Educational Materials

1. Associate Clinical Prof. Dr Aisha EL-Bareg, MD, PhD
Senior Consultant in (Obs & Gyn/Reproductive Medicine)
Faculty of Medicine, Misurata University, LIBYA

2. Abnormal uterine bleeding (AUB)
Any deviation from normal frequency, duration
or amount of menstruation in women of
Reproductive age.
NORMAL MENSES
•Frequency: 21-35 d
•Duration: 3-7 d
•Volume: 30-80 ml

3. AUB- Clinical types
•Polymenorrhoea: frequent (<21 d) menstruation, at
regular intervals
•Menorrhagia: Excessive (>80 ml) & / or prolonged
menstruation, at regular intervals
•Metrorrhagia: Mensturation at irregular intervals.

4. AUB- Clinical types
•Menometrorrhagia: both.
•Intermenstual bleeding: episodes of uterine
bleeding between regular menstruations.
•Hypomenorrhoea: scanty menstruation.
•Oligomenorrhea: infrequent menstruation (>35 d)

5. AUB- Causes

6. Organic cause
1. Pregnancy complications:
•Miscarriages
•Ectopic pregnancy
•Trophoblastic disease
AUB- Causes

7. 2. Genital disease
. Tumors:
Benign: - Fibroid, cervical & endometrial polyp.
Malignant: - Cervical, endometrial Ca.
- Ovarian (estrogen secreting) tumor.
. Infection: - PID
. Endometriosis, Adenomyosis
. IUCD
. Marked uterovaginal prolapse
AUB- Causes

8. Systemic cause:
. Endocrine: - Hypo & hyperthyroidism, DM
- Adrenal gland disease
- Hyperprolactinemia
. Coagulopathy:
•Idiopathic thrombocytopenic purpura,
•Von-Willebrand disease, Liver failure
AUB- Causes

9. • Chronic systemic disease: anemia, heart
failure, liver failure
• Iatrogenic - Hormonal contraception, HRT,
anticoagulants, antipsychotic drugs.
• Emotional
• Under & over weight
AUB- Causes

10. •Definition:
Abnormal uterine bleeding in absence of
obvious pelvic organ disease or a systemic
disorder
•Incidence:
• 60 % of AUB
Dysfunctional uterine bleeding (DUB)

13. Mechanism of hemostasis during menstruation
2. Hemostatic plug formation
in the functional endometrium
1. Vasoconstriction in the
basal layer
Vascular occlusion is not complete, for short time
Until endometrial regeneration is completed

14. DUB- Pathophysiology
1. Anovulatory - 90 %
Endocrine abnormality
• Insufficient follicles
• Persistent follicle
Endometrial changes
• Inadequate proliferative
or atrophic (↓ E).
• Proliferative or hyperplastic
(↑ E).

15. • Estrogen withdrawal bleeding
– Frequently occurs in peri-menopause.
– Short proliferative phase because of abnormal
follicular developments.
– E levels will vary with the quality and state of follicular
recruitment and growth.
– Bleeding might be light or heavy depending on the
individual response.
DUB- Pathophysiology

16. • Estrogen breakthrough bleeding
– Anovularoty cycles have no CL formation
– Progesterone is not produced
– The endometrial continues to proliferate under the
influence of unopposed E.
– Out-of-phase endometrium is shed in an irregular
manner that might be prolonged and heavy.
– Occur in absence of E decline.
DUB- Pathophysiology

17. Endocrine abnormality
Insufficient C. luteum leading
to short luteal phase
Persistent C luteum leading
to long luteal phase
Endometrial changes
Irregular or deficient
Secretory changes
Irregular shedding
A. Hormonal disturbances
DUB- Pathophysiology

18. B. Local endometrial defect
– Increase PGE2/PGF2α- VD
– Decreased Thromboxane A2/Prostacyclin ratio
– Increased activity of the fibrinolytic system locally in
the uterus
Why these changes occur and their exact
causal relation with menorrhagia have not
yet been determined.

19. AUB- Complications
• Iron deficiency anemia
• Endometrial adenocarcinoma: 1-2% of women with
anovulatory bleeding might develop Ca.
• Infertility: as with chronic anovulation, with or without
androgen production : PCOS, obesity, chr HTN, DM
are at risk.
• Complications of the etiology if present .

