Abnormal Uterine Bleeding

Question 1

mean duration of the menstrual cycle is

Answer 1

28 ( + / - ) 7 days.

Question 2

Average menstrual blood loss
Range

Answer 2

35 ml

10-80ml

Question 3

Average number of days of menses
Range

Answer 3

4 d

2-7 up to 12 d.

Question 4

Classification of abnormal, uterine, bleeding.

Answer 4

PALM :
• Polyp
• Adenomyosis
• Leiomyoma
• Malignancy and
hyperplasia

COIEN :
• Coagulopathy
• Ovulatory dysfunction
• Iatrogenic
• Endometrial
• Not yet classified

Question 5

ENDOMETRIAL POLYPS :
What’s the character?

Answer 5

1. localized overgrowths of endometrial tissue, containing glands, stroma, and blood vessels, covered with epithelium.
2. Mostly reproductive-age women
3. estrogen stimulation
4. benign
5. symptomatic polyps : operative hysteroscopy

Question 6

Patient come with IUB bleeding on the examination we found mass, and this mass contain stroma, gland, blood vessel cover with the epithelium :
What’s the diagnosis?
What’s the treatment?

Answer 6

Endometrial polyp
Operative hystroscopy.

Question 7

ADENOMYOSIS

Answer 7

Overgrowth endometrial glands and stroma in the uterine myometrium.

ectopic endometrial tissue leads to hypertrophy of the surrounding myometrium.

Question 8

ADENOMYOSIS risk factors :

Answer 8

1. Multiparity (most significant)
2. dilation and curettage
3. cesarean delivery
4. spontaneous abortion

Question 9

ADENOMYOSIS
What’s the character?
Ultrasound ?

Answer 9

> 40 age + reproductive age + dysmenorrhea.

Enlarged, asymmetric uterus

Question 10

LEIOMYOMA (( myoma , fibroma ))

Answer 10

benign neoplasm in uterus and female pelvis + reproductive age

Question 11

What’s the chance of the fibroid converted to the malignancy?
What’s the name?

Answer 11

0.002%
Layomayosarcoma.

Question 12

What’s the type of the fibroid?

Answer 12

1. submucous fibroids
2. intramural fibroids
3. Pedunculated fibroid
4. Subserosal fibroid

Question 13

What’s the most common type of the fibroid converted to malignancy

Answer 13

Submucosal fibroid

Question 14

Increase risk factor of LEIOMYOMA

Answer 14

• Age 35 to 45 years
• nulliparous or low parity
• Black women
• strong family history
• Obesity
• early Menarche
• Diabetes
• hypertension

Question 15

decrease risk factor of LEIOMYOMA

Answer 15

• ↑↑ parity 🤰
• Exercise ⚽️
• ↑↑intake of green vegetables 🥬
• Progesterone only contraceptives
• Cigarette smoking 🚬

Question 16

LEIOMYOMA decrease after…. Increases during…..

Answer 16

Menopause
Pregnancy

Question 17

Liomyoma high concentrations of ….. receptors in ……. than …….

Answer 17

estrogen
leiomyoma
myometrium

Question 18

FIBROID PATHOLOGY
Gross appearance

Answer 18

Multiple, discrete, spherical, pinkish white, firm capsulated masses protruding from surrounding myometrium. Pseudo capsule is made up of compressed myometrium giving it a distinct outline

Question 19

FIBROID PATHOLOGY
Microscopy

Answer 19

nonstriated muscle fibres are arranged in interlacing bundles of varying size & running in different directions (whorled appearance). Varying amount of connective tissue is intermixed with smooth muscle fibres

Question 20

CLINICAL PRESENTATION
LEIOMYOMA

Answer 20

• Asymptomatic- most common (( small size ))
• Abnormal uterine bleeding m.c (( submucosal)) but may occur with all types
• Anemia due to excessive blood loss • Pelvic pain in 1/3rd patients > backache. -
• Acute pain : due to torsion, infection, expulsion, red degeneration, vascular complication
• Dysmenorrhoea : Spasmodic as well as congestive
• Pressure symptoms (large)
• Urinary symptoms : urgency, frequency, incontinence, rarely urethral obstruction
• Bowel symptoms- constipation, intermittent intestinal obstruction -
• Abdominal distention- with large fibroids
• Rapid growth- with pregnancy and malignancy
• Infertility – 2 to 10 %: cases- Anovulatory, irregular cavity interfering with sperm transport, endometrial changes *
• Rare symptoms : Ascites, polycythemia

Question 21

EFFECTS OF FIBROID ON PREGNANCY :

Answer 21

• Pregnancy : Abortion
Pressure symptoms
Malpresentation
Retrodisplacement of uterus

• Labour : Preterm labour Malpresentation
Uterine inertia
PPH
Dystocia

• Puerperium : Subinvolution
Sec. PPH Puerperal
sepsis Inversion

Question 22

EFFECTS OF PREGNANCY ON FIBROID

Answer 22

-Increase in size & softening (( first trimester ))
- Red degeneration in 2nd trimester due to rapid growth there is congestion with interstitial hemorrhage & venous
thrombosis
-Impaction in pelvis -Torsion -Infection -Expulsion -Injury Pressure necrosis during delivery -Rupture of subserous vein → Internal hemorrhage

Question 23

Fibroid signs

Answer 23

FIBROID - SIGNS
General examination:
Anemia due to prolonged heavy bleeding .
P/A : If > 12 weeks size , firm, nodular, arising from
pelvis, lower limit can’t be reached, relatively well defined, mobile from side to side, nontender, dull on percussion, no free fluid in abdomen
P/S :
Cervix pulled higher up P/V : Uterus enlarged, nodular.
D/D from ovarian tumour → Uterus not separately felt , transmitted movement present, notch not felt.
P/R :
May help in difficult cases .

Question 24

FIBROID - DIAGNOSIS

Answer 24

USG
Hysteroscopy
Saline infusion sonography
MRI

Question 25

DIFFRENTIAL DIAGNOSIS
For any abd. Mass

Answer 25

PREGNANCY
ADENOMYOSIS
Ectopic PREGNANCY
ENDOMETRIOSIS
TUBOOVARIAN MASS
OVARIAN TUMOUR

Question 26

MANAGEMENT LEIOMYOMA

Answer 26

• 1- expectant.
• 2- medical:
NSAIDs
Progestogens, antiprogestogens(Mifepristone), androgens ( Danazol, Gestrinone) &
GnRH analogues are used Progesterone releasing IUD
• 3- surgical :
Hysterectomy \Myomectomy Hysteroscopic myomectomy
• 4- Uterine artery embolization

Question 27

DEGENERATIONS\ SECONDRY CHANGES IN FIBROID

Answer 27

atrophy
Red degeneration
hyaline degeneration M\C
Fatty degeneration or calcification
myxomatous degeneration
Cystic degeneration

Question 28

What’s the diagnosis for the post coital bleeding?

Answer 28

Cervical ca.

Question 29

Malignant can lead to IUB

Answer 29

vulvar, vaginal, cervical, endometrial, uterine, and adnexal (ovarian or • fallopian tube) cancers