Abnormal Uterine Bleeding in Perimenopausal Women
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Dr.Fariha Farooq Assoc.Prof Obs & Gynae,Akhtar Saeed Medical & Dental College Lahore.
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Abnormal Uterine Bleeding in Perimenopausal Women
- 1. Management of Abnormal Uterine Bleeding in Perimenopausal Women Dr.Fariha Farooq Assoc.Prof.Obs & Gynae Akhtar Saeed Medical & Dental College
- 3. Perimenopause • Perimenopause (around menopause) is a transition phase, begins several years before menopause. • Estrogen levels gradually decline. • Irregular menstrual periods, hot flashes, vaginal dryness, sleep disturbances, and mood swings are common, normal signs of perimenopause.
- 6. Anovulatory Bleeding • Corpus luteum is not produced – Ovary fails to secrete progesterone – Continuous, unopposed E stimulation of endometrium: • Endometrial proliferation without P-induced differentiation / stabilization – Endometrium becomes excessively vascular without stromal support fragility and irregular endometrial bleeding
- 7. New FIGO Nomenclature & classification of AUB
- 8. Suggested “normal limits” for uterine bleeding in the mid-reproductive years
- 9. Abnormal Uterine Bleeding New Terminology by FIGO Term HMB (Heavy mentrual bleeding) has replaced the term Menorrhagia: Bleeding that occurs at regular intervals, loss of ≥ 80 mL blood per DUB has been replaced by BEO(Bleeding of Endometrial origin)
- 10. Terminology abandoned by FIGO Munro et al. Int J Gynecol Obstet 2011; 113: 3-13
- 11. FIGO 2015
- 13. Causes of heavy menstrual bleeding ‘PALM’ (structural abnormalities) -Polyp –Adenomyosis –Leiomyoma –Malignancy and hyperplasia ‘COEIN’ (non-structural abnormalities) –Coagulopathy –Ovulatory dysfunction –Endometrial –Iatrogenic –Not yet classified
- 15. Adenomyosis TVS
- 16. Adenomyosis
- 17. Fibroid Uterus
- 25. PCOS
- 26. Anovulatory Bleeding: Later Reproductive Age (40-Menopause) • Incidence of anovulatory bleeding increases due to declining ovarian function. • Incidence of endometrial CA in women 40-49 years: 36.2/100,000 • All women >40 yrs who present with suspected anovulatory bleeding merit endometrial bipsy.
- 27. Each case has 1 identified abnormality
- 29. Diagnosis of Abnormal uterine bleeding • Medical history • Physical examination • Laboratory tests • Imaging tests
- 30. • Age of onset of menses • Frequency/duration of menses • Quantity of flow,number of pads,passage of clots and flooding • Intermenstrual bleeding • Postcoital bleeding • Dyspyerunia • Use of contraceptives/medication • Family history of menarche, menopause,malignancy AUB-History
- 31. AUB-History • Pelvic Pain • Postcoital pain • Vaginal Discharge • Excessive bruising/bleeding from other sites • History of post partum haemorrhage • Family history of bleeding problems • Urinary symptoms • Weight change ,heat or cold intolerance • Stress
- 32. Physical examination • General examination • Abdominal examination • Vaginal / per speculum and pelvic B/M examinations
- 33. Examination • GPE Assess for obesity, hirsutism, stigmata of thyroid disease (hypothyroidism associated with anovulation), signs of hyperprolactinemia (visual field testing, galactorrhea) • ABDOMINAL EXAMINATION Abdominal masses
- 34. • CBC,Coagulation screen – Assays for thyroid hormone • HVS,endocervical swab,Pap smear • Pelvic ultrasound – Abdominal/Transvaginal Ultrasonography (TVS) – Sonohysterography,saline infusion • Endometrial biopsy – Endometrial sampling by Pipelle – Hysteroscopy – Dilation and Curettage (D&C) Biopsy should be performed as first line test(ACOG) • Aged >45 years • Irregular or intermenstrual bleeding CT scan and MRI(special circumstances)) Laboratory and Imaging Tests
- 37. Sonohysterogram
- 38. Hysteroscopy
- 39. Evaluating endometrial cavity Hysteroscopy “Gold standard” for endometrial assessment • Office procedure • Thorough, direct inspection of endometrial cavity • Directed biopsy or treatment possible (e.g., polyp excision)
- 40. Drugs for HMB • NSAID’s • Tranexamic acid • COCP’s – YAZ – Diane-35 – Meliane • Progyluton/Climen • Oral Progestogens • Mirena • Danazol/GNRH analoges
- 42. Progyluton
- 43. Composition •Composed of estradiol-17 valerate and cyproterone acetate * Presented in calendar packs of 21 tablets each * First 11 tablets contain estrogen only; the other 10 contain both hormones Climen
- 44. Contraindications of HRT • PREVIOUS THROMBOEMBOLIC DISEASE • IMPAIRED LFT/ LIVER DISEASE • CARCINOMA BREAST • CARCINOMA ENDOMETRIUM • FIBROIDS &ENDOMETRIOSIS(relative) HYPERTENTION,DIABETES,CARDIO -VASCULAR DISEASE ARE NOT C/I
