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MENSTRUAL DIMENSIONS
MENSTRUAL DIMENSIONS
(2)
Prolonged
> 7 days
DIFFERENTIAL DIAGNOSIS OF
AUB
Ta
bel 1. Differential Diagnosis of AUB by Age Group
Perimenopaus Menopausa
Children
Adolescent
Reproductive
al
l
a.Physiologi a. Anovulatory
a. Pregnancy
a. Anovulatory
a. Atrophy
c
due
to
related
b. Endometrial
b. Endometri
b.Vulvovagin
immaturity of b. Anovulatory
hyperplasia
al
itis
hypothalamic- c. Vaginal/pelvic c. Endometrial
carcinoma
c. Trauma
pituitaryinfection
polyps
c. Endometri
d.Urethral
ovarian axis
d. Pelvic tumor
d. Leiomyomas
al
prolapse
b. Coagulopathy e. Endocrinopath e. Adenomyosis
hyperplasi
e.Endocrinop c. Pregnancy
ies
f. Genital tract
a
athies
d. Vaginal/pelvic f. Coagulopathy
neoplasm
d. Endometri
f. Precocious
infection
al polyp
puberty
e. Benign lesions
e. Leiomyom
g.Ovarian
f. Medications
as
cyst
g. Mllerian
f. Hormone
h.Genital
anomalies
replaceme
tract
h. Genetic
nt therapy
neoplasm
abnormality
DIFFERENTIAL DIAGNOSIS OF
AUB (2)
iagnostic Testing
O
rder laboratory serum testing for human chorionic
gonadotropin (-hCG), thyroid stimulating hormone (TSH),
follicle stimulating hormone (FSH), prolactin, and complete
blood count (CBC).
I
n women with risk factors for neoplastic processes a tissue
diagnosis is required.
I
f anovulatory bleeding and pregnancy have been ruled out,
evaluate for coagulation disorders.
EVALUATION OF AUB
ULTRASONOGRAFI
Transvaginal Ultrasonografi (TVUS)
TVUS is useful to evaluated for the presens of fibroids, intrauterine pregnancy and ectopic
pregnancy.
Saline Infusion Sonografi
It is the most sensitive non invasive method of diagnosis for endometrial polyps and
submucous myomata. But, it does not distinguish between benign and malignant processes.
HYSTE
ROSCOPY
The
advantage of this procedure is that it provide direct visualization of the endometrial cavity and
can be performed in the operating room.
MAGN
ETIC RESONANCE IMAGING (MRI)
Can be
useful in the diagnosis adenomiosis and can accurately localize and measure fibroids,
faciltating determination of the best treatment.
C
I
ETIOLOGY
The predominant causes of DUB are anovulation or oligoovulation.
Anovulation is multifactorial and related to alterations of the hypothalamic-pituitaryovarian axis.
long-term anovulation
estrogen production occurs without the progesterone
produced from the corpus luteum
thus creating an unopposed estrogen state
risk for endometrial hyperplasia
Anovulation is also associated with polycystic ovary syndrome, which also places
women at risk for endometrial hyperplasia.
Morbid obesity
Peripheral conversion of androstenedione to estrone occurs in adipose tissue
producing elevated estrogen levels
Occasionally, DUB may be associated with ovulatory cycles.
SURGICAL TREATMENT
overall success rate is 80% to 90%, with 30% to 50% of women reporting
amenorrhea 6 months postprocedure. Still, within 5 years, 15% will have a
second ablation and 20% will have a hysterectomy.
Pharmacologic Management of
Abnormal Uterine Bleeding
Hormonal
Manageme
nt
Progestin
s
Combined
estrogen
and
progestin
s
a.
b.
c.
d.
Oral contraceptives
Transdermal preparations
Vaginal ring
Hormone replacement therapy
Pharmacologic Management of
Abnormal Uterine Bleeding (2)
Nonsteroidal Anti-inflammatory a. Mefenamic acid 500 mg 3/d
Drugs (NSAIDs)
b. Ibuprofen 600-800 mg every
6 hr
c. Meclofenamate sodium 100
mg 3/d
d. Naproxen sodium 550 mg
1, then 275 mg every 6 hr
Antifibrinolytic Agents
Coagulation Disorders
enorrhagia during adolescence should be attributed
to a coagulation disorder until proven otherwise.
Bleeding from multiple sites (e.g., nose, gingiva,
intravenous
sites,
gastrointestinal,
and
genitourinary tracts) may suggest coagulopathy.
here is a higher prevalence of bleeding disorders in
women with menorrhagia.
ENDOCRINE DISORDERS
ndocrinopathies can cause anovulation, producing
an estrogen without progesteron.
he endometrium eventually breaks down, which
may or may not lead to the formation of
hyperplasia.
Hepatic Dysfunction
ecreased metabolism of estrogen and decreased
clotting factor synthesis are common ramifications
of liver failure.
novulation may also ensue. Menometrorrhagia is
common.
iver function tests are necessary to make the
diagnosis,
finding
of
jaundice,
ascites,
hepatosplenomegaly, palmar erythema, pruritus,
and spider angioma are suggestive of liver failure.
Psychotropic
a.Certain
b.Antipsychotic
medications (i.e., dopamine antagonists) Phenothiazines and antidepressants
Hormone
Medications
a.Medroxyprogestero
ne acetate
b.Combination OCPs
c.Progestational
agents
Other Medications
a.Anticoagulants
b.Digitalis,
phenytoin, and corticosteroids
Intrauterine
Devices
a.Copper-containing
intrauterine devices, unlike the levonorgestrel-releasing Mirena intrauterine system
b.Such bleeding is
often treated successfully with NSAIDs.
Benign Pathology
Leiomyomata
Leiomyomata (fibroids) are the most common uterine
neoplasm, and is the number one indication for
hysterectomy in the United States.
Endometrial Polyps
Generally, benign endometrial lesions tend to be
asymptomatic but may be present in 10% to 33% of
women with complaints of bleeding, typically
metrorrhagia.
Endometrial Hyperplasia
Endometrial hyperplasia, a precursor to endometrial
carcinoma, is classified into simple or complex, based on
architectural features, and typical or atypical, based on
cytologic features.
Malignancy
Endometrial Cancer
Endometrial
carcinoma is rare in patients younger than age 40. Postmenopausal bleeding,
should be assumed to represent endometrial cancer until proven otherwise.
Cervical
Cancer
a.Cervical
carcinoma is a disease of both the relatively young and the old it cause abnormal
bleeding.
b.The most
common bleeding patterns associated with cervical carcinoma are intermenstrual
and postcoital bleeding
Ovarian
Cancer
Estrogenproducing ovarian tumors, such as a granulosa-theca cell tumor, can produce
endometrial hyperplasia and AUB.
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