Abnormal Uterine Bleeding

Types of abnormal bleeding from the genital tract:

1- Polymenorrhea: too frequent menstruation. The menstrual cycle<21 days. 2- Menorrhagia: means excessive and /or prolonged menstruation. Menstruation is excessive if the amount of menstrual blood is greater than 80 ml. Menstruation is prolonged if bleeding continues for > 7 days. 3- Metrorrhagia: Means irregular uterine bleeding not related to menstruation (Metrostaxis). 4- Oligomenorrhea: means infrequent menstruation, so the length of the cycle is more than 35 days. 5- Hypomenorrhea: means scanty menstruation or the duration of the flow is less than days.

6- Oligohypomenorrhea: means scanty and infrequent menstruation.

Polymenorrhea
Aetiology: It is due to 1)Short proliferative due to premature maturation of Graffian follicle which may result from pituitary Hyperstimulation Near menopause Degeneration of CL

2) Short secretory phase due to early degeneration of C.L.

Dysfunctional occurring shortly after menarche, pelvic congestion ovarian congestion

Treatment:
A)General treatment: of anemia if present. B) Hormonal treatment: given for 3 successive months to prevent recurrence of abnormal bleeding.

1) Progesterone given in 2) Oral contraceptive tablets The 2nd half of the cycle given from the first day of the As norethisterone 10 mg daily cycle for 21 days for 10 days starting on day 15 of the cycle

Menorrhagia
Aetiology:
I)General Causes 1- Anticoagulent therapy 2- Liver cirrhosis 3- Psychological disturbances 4- Smoking (II) Local Causes I] All causes of pelvic congenstion 1- Chronic pelvic infection 2- Pelvic neoplasm 3- Abnormal position of The uterus as prolapse 4- Chronic constipation 5- Chronic appendicitis II) Intrauterine devices III) Complicate tubal ligation (III) Dysfunctional = Menorrhagia in absence of an organic causes

I-Irregular ripening of The endometrium Due to poor formation and function of corpus luteum Permenstrual spostting Diagnosed by Premenstral endometrial Biopsy mixed proliferative +Secretory changes

II- Irregular shdding of The endometrium due to incomplete and slow degeneration of CL Delayed sheeding of The endometrium Postmenstrual spotting Diagnosed by

III- Failure of endometrial Mecchanism that limit Menstrual bleeding 1- Failure of vasoconstriction (V.C.) due to PGI2 or PGF2 2- Failure of formation of platelet thrombin plug. 3- Fibrinolytic activity

Endometrial biopsy on the 4th or 5th day of menstruation Mixed proliferateive + secretory changes

4- Failure of endometrial proliferation

Why liver cirrhosis menorrhagia ? because it 1- Impair metabolism and excretion of estrogen hyperestrinism Endometrial hyperplasia menorrhagia. 2- Affect formation of clotting factors. Why psychological disturbances menorrhagia ? because it Affect neurotransmittors control of hypothalamus. Affect the autonomic nervous system pelvic congestion

Why menstruation is self limited? Because bleeding from the endometrium is controlled by 1- Vasoconstriction 2-Myometrial contration 3- Local aggregation of platelets with deposition of fibrin around them. 4- release of prostaglandin F2 which causes V.C + myometrial contraction + platelets aggregation.

Diagnostic work up : Investigation of a case of abnormal uterine bleeding (see later)

Treatment: A)General treatment: 1- Rest in bed and nutrition and treatment of cause. 2-Treatment of anemia: a)Iron, folic and others multiple vitamins and minerals. b)Blood transfusion in severe cases. 3- Antifibrinolytic agents: reduce the menstrual blood loss by 50% of cases of menorrhagia: Tranexamic acid [cykolokapron] is given as one gram orally 4 times daily during the period. 4- Antiprostaglandins as Brufen tablets 400 mg 3 times daily. 5- Drugs reducing capillary fragility [Haemostatic agents] such as diosmin [Dicynon, Daflon tablets].