20. Aim:
1. Nature & severity of bleeding
2. Exclusion of organic causes
3. Ovulatory or anovulatory
Diagnosis

21. I. History
1. Personal: Age
2. Present H: onset of the problem, amount of
bleeding, duration, frequency, relation to
sexual intercourse, associated symptoms (pain,
abdominal mass).
3. Menstrual H.
4. Sexual activity: infection.
Diagnosis

22. 5. Obstetric and gynecological H
6. Contraceptive H.
7. Past medical & surgical H.
8. Family history
9. Current medication
Diagnosis
I. History

23. II. Examination:
1. General examination
 Obesity (BMI)
 Signs of androgen excess (hirsutism, acne)
 Signs of hypo or hyperthyroidism
 Galactorrhea
 Visual field defect (pituitary lesion)
 Ecchymosis, purpura
 Signs of anemia
Diagnosis

24. 2. Abdominal examination
– liver, spleen, pelvi-abdominal mass
3. Local examination
• External genital lesions
• Speculum ex: assess the bleeding, vaginal discharge,
vaginal & cervix lesions
• Bimanual ex: uterine size, shape, countour, adnexa
for ovarian mass.
Diagnosis

25. III.Investigations
Systemic
1. CBC, peripheral blood smear, Iron studies .
2. B.HCG
3. Hormonal assay: LH, FSH, androgens, prolactin, TFT
4. LFT, RFT
5. PT, APTT, BT, platelets, Von Willebrand factor
Diagnosis

26. III.Investigations
Local
1. Pap smear, cervical swap for infection
2. USS, saline-infusion-sonography
3. Endometrial biopsy, D & C biopsy
4. Fractional curettage
5. Hysteroscopy
Diagnosis

27. 1. TAS: can exclude pelvic masses, pregnancy
complications.
2. TVS:
• More informative than TAS.
• Measurement of the endometrial thickness.
• Endometrial carcinoma in postmenopausal is suspected if
endometrial thickness > 3.5 mm.
Ultrasonography

28. 3. Saline infusion sonography:
Infusion of saline into the uterine cavity.
Ultrasonography

29. TVS is recommended
1. Weight >90 Kg
2. Age > 40
3. Other risk factors for endometrial hyperplasia or
carcinoma e.g. infertility, nulliparity, family history of
colon or endometrial cancer, exposure to unopposed
estrogen.
Ultrasonography

30. Indications:
• Between 20 & 40 yrs.
• If endometrial thickness on TVS is >10mm,
endometrial sample should be taken to exclude
endometrial hyperplasia.
Aim
• Diagnosis of the type of the bleeding
• Exclude local pathology
Endometrial biopsy

31. Methods:
•As an outpatient procedure.
1.Pipelle curette
2.Sharman curette
3.Accrette
4.vabra aspirator
Advantages: An adequate & acceptable screening
procedure in females under 40 yrs
Endometrial biopsy

32. Indications
1. Mandatory after 4o yrs.
2. Persistent or recurrent bleeding after medical tt in
patient between 20 & 40 yrs.
Aim
1. Diagnosis of organic disease e.g. endometritis,
polyp, carcinoma, TB.
2. Diagnosis of the type of the endometrium,
hyperplastic, proliferative, secretory, atrophic.
Dilatation & Curettage (D & C)

33. 3. Arrest of the bleeding, if the bleeding is severe or
persistent, particularly hyperplastic endometrium.
Curettage is essentially a diagnostic & not a
therapeutic procedure.
Disadvantages
1.Small lesions can be missed.
2.The sensitivity of detecting intrauterine pathology is
only 65% .
Dilatation & Curettage (D & C)

34. Indication: >40 yrs
Method: 3 samples: endocervical, lower segment
& upper segment
Fractional curettage

35. • It is an endoscopic
visualization of endometrial
cavity.
Hysteroscopy
•Using a telescope, camera and light source.
• Use distensile media
CO2, normal saline, Glycin 1.5%

36. Hysteroscopy
1) To locate submucous myoma.
2) To diagnose uterine septum.
3) To locate & remove lost I.U.C.D.
4) To locate Endometrial polyp.
5) To locate uterine synechae.
6) To detect endometrial cancer.
• Indications

37. hysteroscopy

38. • Aim
1. Excellent view of the uterine cavity & diagnosis of
polyps, submucous fibroid, hyperplasia.
2. Biopsy of the suspected areas.
3. Treatment
- Endometrial ablation, removal of Polyp
- Resection of Submucous myoma, Uterine septa
- Resection of Intrauterine adhesion
Hysteroscopy

40. Hysteroscopy
1. Acute and chronic upper genital tract infection.
2. Recent uterine perforation.
3. Pregnancy.
• Contraindications

41. Complications of hysteroscopic methods
1. Uterine perforation
2. Bleeding
3. Infection.
4. Fluid overload
5. Gas embolism
6. Complications of anaesthesia
Hysteroscopy

42. Disadvantages
1. Cost of the apparatus.
2. Lack of availability or experience.
Hysteroscopy

43. AUB- Treatment
• Principle of management
– Control of the bleeding followed by regulation
of menses.
– Induction of ovulation in patients with
infertility.

