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Disfunctional uterine bleeding.gynaecology

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Disfunctional uterine bleeding.gynaecology

  1. 1. Disorders of the menstrual cycle are one of the most commonreasons for women to attend their general practitioner and,. subsequently, a gynaecologistAlthough rarely life threatening, menstrual disorders lead to major -social and occupational disruption, and can also affect.psychological well-beingMenstrual disorders include : 1 – menorrhagia. 2 – dysmenorrhea. 3 – amenorrhoea/oligomenorrhoea. 4 – PCOD. 5 – postmenopausal bleeding. 6 – premenstrual syndrome .
  2. 2. There are many Latin words to describe abnormal vaginal -. bleeding.The classic terms are still in use and need definition -Menorrhagia : an excessive loss of blood (>80ml) with •.regular menstruation.Metrorrhagia: prolonged bleeding from the uterus •.Metro-menorrhagia : heavy and prolonged periods •.Polymenorrhoea : frequent menstruation •
  3. 3. Menorrhagia:: Definition.Subjective : heavy Regular menstrual bleeding-Objective : menstrual blood loss more than 80 ml (more accurate), -.but not used in practice , just in researchesThis definition is rather arbitrary, but represents the level of -blood loss at which a fall in haemoglobin and haematocrit.concentration commonly occurs: Prevalence. Menorrhagia is extremely common -Indeed, each year in the UK, 5 per cent of women between theages of 30 and 49 consult their general practitioner with this . complaint
  4. 4. .Systemic pathology 5%-.Pelvic pathology 35%-.Dysfunctional Uterine Bleeding (DUB) 60%-
  5. 5. .Thyroid: hypothyroidism-...Coagulation disorder: ITP, VWD, leukemia-.Advanced liver diseases-.Drugs: Warfarin, Heparin, Aspirin, Tamoxifine, and hormones-
  6. 6. (.Fibroid (sub-mucosal-.Endometriosis-.Adenomyosis-.Chronic PID-.Copper releasing IUCD-.Endometrial hyperplasia and malignancy-.Ovarian tumors; Estrogen producing-
  7. 7. Defined as Menorrhagia in the absence of organic (pelvic,-. systemic) pathology.Is a diagnosis of exclusion-
  8. 8. .PG E2 and PG F2α-1.Fibrinolytic system-2.Blood Vessels of the endometrium-3The most important is prostaglandin release and Fibrinolytic -.system  any disturbance in them  bleedingDisturbance in prostaglandin release such as if PGE2 increased-(it is a vasodilator) will lead to bleeding and increased PG F2α.which will cause spasmodic or primary dysmenorrhea.Also, if too much fibrinolytic system activity menorrhagia-
  9. 9. :Ovulatory DUBEndometrial dysfunction:). - PG’s imbalance:- (decrease PGF2a : increase PGE2 ratio.Increased fibrinolytic activity-Ineffective contraction of myometrial -. vessels
  10. 10. :Hypothalamic – Pituitary – Ovarian hormonal axisMost common age at presentation is less than 20 and more -.than 40yearsThose who are less than 20 years ,this axis is still immature and -.they have anovulatory cyclesWhile those who are more than 40 years there are decrease in-the number and quality of ovarian follicles with many. anovulatory cycles
  11. 11. How to approach a case with ?DUB 12
  12. 12. HistoryThe hallmark of menorrhagia is the complaint of regular -excessive menstrual loss occurring over several. consecutive cyclesthis is largely a subjective definition and it can be hard for -the woman to communicate in words how much blood she is losingDiscussion of the number of towels and tampons used perday may be useful - perhaps accompanied by a menstrual. pictogram in selected casesOf perhaps greater relevance is to determine the impact -. of the condition on the patients lifestyle and quality of lifeFor example, the patient whose menorrhagia is so severe -that she does not leave the house during her period clearlyhas a much greater problem (and may wish to pursuetreatment further) than one to whom menorrhagia is a.minor inconvenience... 13
  13. 13. It is also important to determine the duration of the current problem, -and any other symptoms or factors of potential importance. Thefollowing 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 -, Dyspareunia, pelvic pain or premenstrual pain -Excessive bleeding from other sites or in other situations (e.g. after -.(tooth extraction
  14. 14. :Examination General examination: ««? - general condition: does she look pale or not.Vitals -.Weight -.Thyroid -.Lymph nodes: axillary and inguinal -.Breast -.Abdomen: Pelvi-abdominal mass/ ascites -:Pelvic examination ««.Speculum examination -.Bimanual examination - 15
  15. 15. 16
  16. 16. :Treatment.Treat the cause if present-groups of patients with DUB: 3- Less than 20 years old.- More than 40 years old.- Between 20 and 40 years old
  17. 17. :Medical treatment:A- Non-Hormonal drugsnon-steroidal anti-inflamatory drugs: Is the most- 1commonly used.(: »» Mefenamic acid (PonstanIs the most common drug used by adolescent -. female; for dysmenorrhea as wellcapsules daily, from day 1 to day 3 -. 5 of the cycle.It decreases menstrual blood loss by 25% -.Side effects: gastritis, gastric ulcer - 18