Hormonal treatment: Should be given for at least 3 successive months to prevent recurrence of bleeding. 1- Progestegens: as nerothisterone or Dydrogesterone [Duphaston is identical to the natural endogenous progesterone]. Dose: 10-30 mg by mouth daily for 20 days. Aim : hoping to spontaneous correction. When treatment is stopped shedding of the endometrium and withdrawal bleeding occur [medical curettage]. 2- Estrogen and progesterone [oral contraceptive tablets] Dose: Two to four tablets daily until bleeding stops then one tablet daily for 20 days. Aim : Inhibit hypothalamic-pituitary ovarian axis then after stopped spontaneous correction occur. 3- Gonadotrophin releasing hormone analogues: amenorrhoea Given in the form of daily nasal spary or IM or SC 4- Induction of ovulation: If patient seeking pregnancy. 5- Estrogens: Estrogen alone not used because it a) Endometrial hyperplasia b) When treatment is stopped the withdrawal bleeding is often excessive hyperplasia. 6- Donazol [synthetic androgen] not used because a) It is very expensive b) Several side effects

C) Surgical Treatment:

1-Uterine curettage: I) Indications 1- If the bleeding is severe 2- Failure of above measures 3- If patient is above 40 to exclude an organic causes as endometrial carcinoma

II) Advantages 1- Stop bleeding in about 60% cases by removing the necroting endometrium 2- Determine the type of dysfunciontal bleeding 3- Reveal an organic causes as endometrial carcinoma

2-Hysterectomy: Indications 1.Patient above 40 years with failure of hormonal therapy and repeated curettage at least twice. 2.Associated other pelvic pathology as fibroid. 3-Endometrial ablation: Indications: a. Patient is unfit for hysterectomy as in case of D.M, severe hypertension, marked obesity. b. Simple hyperplasia

Aetiology: Local lesion in the genital tract which may be : a. Traumatic lesions as retained pessary. b. Inflammatory as cervical erosion or polyp. c. Neoplastic as feminizing ovarian tumours, fibroid polyp. With necrotic tip. Complications of pregnancy e.g. abortion, ectopic pregnancy, vesicular mole (V.M.). Irregular intake of hormones or contraceptive tablets. Intrauterine contraceptive device (IUD). Dysfunctional uterine bleeding as : a. Metropathia haemorrhagica. b.Threshold bleeding Treatment: According to the cause

Metropathia haemorrhagica
Definition: Acyclic bleeding characterized by 1- Excessive or prolonged bleeding from a hyperplasic endometrium. 2- Preceded by a short period of amenorrhoea. Aetiology: The exact cause is unknown. There are theories: 1- The graffian follicle fails to rupture and continues to grow to form a cyst production of excessive amounts of estrogen Endometrial hyperplasia and hypertrophy of myometrium. 2-When estrogen reaches a high level (-) of FSH degeneration of the cystic follicle and drop in the level of estrogen separation of the endometrium and withdrawal bleeding which is excessive or prolonged. 3-The endometrium grows so thick that its blood supply becomes inadequate necrosis and sloughing.

Pathology:

Uterus: I-Macroscopical appearance: 1- Slightly symmetrically enlarged and soft in consistency due to vascularity. Cut section: a- The endometrium Thickened, haemorrhagic and may become polypoidal. b- The myometrium hypertrophy.
II) Microscopical appearance: The endometrium shows cystic glandular hyperplasia [now called simple hyperplasia] The Ovaries: One ovary is enlarged and cystic. It contains one or multiple follicular cysts lined by granulosa cells. A corpus luteum is absent. The cysts may be bilateral

Diagnosis: A)Symptoms: 1-There is severe painless [anovulatory] uterine bleeding unrelated to menstruation. 2-Usually bleeding preceded by a short period of amenorrhoea 6-8 weeks 3-Symptoms of anemia if bleeding is severe or prolonged. B) Signs: 1) The uterus is slightly symmetrically enlarged and soft. 2) One or both ovaries may be felt enlarged and cystic. C) Investigations: Endometrial biopsy confirm the diagnosis D) Differential diagnosis: of symmetrically enlarged uterus 1- Normal pregnancy 2-Abnormal pregnancy as abortion, ectopic, pregnancy, V.M. 3- Submucous fibroid 5- Cancer body 4- Adenomyosis 6- Haematometra or pyometra Treatment : as menorrhagia

Threshold bleeding
Age incidence: after puberty and before menopause.

Aetiology: Theres a certain level of estrogen known as the threshold level.Below this level, loss of hormonal support of endometrium and bleeding occurs while above this level the endometrium proliferate and bleeding stops. In threshold bleeding the amount of estrogen in serum fluctuates around this level metrorrhagia.
Diagnosis by uterine curettage Treatment: Oestrogen given for 21 days with a progestogen added during The last week of therapy. The treatment is repeated for 3 months.

