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2.  Normal menstrual bleeding:
Cyclic menses every 21-35 days, lasting less
than 8 days with 20-80 ml blood loss.
 Menopause: cessation of menses for 12
months due to ovarian follicle inactivity.
 Average age = 50 [range 43 – 57].
 Perimenopause:period before menopause
and one year after menopause.
 Abnormal uterine bleeding: excessive in
amount, duration or frequency.
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3.  INCIDENCE:13:1000 at 50 yrs to 2:1000 at 80
yrs of age.
 Risk of Ca endometrium: rises from 1% at age
50, to 25% at age 80 years.
 AETIOLOGY:
Organic – a)reproductive tract disease,
b)systemic disease,
c)trauma
d)pharmacologic alterations.
Nonorganic – dysfunctional ‘DUB’, by
exclusion of organic causes ;
a)ovulatory,
b)anovulatory
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4. S Y S T E M I C L O C A L
Bleeding
disorders
Exogenous
oestrogens
Endogenous
oestrogens
Benign Malignant /
premalignant
+Coagulo-
pathy[vwd,
itp,leuka]
+Endocrin
opathy[hyp
othyrod.,h
yperprol].
+Liver f.
+HRT
+Ginseng
+Peripheral
conversion of
androstenedn
+E2 producing
tumours.
+End.polyps
Endometritis.
+Cx polyps
cervicitis
cx trauma.
+Atrophic vaginitis
Vaginal trauma
Vag inflamation
Vaginal polyps.
+Vulval dystrophy
Vulval dermatitis
Vulval trauma.
+F.tube Ca
+Leiomyosarcoma
+End.Ca
+End.hyperplasia
+Cervical Ca
+Vaginal Ca
+Vulval Ca
+Sec. tumours.
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5. [I] HISTORY:
1)AGE: Risk of end.Ca = 5% at < 50 yrs
33% at > 70 yrs
2)RISK FACTORS:
80% --- Early menarche ( < 10 yrs )
40-45% --- a) Late menopause (> 55 yrs )
b) Nulliparity
c) Unopposed oestrogens
30-40% --- a) Bleeding; moderate or severe
b) Obesity
c) Hypertension
d) Liver disease
< 30% --- Persistent / recurrent bleeding
3)NUMBER OF RISK FACTORS:
a) None = 2.5% ; b) Two = 20% ; c) Four = 85%
[II] EXAMINATION:
a) General b) Vaginal c) Cervical cytology ( Ca cx in
30% )
d) Colposcopy.
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6.  The aim is to exclude :
a) Endometrial carcinoma
b) Atypical hyperplasia.
 Methods :
Outpatient ; 1) End.sampling
2) Hysteroscopy + End.biopsy
3) TVS ( End. Thickness )
4) Sonohysteroscopy.
Inpatient ; I] D & C
II] Dilatation & Fractional curettage
III] Hysteroscopy & curettage
IV] Hysteroscopy + End.biopsy
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7.  Continue investigations ;
 Methods’evaluation :
A) D & C ; (1)Expensive,(2)Associated with
complications,(3)Inaccurate & may miss diagnosis.
B) End.Sampling;(1)Vabra aspirator--better than D&C
but samples 40% of surface.(2) Pipelle; better
tolerated,samples 4% of surface,detection
rate=90% (3)Novak curette; DR = 85-95%.
C) Hysteroscopy +Sampling; Using rigid and flexible
instruments.Possible complications are; [a] water
intoxication, [b] pulmonary oedema, [c] Air
embolism [d]Anaphylaxis, [e] Neoplastic
implantation--??.
D) Ultrasound; TVS is more reliable than TAS. Cut- offs
are different ethnically = 3,4 or 5mm are used.
Sensitivity is 80% at cut-off 5mm of endometrial
thickness.
E) Others; [1] MRI : high degree of sensitivity, low
specificity, detects myometrial invasion, but costly.
[2] Tumour m.
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8.  {A} Observation & follow-up: 3-6 monthly, using TVS,TAS or
SHG. Tissue sampling is occasionally needed.
 {B} Medical: In typical end.hyperplasia – cyclic monthly
progestins or COCs for 3-6 m.
 {C} Minimal access techniques: In DUB – using different
ablative techniques;
1]Hysteroscopic TCRE + ELA
2]MEA + Thermal Balloon Ablation; best evaluated.
3]Others: HTA(hydrothermal ablation), Cryo-
ablation.Photodynamic therapy(PDT) and Levonorgestrel
Intrauterine System(LNG-IUS).
 {D} Surgical: In atypical end.hyperplasia – Hysterectomy is
needed as 25% will progress to Ca end. Continuous
progestins are used in few cases for 6 months with tissue
sampling every 3-6 months.
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