- 45. Oral Progestogens • Norethisterone acetate(Primolute N) • Dose is 5-10mg three times a day from day 6 to 26 of the cycle
- 46. The levonogestrel intrauterine system (LNG-IUS), Mirena
- 47. What is Mirena® used for? Indications: –Contraception –Treatment of heavy menstrual bleeding (idiopathic menorrhagia) –Protection from endometrial hyperplasia during oestrogen replacement therapy
- 48. Endometrial effects with Mirena® Before Mirena® Endometrial changes Ovulation Menstruation Reduced menstruation After Mirena® Ovulation
- 49. Surgical treatment Endometrial ablation •First-generation: – Rollerball – Transcervical resection of the endometrium •Second-generation: – Impedance-controlled bipolar radiofrequency – Balloon thermal – Microwave – Free-fluid thermal
- 50. Surgical treatment • Uterine artery embolization(UAE) • Hysteroscopic myomectomy • Myomectomy • Hysterectomy – Abdominal – Vaginal – Laparoscopic
- 51. Uterine artery embolization for Fibroids
- 52. • Defintion: Post menopausual bleeding is defined as: vaginal bleeding after the menopause in women who are not taking HRT. • Aetiology: • Atrophic vaginitis • Endometerial polyp • Endometerial hyperplasia • Endometerial carcinoma • Cervical carcinoma Post menopausal bleeding
- 53. MANAGEMENT OF PMB Diagnosis Management Atrophic vaginitis Topical oestrogen cream, oestrogen pessaries or estringTM oestrogen ring pessary. Cervical polyp Remove via speculum examination using polyp forceps Endometrial polyp Remove under direct visualization at hysteroscopy Simple hyperplasia Progestogens: oral preparation or LNG-IUS (Mirena) Complex hyperplasia Progestogens: oral preparation or LNG-IUS (Mirena) Atypical hyperplasia Total abdominal hysterectomy as significant risk of progression to malignancy. Endometrial cancer Total abdominal hysterectomy + BSO + Washings ± adjuvant therapy.
- 54. QUESTIONS?
Notas do Editor
- Munro MG. Rev Endocr Metab Disorder (2012) 13: 225-234
- There are three indications for Mirena®: Contraception Treatment of heavy menstrual bleeding (idiopathic menorrhagia) Endometrial protection during oestrogen replacement therapy. This presentation will focus on the use of Mirena® for the treatment of heavy menstrual bleeding. Currently, Mirena® is marketed in 113 countries and has market authorisation in a further 15 countries. As of December 2012, there have been 28.4 million cumulative Mirena® placements since launch, corresponding to 83.4 million cumulative women-years of experience.
- This figure shows the endometrial changes that occur with Mirena use, compared with the ‘normal’ cyclical changes observed without Mirena® use. Mirena® induces profound morphological and biochemical changes in the endometrium, mainly as a result of the high endometrial levonorgestrel concentration. This downregulates endometrial oestrogen and progesterone receptors, making the endometrium insensitive to circulating oestradiol (thereby suppressing endometrial growth).1,2 After only a couple of months of Mirena® use, the glands of the endometrium atrophy, the stroma becomes swollen and decidual, the mucosa thins and the epithelium becomes inactive. Vascular changes include a thickening of arterial walls, suppression of the spiral arterioles and capillary thrombosis.3 An inflammatory reaction characterised by an increase in neutrophils, lymphocytes, plasma cells and macrophages is described3,4 and focal stromal necrosis may also occur.2,4 The endometrium becomes uniformly atrophic and suppressed within 3 menstrual cycles after Mirena® placement,3 and persists in this thin, inactive state with no further histological development taking place over the long-term.2 The initial changes in the endometrium caused by Mirena® may be associated with irregular bleeding or spotting, particularly in the first few months of treatment. With Mirena® use, once the endometrial effects are established, bleeding becomes less in quantity than usual, or may cease altogether. Following Mirena® removal, the morphological changes in the endometrium revert to ‘normal’, and menstruation has been reported from as early as the first month afterwards.5 References Pakarinen PI, et al. Hum Reprod 1998; 13: 1846–53. Silverberg SG, et al. Int J Gynecol Pathol 1986; 5: 235–41. Zhu PD, et al. Contraception 1989; 40: 425–38. Phillips V, et al. J Clin Pathol 2003; 56: 305–7. Nilsson CG & Lahteenmaki P. Contraception 1977; 15: 389–400.