Professional Documents
Culture Documents
Bleeding
Mitra A. Razzaghi, MD
Womens Integrated Services in Health
WISH
Why WISH?
Objectives
Case
AUB - Overview
Non-Uterine Genital
Sources
Terminology
Menorrhagia
Metrorrhagia
Menometrorrhagia
Oligomenorrhea
Amenorrhea
bleeding >80cc/cycle
Structural
Dysfunctional (DUB)
Leiomyoma
Polyps
Carcinoma
Pregnancy complications
Ovulatory
Anovulatory
Diagnostic tools
Endometrial sampling
11
12
Polyp
Endometritis
Hyperplasia without atypia
Atypia or carcinoma
Disordered endometrium, stromal collapse,
proliferative or secretory
13
Hysteroscopy or D&C
Observation sometimes acceptable
Saline Infused
Sonohystogram (SIS)
Indication
How it is done
14
Hysteroscopy
15
Endometrial polyp
16
17
Thyroid disease
Chronic liver disease
Cushing syndrome
Renal disease
Emotional or physical stress
Excessive exercise
smoking
Common medications
causing AUB
18
Polycystic Ovarian
Syndrome
Affects 10% of women in the US
Oligo- or anovulation
Hyperandrogenism
Exclusion of other causes of hypergonadism and menstrual
irregularity
19
Anovulation
Hyperandrogenism
Polycystic ovaries by ultrasound
PCOS - Pathophysiology
20
PCOS
Clinical manifestations
Medical complications
21
Irregular menses
Androgen excess
Obesity
Acanthosis nigricans
Endometrial cancer
Insulin resistance/Diabetes
Infertility
Coronary artery disease (CAD)
Obstructive sleep apnea (OSA)
Non-Alcoholic steatohepatitis (NASH)
PCOS - Diagnosis
Menstrual irregularities
Androgen excess
22
Pregnancy
Hyperprolactinemia
hypothyroidism
Hyperprolactinemia
Nonclassical adrenal hyperplasia
Androgen secreting tumors
PCOS - Work up
Supportive data
23
PCOS - Treatment
24
Adenomyosis:
25
Uterine Leiomyoma
26
Uterine Leiomyoma
(Fibroids)
Most common gynecological tumor
27
Menorrhagia
Pelvic pressure/pain
Decreased fertility
Uterine Fibroids
Increased risk
Reduced risk
28
Nulliparity
Obesity
ETOH use
Black-American ethnicity
Genetic/Familial predisposition
Pregnancy
Combination OCP
Depo-Provera
Tobacco use
Uterine Fibroids
Asymptomatic
Expectant management
Mildly symptomatic
OCP
NSAIDs
Useful in idiopathic menorrhagia
Do not reduce blood loss caused by fibroids
May alleviate cramping
29
Hormonal
Uterine artery embolization
MR directed ultrasound (ExAblate)
Myomectomy
30
Hysteroscopic resection
Laparoscopic myomectomy
GnRH Agonists
31
Raloxifene
Side effects
32
Other Therapies
Danazole
Mifepristone (RU-486)
Antiprogestin
Side effects: vasomotor symptoms, 25%
hyperplasia
Levonorgestrel-releasing IUD
33
Androgenic steroid
Inhibits pituitary gonadotropin secretion
Side effects: weight gain, acne, oily skin
34
Uterine Artery
Embolization-UAE
35
Disadvantages of UAE
36
Painful!!!
Reduces bleeding more than bulk
Pedunculated fibroids cannot be embolized
Not definitive
Can induce menopause
Not recommended for women who desire
fertility
IR data skewed- minimal long term follow
up
MR Guided Ultrasound
(ExAblate)
37
Uterine Leiomyoma
38
ExAblate
39
Limitations of MR-US
Ablation
40
Abdominal Myomectomy
41
Major surgery
Complications significantly higher than
hysterectomy
Long recovery
Recurrence rate 50%
Small chance of uterine perforation in
subsequent pregnancy
Laparoscopic Myomectomy
42
Hysteroscopic myomectomy
43
Hysterectomy
44
Laparoscopic Hysterectomy
45
Treatment of
Dysfunctional
Uterine Bleeding
Chewable tablet
47
Contraindication to OCP
48
Progestins
49
Levonorgestrel IUD
(Mirena)
T-shaped polyethylene with a collar
containing 52 mg of levonorgestrel
Visible on X-Ray
Effective up to 7 years, approved for 5
As effective as endometrial ablation for
treatment of menorrhagia
May also decrease the risk
of PID
50
Implanon (contraceptive
implant)
51
Balloon Ablation
52
Advantages of Ablation
53
Disadvantage of Ablation
54
55
Postmenopausal bleeding
56
Atrophy 59%
Polyp 12%
Endometrial cancer 10%
Endometrial hyperplasia 9.8%
Hormonal effect 7%
Cervical cancer <1%
Other 2%
Endometrial Hyperplasia
57
Adenocarcinoma
58
Postmenopausal bleeding
59
Neoplasm
Atrophy
Medications
Foreign body
Mean age for cervical cancer 52.2
Visible lesion needs biopsy even if pap is normal
Postmenopausal bleeding
Evaluation to include
60
Pap test
Transvaginal Ultrasound
Endometrial biopsy if endometrial thickness
5mm or higher
EMBx <5 mm if risk factors like obesity, chronic
anovulation, breast cancer, Tamoxifen use, FHx
of endometrial, ovarian, breast or colon cancer
May need SIS or hysteroscopy for focal lesions
MRI if US not definitive for fibroids or
adenomyosis
Special considerations
Intrauterine infection
61
Quick Practical
Summary
63
Bleeding patterns
Normal
Irregular
Menorrhagia
64
65
66
Endometritis
Medications
Advanced systemic disease
PCOS
OCP low -> high
Progestins: oral, injection, implant, IUD
Menorrhagia
68
Hospital admission
Studies: Coags, CBC, TSH, Platelet function, TVUS
IV Conj Estrogen (Premarin) 25 mg Q4h + antiemetic
and OCP
D&C if no response after 2 doses
Hemodynamically stable
69
Peri-menstrual Spotting
70
Breakthrough Bleeding
Amenorrhea
71
72
Progesterone-releasing IUD
Depo-Provera Associated
Bleeding
73
74
MENtal illness
MENstrual cramps
MENtal breakdown
MENopause
G(U)Ynecologist
H(I)Sterectomy
75
76