Abnormal Uterine Bleeding Flashcards
mean duration of the menstrual cycle is
28 ( + / - ) 7 days.
Average menstrual blood loss
Range
35 ml
10-80ml
Average number of days of menses
Range
4 d
2-7 up to 12 d.
Classification of abnormal, uterine, bleeding.
PALM :
• Polyp
• Adenomyosis
• Leiomyoma
• Malignancy and
hyperplasia
COIEN :
• Coagulopathy
• Ovulatory dysfunction
• Iatrogenic
• Endometrial
• Not yet classified
ENDOMETRIAL POLYPS :
What’s the character?
- localized overgrowths of endometrial tissue, containing glands, stroma, and blood vessels, covered with epithelium.
- Mostly reproductive-age women
- estrogen stimulation
- benign
- symptomatic polyps : operative hysteroscopy
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?
Endometrial polyp
Operative hystroscopy.
ADENOMYOSIS
Overgrowth endometrial glands and stroma in the uterine myometrium.
ectopic endometrial tissue leads to hypertrophy of the surrounding myometrium.
ADENOMYOSIS risk factors :
- Multiparity (most significant)
- dilation and curettage
- cesarean delivery
- spontaneous abortion
ADENOMYOSIS
What’s the character?
Ultrasound ?
> 40 age + reproductive age + dysmenorrhea.
Enlarged, asymmetric uterus
LEIOMYOMA (( myoma , fibroma ))
benign neoplasm in uterus and female pelvis + reproductive age
What’s the chance of the fibroid converted to the malignancy?
What’s the name?
0.002%
Layomayosarcoma.
What’s the type of the fibroid?
- submucous fibroids
- intramural fibroids
- Pedunculated fibroid
- Subserosal fibroid
What’s the most common type of the fibroid converted to malignancy
Submucosal fibroid
Increase risk factor of LEIOMYOMA
• Age 35 to 45 years
• nulliparous or low parity
• Black women
• strong family history
• Obesity
• early Menarche
• Diabetes
• hypertension
decrease risk factor of LEIOMYOMA
• ↑↑ parity 🤰
• Exercise ⚽️
• ↑↑intake of green vegetables 🥬
• Progesterone only contraceptives
• Cigarette smoking 🚬
LEIOMYOMA decrease after…. Increases during…..
Menopause
Pregnancy
Liomyoma high concentrations of ….. receptors in ……. than …….
estrogen
leiomyoma
myometrium
FIBROID PATHOLOGY
Gross appearance
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
FIBROID PATHOLOGY
Microscopy
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
CLINICAL PRESENTATION
LEIOMYOMA
• 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
EFFECTS OF FIBROID ON PREGNANCY :
• Pregnancy : Abortion
Pressure symptoms
Malpresentation
Retrodisplacement of uterus
• Labour : Preterm labour Malpresentation
Uterine inertia
PPH
Dystocia
• Puerperium : Subinvolution
Sec. PPH Puerperal
sepsis Inversion
EFFECTS OF PREGNANCY ON FIBROID
-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
Fibroid signs
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 .
FIBROID - DIAGNOSIS
USG
Hysteroscopy
Saline infusion sonography
MRI
DIFFRENTIAL DIAGNOSIS
For any abd. Mass
PREGNANCY
ADENOMYOSIS
Ectopic PREGNANCY
ENDOMETRIOSIS
TUBOOVARIAN MASS
OVARIAN TUMOUR
MANAGEMENT LEIOMYOMA
• 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
DEGENERATIONS\ SECONDRY CHANGES IN FIBROID
atrophy
Red degeneration
hyaline degeneration M\C
Fatty degeneration or calcification
myxomatous degeneration
Cystic degeneration
What’s the diagnosis for the post coital bleeding?
Cervical ca.
Malignant can lead to IUB
vulvar, vaginal, cervical, endometrial, uterine, and adnexal (ovarian or • fallopian tube) cancers
