are grossly overweight. Norethisterone: It is oral progesterone, it is helpful in the management of women with irregular (anovulatory) HMB at the extremes of reproductive life.

23 Benefits: safe and effective which can regulate bleeding pattern.
Disadvantage: it is not a contraceptive, can cause breakthrough bleeding. Dose: given in cyclical pattern from day 6 to day 26 of menstrual cycle as 5-10mg tds.

24 Levonorgestrel - releasing intrauterine system:

25 It provides a highly effective alternative to surgical treatment
It provides a highly effective alternative to surgical treatment. Mean reduction of menstrual blood loss of around 95% by one year after LNG-IUS insertion. Benefits: Provides contraceptive cover comparable with sterilization. Evidence proves it is effective for associated dysmenorrhea. Around 30% of women are amenorrhic by one year after insertion. Disadvantage: irregular menses and breakthrough bleeding for the first 3-9 months after insertion. LNG-IUS may be inserted in the outpatient setting and requires changes every 5 years.

26 GnRH agonists: they act by downregulating the HPO axis and induce ovarian suppression leading to amenorrhea. Benefits: effective for associated dysmenorrhea. Disadvantage: They can cause irregular bleeding. They can be associated with flushing and sweating. Only suitable for short term usage (6 months), because of their effect on bone density. Their beneficial effect does not continue after stopping treatment.

27 Surgical Treatment Many options depending on the underlying pathology.
Polypectomy: Endocervical polyp can be avulsed in the outpatient. Endometrial polyps can be removed either blindly under GA or by hysteroscopic resection. 2) Fibroid: Myomectomy: Surgical removal of a fibroid from the uterus wall with conservation of the uterus.

28 Can be done by laparotomy, laparoscopy, or hysteroscopy, depending on number, site, size of the fibroid. GnRH analogue treatment is often used for 3 months prior to surgical intervention in an attempt to reduce the vascularity of the fibroids. Pregnancy following myomectomy appears to be safe, with a very low risk of uterine rupture with a vaginal delivery.

29 b. Uterine artery embolization:
Embolic agent is introduced to block both uterine arteries which results in fibroids becoming avascular and shrinking. As the normal myometrium subsequently derives its blood supply from the vaginal and ovarian vasculature, UAE is thought to have no permanent effect on the rest of uterus. There is a theoretical risk of premature ovarian failure after UAE, so this procedure is not currently recommended for women who wish to maintain their fertility. c. Hysterectomy:

30 3) Endometrial ablation:
it is targeted destruction of the endometrial lining of the uterus to sufficient depth, so that to prevent regeneration of the endometrium. Success rates: Mean reduction in blood loss is 90% for these undergoing 2nd generation techniques, 40% will become amenorrhic, 40% will have remarkaedly reduced blood loss, 20% will have no difference. First generation: include transcervical resection of the endometrium with electrical diathermy loop or rollerball ablation. Second generation techniques: include thermal uterine balloon therapy, microwave ablation, impedence controlled endometrial ablation. Preprocedure: the patient should understand the description of procedure, its success rate, alternative options.

31 Understand the complications:
Endometritis, hematometra, fluid overload (due to absorption of distension medium) uterine perforation, abdominal visceral injury. The procedure is taken as outpatient or day case procedure under local or GA. Prior to it hysteroscopy is done, also after completing the ablation. Post-procedure: symptoms to be expected: Cramps and pain for 24 hours. Watery brown discharge for 3-4 weeks. Need to have prophylactic antibiotics. Need to use long term effective contraception. The rationale behind this is the lack of knowledge about the effects of endometrial ablation on future reproductive potential.

32 4) Hysterectomy: Should only be considered in the treatment of HMB when women has completed her family and when medical and less invasive surgical options have failed or are inappropriate. The UK NICE guidelines advice that hysterectomy route for HMB should be considered in the following order: Vaginal Abdominal Laparoscopic But individual patient characteristics and surgical expertise are important determinants. Vaginal hysterectomy: absence of abdominal wound and minimal disturbance of the intestine result in less postoperative pain, earlier mobilization and earlier discharge from hospital.

33 Abdominal hysterectomy:
Is necessary in women with: History of PID. History of caesarian section. Endometriosis. Long vagina +/or narrow pubic arch making the vaginal approach technically difficult. It can be total or subtotal. Laparoscopic hysterectomy: This allows diagnosis and treatment of other pelvic disease like endometriosis. It can be divided to laparoscopy – assisted vaginal hysterectomy LAVH and total laparoscopic hysterectomy TLH.

34 Thank you