Dysfunctional uterine bleeding

Definition: DUB is abnormal uterine bleeding occurring in the absence of an organic cause. It is due to disturbances in hypothalamic- pituitary ovarian axis. Age incidence: More common near the menopause or shortly after menarche. Classification: [I] Clinical classification I- Cyclic II- Acyclic 1-Dysfunctional menorrhagia 1- Metropathia haemorrhagica 2-Dysfunctional polymenorrhea 2- Threshold bleeding [II] Histological classification I- Secretory endometrium II- Proliferative endometrium 1-Dysfunctional menorrhagia 1- Metropathia haemorrhagica 2-Dysfunctional polymenorrhea 2- Threshold bleeding [III] Other classification

Primary D.U.B
Dysfunctional in hypoth. Pituitary-ovarian Endometrium relations

Secondary D.U.B.
-2ry to extragenital causes = general causes

Iatrogenic
- Hormonal contraception - IUDs

Diagnosis of DUB: A)History : 1-Personal history: Age: DUB more common after puberty or late before menopause Material state: to exclude complications of pregnancy as abortion. Menstrual history: 2-Menstrual history: If bleeding is preceded by a short period of amenorrhea suspect pregnancy or metropathia haemorrhagica. 3-Obstetric history: Recent abortion or labour bleeding is usually DUB. Vesicular mole (V.M) choriocarcinoma. 4-Past history: Contraceptive tablets intake, IUDs. 5-Present history Amount + Associated symptoms Onset of bleeding as pain and foul discharge Duration urinary and gastrointestinal Character symptoms

Postmenopausal Bleeding [PMB] Definition: It is bleeding from the gential tract occurring 6 months or more after cessation of menstruation in a woman above the age of 40. Malignant tumour account for 25% of all causes of postmenopausal bleeding so any postmenopausal bleeding must be considered carcinoma [especially endometrial carcinoma] till proved otherwise and any PMB fractional curettage is a must. Aetiology: A)General causes: Hormonal replacement therapy (HRT). B)Local causes: Urethra, vulva, vagina, cervix, body,tubes,ovaries and rectum. 1- Urethral causes: caruncle and hematuria [urinary bladder or kidney causes]. 2- Rectal causes: piles, carcinoma

Organ
Vulva

Traumatic
Direct, surgical

Inflammatory
Vulvitis, HPV

Neoplastic
VIN, 1 ry carcinoma VAIN, 1 ry, carcinoma or 2ry

Vagina

Direct, surgical Neglected pessary

Atrophic vaginitis Trophic ulcer, HPV

or

2ry

Cervix

Direct, surgical post irradiation

Surgical

Severe infection Trophic ulcers

Endometritis

CIN, 1ry or carcinoma

2ry

Uterus

Endometrial carcinoma Leimyosacroma

Ovaries

Feminizing ovarian tumour

Diagnosis of PMB: History: 1- Personal History: a) Not married or infertility suggestive carcinoma of the body or ovaries. b) Living in endemic area for bilharziasis urinary bladder or rectal causes. c) Smoking and addiction suggestive carcinoma of the cervix. 2- Menstrual history: Early menarche, late menopause and menstrual irregularities during childbearing period with periods of infertility endometrial or ovarian carcinoma. 3- Obstetric history: Low parity carcinoma of body or ovary High parity carcinoma of cervix 4- Past History : Any malignant tumour e.g. breast 2ry or multiple carcinoma ERT withdrawal bleeding or carcinoma o body Any irradiation before post irradiation bleeding May be patient still has IUD [not removed] 5- Present History : Details of present bleeding [ onste, course, duration ] Any treatment received by the patient, and any other complaint

B) Examination :

1- General examination Blood pressure Any mass (2ry) Cancer corporeal triade

lymph node cachexia

2- Abdominal examination: Liver and both kidneys must be carefully examined Ascites, dilated veins, scars of previous operation and any pelviabdominal swelling 3- Local examination: A) Inspection: Urethral caruncle or urethral mass, piles or rectal mass Evidence of direct trauma in vulva or vagina Discharge due to inflammation (Hot, red and oedema) or evidences of a specific inflammation is seen e.g. HPV condyloma, HSV viscles or ulcers. Genital prolapse and trophic ulcers Necrotic friable mass vagina, cervical or endometrial carcinoma

B) Palpation:

Any vulval nodule examine for mobility and drainage lymph node. Palpate vagina for any swelling carcinoma of vagina (rare) or you may feel pessary or neglected forigen body Palpate cervix mass, ulcer, nodules, polyp, threads of IUDs Palpate uterus (bimanual) for size and mobility If fibroid present sarcomatous change is suspected Any adnexal swelling, mass or nodules in Douglas pouch C) Per-rectum examination: Feel parametrium, uterosacral ligaments rectal wall and rectal mass. Investiagation: As endometrial carcinoma( screen and confirm).