ABNORMAL UTERINE BLEEDING

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					ABNORMAL UTERINE
BLEEDING


A.JAGA JANANI,
FINAL YR MBBS,
IOG.
    ABNORMAL UTERINE BLEEDING

Arise from a number of
 causes.
Prior to menopause 20%
 of gynecology visits & ¼
 th of gynecological
 procedures are done.
          INCIDENCE OF AUB

Affects 10 – 30% of
 reproductive aged women
 & upto 50% of
 perimenopausal women.
        NORMAL MENSTRUAL CYCLE

 MENSTRUATION:
           Periodic physiologic discharge of blood,mucus
& other cellular debris from the uterine mucosa,occurs at
more or less regular intervals from time of puberty to
menopause.
 Cycle length - 28 +/- 7 days
 Duration      - 2 to 6 days
 Blood loss - 50 to 80 ml.
         PHASES OF MENSTRUAL CYCLE
     PHASES
1.MENSTRUATION
2.PROLIFERATIVE
OR FOLLICULAR
PHASE
3.OVULATION
4.SECRETORY OR
LUTEAL PHASE
5.PREMENSTRUAL
PHASE
                    HPO AXIS

Menstruation is an
 external indicator of
 ovulation events
 controlled by
 hypothalamic-pituitary-
 ovarian axis.
NEUROHORMONAL CONTROL OF
   OVARIAN  FUNCTION
HORMONAL CHANGES




                   Progesterone
          ROLE OF EICOSANOIDS IN
          NORMAL MENSTRUATION
•     PROLIFERATIVE PHASE:
     Endometrium sythesises equal amounts of
    PGF2a & PGE2. [PGF2a:PGE2 = 1:1]
•     SECRETORY PHASE:
     PGF2a increases under the influence of
    progesterone [PGF2a:PGE2 = 2:1] causing
    vasoconstriction,platlet aggregation,myometrial
    contraction as predominant action.
• Relative proportion of various PGs in
  endometrium is responsible for blood flow.
     HOW DOES MENSTRUAL FLOW CEASE?
 Primary - fibrin and platelet-onion skinned plug
  formations
 Around 24hrs- most of superficial layer shed
 After 24hrs- Intense vasoconstriction of spiral arterioles
  and endothelial swelling

         OCCLUSION OF ARTERIOLES
 By 48-72hrs - regeneration of basal glands whose rate
  proportional to growth of follicle.
      Disturbance of endometrial degeneration and
    sloughing in a regular cyclic fashion results in
    aberrant uterine bleeding.
Bleeding in any of the following situations is
 abnormal:
• Bleeding between periods
• Spotting anytime in the menstrual cycle
• Bleeding heavier or for more days than normal.
    DIFFERENTIAL DIAGNOSIS OF AUB

Systemic abnormalities:
Organic lesions:
   -Pregnancy associated.
   -Anatomic uterine lesions.
   -Anatomic non uterine lesion.
Non organic:
    -DUB.
        SYSTEMIC ABNORMALITIES
Exogenous hormone administration
             - sex steroids,corticostroids.
Coagulopathies
Hepatic failure
Chronic renal failure
Endocrinopathies – thyroid disorder,adrenal
                     disorder,DM,PCOD,obesity.
   PREGNANCY ASSOCIATED CAUSES

 Implantation spotting
 Abortion
 Ectopic pregnancy
 Gestational trophoblastic disease
 Postabortal or postpartum infection
      ANATOMIC UTERINE LESIONS

• Neoplasm - leiomyoma,polyp,endometrial
                hyperplasia,cancer.
• Infections - STD,tuberculosis.
• Mechanical - intra uterine device,perforation.
• Arteriovenous malformation.
   ANATOMIC NON UTERINE LESIONS