  18. 18. :Antifibrinolytic-2:Tranexamic acid»»capsule daily, from day 1 to day 5 of the 3 -. cycle.It decreases menstrual blood loss by 50% -Main side effects; nausea and vomiting, ~ 25% -. of patients stop it because of these side effectsRarely, it may cause cerebral thrombosis, so it - is contraindicated in patient with risk factors. for thromboembolism.In certain cases we may use both drugs** 19
  19. 19. :B- Hormonal Drugs :Progestogens-1Norethisterone and Medoxyprogesterone -. acetateIt is the most common drug used for DUB. - - 5 mg twice daily, from day 5 to day 25 of. the cycle.It decreases menstrual blood loss by 25% -. No serious side effects -. So its safe to use - 20
  20. 20. :Combined oral contraceptive pill- 2.1tab daily for 21 days, from day 5 -.It decreases menstrual blood loss by 50% -Minor side effects: Nausea , vomiting , -... headache , irritability , increase in weightMajor side effects: HT , thromboembolism, -… cardiovascular 21
  21. 21. Danazol:- 3 - It is an androgen analogue (17-α–ethinyl testosterone.. - Also, has antiestrogentic & antiprogestrogenicDepression of the HPO- axis and has a direct - suppressive effect on endometrium.. - Decreases menstrual blood loss by 80 – 100%:Side effects -.Hoarseness of voice ». Hirsutism and acne ».Increase muscle mass ».Cliteromegaly »Breast atrophy. ». » Hypooestrogenic: Menopausal symptoms 22
  22. 22. GnRH analogues:- 4. - 3.75mg IM monthly, for 4 monthsDecreases Menstrual blood loss by 80- 100%. - - Depression of the HPO- axis; Menopausal. symptomsMajor risk: Osteoporosis if used more than 6 -. months 23
  23. 23. :Between 20 & 40 years old Two lines of management: **. »»Medical: same as for the teenagersLevonorgestrol releasing IUCD (Mirena( »». If they desire contraception; very effective.mcg of levonorgestrol daily 20 - %.It decreases menstrual blood loss by 80–90 -of women are amenorrhoeic after one year of insertion. 30% -~ - It decreases the incidence of PID.. - Doesn’t increase risk of ectopic pregnancySide effects: breakthrough bleeding & spotting -. for the first 3-6 months after insertion 24
  24. 24. :Surgical treatments for menorrhagiaSurgical treatment is normally restricted to women for whom medical.treatments have failedWomem contemplating surgical treatment for menorrhagia should be certain. that their family is completeWomen wishing to preserve their fertility for future attempts at childbearingshould therefore be advised to have the LNG-IUS rather than endometrial.ablation or hysterectomy
  25. 25. Endometrial ablation .1All endometrial destructive procedures employ the principle that ablation ofthe endometrial lining of the uterus to sufficient depth prevents regeneration. of the endometriumDuring normal menstruation, the upper functional layer of the endometrium is-.shed, whilst the basal 3 mm of the endometrium is retainedIn endometrial ablation, the basal endometrium is destroyed, and thus there-is little or no remaining endometrium from which functional endometrium.can regenerateThere is a variety of methods by which endometrial ablation can be achieved,:including the following
  26. 26. Methods performed under direct visualization at:hysteroscopyLaser•Diathermy•.Transcervical endometrial resection•Methods performed non-hysteroscopically (i.e. withoutdirect visualization of the endometrial cavity at the time of(the procedureThermal uterine balloon therapy•Microwave ablation• • Heated saline.All the above operations are performed through the uterine cervix. Most takearound 30-45 minutes to perform, and in the majority of cases the patientcan return home that evening. The mean reduction in MBL associated with.endometrial ablation is around 90%
  27. 27. The complications associated with endometrial ablation.include -uterine perforation. Haemorrhage-. 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 procedure
  28. 28. Hysterectomy involves the removal of the uterus. It is an extremely -.common surgical procedureHysterectomy can be total, in which the uterine cervix is also -. removed, or subtotal, in which the cervix is retainedHysterectomy is often accompanied by bilateral oophorectomy(. (removal of both ovariesThe precise choice of operation should be determined after detaileddiscussion between the doctor and patient. In terms of the treatmentof menorrhagia, it is removal of the uterus that effects a cure, and -.thus removal of the cervix and/ or ovaries is an optional extra
  29. 29. The main perceived advantage of oophorectomy is a reduced risk of ovarian. cancerAdditionally, women with pelvic pain and/or severe premenstrual syndrome in-addition to their menorrhagia may find that hysterectomy and bilateralsalpingo-oophorectomy is more effective at treating their symptoms than. hysterectomy aloneThese advantages have to be set against the adverse effects of oestrogen-loss on bone density for women who do not take hormone replacement.therapy (HRT) after oophorectomyMode of hysterectomy:Total hysterectomy may be achieved using three main techniquesabdominal hysterectomy•vaginal hysterectomy•. laparoscopically assisted hysterectomy•
  30. 30. Thank you