Abnormal Uterine Bleeding Flashcards
Usg findings in AUB
Uterine size - increased adenomyosis and fibroid
Endometrial thickness - more than 12mm in menstruating and 4mm in post menopausal women
Adnexal thickness - tubo ovarian mass
Fluid in pouch of douglas
Define AUB
It is defined as any bleeding from genital tract, which is a deviation from normal frequency, cyclicity or quantity .
DUS - is AUB without any demonstrable pelvic pathology or systemic or endocrine causes
Types of DUB ( dysfunctional)
80% anovulatory cycles - puberty menorrhagia, metropathia haemorrhagic a
20% ovulatory - irregular ripening and shedding, IUCD insertion and tubal sterilization
Causes of AUB in adolescent
HPO axis is immature
Bleeding and coagulation disorders - Von Willebrand’s disease and ITP
PCOS
Tuberculosis
Thyroid disorders
Causes of AUB in reproductive age group
DUB
Thyroid disorders
PCOS
Pregnancy related complications
Fibrosis and PID
Causes of AUB in perimenopausal age group
Anovulatory cycles
Pre malignant and malignant lesions of uterus, cervix, ovary
Fibroid , adenomyosis and endometriosis
What is the Figo classification of AUB
PALM COEIN
polyp
Adenomyosis
Leiomyoma
Malignancy
Coagulation disorders
Ovulatory dysfunction
Endometrial
Iatrogenic
Not yet classified
What is Metropathia Haemorrhagica ?
Seen in perimenopausal women
Ovarian follicles develop and produce oestrogen but failure of release of dominant follicle - no ovulation and formation of follicular cyst
No progesterone is produced and unopposed oestrogen - endometrial proliferation - amenorrhea
When the thickness exceeds the blood supply there is shedding of the endometrial layer
On HPE -swiss cheese pattern: cytoglandular hyperplasia
Causes of irregular shedding
Incomplete atrophy of corpus luteum due persistent LH - progesterone secretion- spotting variable after normal periods
Cause of irregular ripening
Poor formation of corpus luteum - inadequate progesterone: cannot support the endometrium
Indications of fractional curettage
AUB in women above 40 years
Post menopausal bleeding, suspected endometrial carcinoma
How to perform fractional curettage?
Patient in supine position - with adequate analgesia place in lithotomy position, after cleaning and draping - bimanual examination is performed
Sim’s speculum is introduced in the posterior vaginal wall and ant lip is held with vulsellum
Before the introduction of uterine sound and dilatation of the cervix ( mathew Duncan)- take endocervical curetting
The uterus is curetted from fundus, ant,post and lateral wall
These samples are sent to HPE
Uses of DandC
To study endometrial pattern
To rule out endometrial carcinoma
To rule of endometrial tb
Indications of Hysterectomy
Removal of endometrial polyp
Removal of submucosal fibroid
Excision of septum adhesiolysis in ashermann’s syndrome
Non hormonal treatment of AUB
NSAIDS- mefenamic acid, naproxen, ibuprofen
Anti- Fibrinolytics - tranexemic acid , epsilon aminocarporic acid
Ethamsylate- prevents capillary fragility
What is medical Curettage ?
To arrest bleeding - initial dose of 30mg medroxy progesterone acetate or norethisterone acetate is given - 24-48hrs till bleeding stops.
Dose is gradually reduced to 10 mg twice a day and then 10mg once a day for a total of 21 days and then stopped
After 2-3 days withdrawal bleeding occurs
This is called medical Curettage
Mechanism of action of MIRENA - LNG IUD
Contains a total of 52 mg levonorgesterol
Releases 20ug of levonorgesterol
This leads to glandular atrophy and stromal decidualization - prevents implantation, lead to scanty periods then amenorrhea
Various Surgical modalities to treat AUB
Conservative or minimally invasive
Hysterectomy
Endometrial ablation -
1st generation and 2nd generation
Indications for mis
Failure of medical therapy
Patient wants to conserve uterus
C/I - conserve fertility, uterus more than 12 weeks, large fibroid, endometrial hyperplasia and carcinoma
Ablative procedure
1st gen - Transcervical resection of endometrium
2nd gen- thermal ablation, microwave ablation
Radio frequency induced thermal ablation