Ovarian lesions     - hormonally functional
                         neoplasm.
Fallopian tube         - salpingitis,cancer.
Cervical and vaginal
              lesions - cancer,polyp,infection,
                          foreign body,trauma.
     USUAL CAUSES OF AUB BY AGE
             ANOVULATION,
             COAGULOPATHIES,                     ANOVULATION,
             INFECTIONS.                         POLYP,MYOMA,
                                                 ENDOMETRIAL HYPERPLASIA,
ESTROGEN
                                                 CERVICAL/ENDOMETRIAL CA.
WITHDRAWAL

BIRTH        10       20        30          40          50         60


FB,                        ANOVULATION,
TRAUMA,                    HORMONAL CONTRACEPTION,        VAGINAL/ENDOMETRIAL
INFECTION,                 PREGNANCY COMPLICATION,                   ATROPHY,
OVARIAN TUMOR.             INFECTION,                     HORMONE THERAPHY,
                           ENDOCRINE DISORDER,            ENDOMETRIAL CA.
                           POLYP,MYOMA.
DIAGNOSTIC EVALUATION OF
         AUB
                     HISTORY
• Menstrual History:
       - Onset of abnormal menses
       - Duration
       - Volume
       - Intermenstrual interval.
• Marital History:
  H/O - Post coital bleeding
       - Any oral contraceptives
       - IUCD insertion.
• Obstetric History:
  H/O - Abortion
       - Ectopic pregnancy
       - Infertility
• Past History:
       - Underlying systemic illness
        [renal,hepatic,thyroid,hematopoietic]
       - Any bleeding disorder
       - Medications[hormonal,anticoagulant].
• Family History:
     - Tuberculosis contact
     - Any bleeding diathesis.
• Clinical Evaluation:
      The site of uterine bleeding must be
      confirmed.
    The details of history and physical findings
narrow the number of possibilities to establish the
diagnosis.
         OBJECTIVE METHODS

 Objective methods for measuring menstrual
  blood loss:
     1.Photometric alkaline hematin test
     2.Pictorial bleeding assessment chart
PICTORIAL BLEEDING ASSESSMENT
         CHART
LABORATORY EVALUATION OF
         AUB
 Complete blood count:
       -to exclude anemia & thrombocytopenia.
 Differential count:
 Coagulation profile:BT,CT,PT.
 Nucelic acid based test for chlamydia &
                             gonorrhea.
 Wet prep to exclude trichomonas.
 Sonography:
    Transvaginal Sonography:
       - offers anatomic
information regarding the
myometrium.
        - offers greater patient
comfort and comparable detection
of endometrial hyperplasia and
cancer.
 Saline-Infusion Sonography:
     -used to accurately evaluate the
myometrium, endometrium, and
endometrial cavity.
     -permits detection of intracavitary
masses as well as differentiation of
lesions as being endometrial,
submucosal, or intramural.
 Transvaginal Color Doppler
   Sonography:
      -This technique has been
evaluated in identifying and
differentiating endometrial pathology in
the context of uterine bleeding
• Cytologic Examination:
      Both cervical and endometrial cancers can
cause abnormal bleeding and evidence for these
tumors can often be found with Pap smear
screening.
       Endometrial Sampling


    Dilatation&     Fractional
    Curettage        Curettage
 Hysteroscopy:
         -to detect intracavitary lesions such as
leiomyomas and polyps that might be missed using
transvaginal sonography or endometrial sampling.
Thyroid Function Test:
Liver Function Test:
Renal Function Test:
Urine Pregnancy Test:
         -exclude the possibility that relates to a
         complication of pregnancy.
Serum Progesterone:
         -to document ovulation or anovulation.
Diagnostic Goal:
       - to exclude cancer
       - to identify the underlying pathology to
         allow optimal treatment.
In approximately one half of cases, no organic
pathology is identified.

    DYSFUNCTIONAL UTERINE
          BLEEDING
is diagnosed, that is,
     “A DIAGNOSIS OF EXCLUSION”.
THANK
    YOU

				
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posted:4/22/2012
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Description: Abnormal Uterine bleeding,classification,causes,symptoms and management