DUB

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undergrad OBGYN topic

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Abnormal and Excessive Menstrual Bleeding : 

Abnormal and Excessive Menstrual Bleeding Dr Prasanna Kumar Shetty, MD Asst Prof Dept of OBG KSHEMA

Definitions : 

Definitions Menorrhagia: (hypermenorrhoea) regular bleeding at normal intervals which is either excessive in amount (>80ml) or duration(>7days) or both. Polymenorrhoea: cyclic bleeding where the cycle is reduced to 21 days or less and remains constant at that frequency (epimenorrhoea)

Definitions : 

Definitions Metrorrhagia: Irregular, acyclical bleeding from the uterus. Amount of bleeding is variable. Bleeding from any part of genital tract is included under this heading in clinical practice. Oligomenorrhoea: Menstrual bleeding occurring more than 35 days apart and which remains constant at that frequency

Definitions : 

Definitions Hypomenorrhoea: when the menstrual bleeding is unduly scanty and lasts for less than 2 days. Dysfunctional Uterine bleeding (DUB): Abnormal uterine bleeding without any clinically detectable organic pelvic pathology- tumour, inflammation or pregnancy.

Common Causes of Abnormal Uterine or Vaginal Bleeding : 

Common Causes of Abnormal Uterine or Vaginal Bleeding Abnormal menstrual bleeding. Menorrhagia Polymenorrhoea Metrorrhagia Oligomenorrhoea Postmenopausal, Precocious, delayed menopause Non-menstrual Foreign Body Urethral caruncles Genital malignancies Postcoital Intermenstrual Abortion Breakthrough Bleeding

Menorrhagia : 

Menorrhagia Symptom of underlying pathology Pelvic Pathology: Congestion, increased surface area or hyperplasia of the endometrium Fibroid uterus, Adenomyosis, Pelvic Endometriosis, IUCD, Chronic tubo-ovarian mass, granulosa cell tumour of ovary. Common causes: DUB, Fibroid, Adenomyosis, Chronic PID

Menorrhagia : 

Menorrhagia Systemic: Liver Dysfunction, Endocrine: Hypothyroidism, hyperthyroidism Blood Dyscrasias: ITP, leukaemias, von Willebrand’s disease Functional: disturbed hypothalamo-pituitary axis.

Menorrhagia : 

Menorrhagia Long duration of flow, passage of big clots, use of increased no of sanitary pads, pallor, low Hb% Treatment: Definitive treatment of the cause of menorrhagia as the case maybe, eg: fibroid: myomectomy or hysterectomy, removal of IUCD, treatment of hypothyroidism.

Polymenorrhoea : 

Polymenorrhoea Causes: dysfunctional, during adolescence, preceding menopause and following delivery/abortion. ?hyperstimulation of ovary by pituitary gonadotrophins Ovarian hyperaemia: PID, ovarian endometriosis Treatment: Hormonal

Metrorrhagia : 

Metrorrhagia Causes: DUB- adolescence, following childbirth/abortion and perimenopause Submucous fibroid Uterine polyp Carcinoma cervix and endometrial carcinoma Contact bleeding: Ca cervix, mucous polyp of cervix, vascular erosion of cervix esp during pregnancy, infections: chlamydia

metrorrhagia : 

metrorrhagia Causes of Intermenstrual bleeding: urethral caruncle, ovular bleeding, breakthrough bleeding (pill use), IUCD in utero, decubitus ulcer (prolapse) Treatment: directed to underlying cause Malignancy to be excluded prior to any definitive treatment.

Oligomenorrhoea : 

Oligomenorrhoea Common causes: Age related- adolescence, preceding menopause Weight- obesity Stress & exercise related Endocrine: PCOD, hyperprolactinaemia, hyperthyroidism Androgen producing tumours- ovarian, adrenal Tubercular endometritis: late cases.

Hypomenorrhoea : 

Hypomenorrhoea Local causes: uterine synechiae or endometrial tuberculosis Endocrinal: oral contraceptives Thyroid dysfunction Perimenopausal Systemic: malnutrition

EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING : 

EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING Differential diagnosis Reproductive tract pathology: cervicitis, cervical neoplasia, endometritis, endometrial polyps, endometrial hyperplasia, uterine leiomyomas, adenomyosis, uterine sarcomas, ovarian neoplasms (estrogen producing)

EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING : 

EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING Medications: Estrogen administration Oral contraceptives Progesterone-only contraceptives Aspirin Anticoagulants Psychotropic medications Trauma Foreign Body Lacerations Intrauterine device . Endocrine gland dysfunction Hypothyroidism Hyperthyroidism

EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING : 

EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING Ovulatory dysfunction Anovulation Shortened follicular phase Luteal Phase deficiency Prolonged corpus luteum function Pregnancy-related conditions Threatened abortion Spontaneous abortion Ectopic pregnancy Gestational trophoblastic neoplasms

EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING : 

EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING Systemic disease Haematological disorders Von Willebrand’s disease Thrombocytopaenia Hepatic disease Renal disease

EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING : 

EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING Complete History Current bleeding history Menstrual history Contraceptive use Medical history Drug history

EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING : 

EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING Complete Physical Examination: detects organic causes of bleeding, signs of anovulation General physical examination-thyroid enlargement, galactorrhoea, ecchymosis, purpura

EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING : 

EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING Gynaecological examination- including Pap smear detects organic causes of abnormal bleeding Laboratory studies: not all tests necessary in all patients Pregnancy test Complete blood count

EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING : 

EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING Contd. TSH/Prolactin Coagulation profile: PT, PTT, BT Androgen profile: Testosterone, DHEA, OH-progesterone-in women with anovulatory bleeding and hirsutism

EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING : 

EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING Diagnostic studies Endometrial biopsy- all women >40 with chronic anovulatory bleeding D and C Hysteroscopy, or direct visualization of endometrial cavity