44. Treatment
A. General B. Management of bleeding
Medical Surgical

45. 1. General measures
• Treatment of iron deficiency anemia
• Treatment of systemic diseases
• Treatment of endocrinological diseases
Treatment

46. Treatment < 20 yrs 20-40 yrs > 40 yrs
Medical always
First resort after
endometrial biopsy
Temporary & if
surgery is refused
or imminent
menopause
Surgical
never
Seldom, only if
medical treatment
fail
First resort if
bleeding
is recurrent
Strategy of treatment

47. I. Non –hormonal
1. Antifibrinolytics
2. Prostaglandin synthetase inhibitors (PSI)
3.Ethamsylate
II. Hormonal
1. Progestagen 4. Danazol
2. Oestrogen 5. GnRh agonist
3. COCP 6. Levo-nova (Merina)
Medical therapy

48. 1. Antifibrinolytics
Tranexamic acid (tranex)
Mechanism of action:
The endometrium possess an active fibrinolytic system,
& the fibrinolytic activity is higher in menorrhagia.
Effect:
• ↓ menstrual bleeding > other therapies (PSI, oral
luteal phase progestagen & etamsylate)
• Is effective in treating menorrhagia associated with
IUCD.

49. Side effects
•Is dose related.
•GIT upset, dizziness.
•Rarely: - Transient color vision disturbance
- Intracranial thrombosis.
1. Antifibrinolytics

50. 2. Prostaglandin synthetase inhibitors (PSI)
Mefanemic acid
Mechanism of action: Antiprostaglandins
Effects:
• Decrease MBL by 24%
• The beneficial effect on other symptoms e.g.
dysmenorrhea, headache, nausea, diarrhea &
depression persists for several months.

51. Side effects
• GIT upset, dizziness.
• Rarely: hemolytic anemia, thrombocytopenia.
•The degree of reduction of MBL is not as great as
it is with tranxamic acid but PSI have a lower side
effect profile.
2. Prostaglandin synthetase inhibitors (PSI)

52. Mechanism of action: (Hemostatic)
Maintain capillary integrity, anti-hyalurunidase activity
& inhibitory effect on PGE2
Effect:
• Starting 5 days before anticipated onset of the
cycle & continued for 10 days
• 20% reduction in MBL.
Side effects
headache, rash, nausea
3. Etamsylate (Dicynone)

53. •Norethisteron
•medroxyprogesterone acetate
•Effect:
Effective if given at higher dose for 3 w out of 4 w (5 mg
tds from D5 to 26)
•Side effects:
weight gain, nausea, bloating, edema, headache, acne,
depression, exacerbation of epilepsy & migraine, loss of
libido
Systemic progestagens

54. Levonorgestrel intrauterine system
•levonova,Mirena: Delivers 20ug LNG /d. for 5 yr
•Metraplant: T shaped IUCD & levonorgestrel on
the shoulder & stem
Intrauterine progestagens

55. Effect
1. Decrease MBL by 80%-90%
2. Cost effective (used for 5 yrs)
2. May be an alternative to hysterectomy in some
patients
Special indications
1. Intractable bleeding associated with chronic
illness
2. Ovulatory heavy bleeding
Intrauterine progestagens

56. Side effects
1. Breakthrough bleeding in the first 3-4 cycles
2. 20% develop amenorrhea within 1 yr
Intrauterine progestagens

57. Mechanism of action:
Ovulation suppression
Effect
Reduce MBL by 50%
Side effects
headache, migraine, weight gain, breast tenderness,
nausea, cholestatic jaundice, hypertension,
thrombotic episodes
The combined contraceptive pill
COCP

58. synthetic androgen with antioestrogenic &
antiprogestagenic activity
Mechanism of action
Inhibits the release of pituitary Gn & has direct
suppressive effect on the endometrium
Effect
Reduction in MBL , amenorhea at doses >400 mg/d
Danazol

59. Side effects
headache, weight gain, acne, rashes, hirsuitism,
mood & voice changes, flushes, muscle spasm,
reduced HDL, diminished breast size. Rarely:
cholestatic jaundice.
It is effective in reducing blood loss but side effects
limit it to a second choice therapy or short term use
only

60. Injectable : SC, Monthly for 3-6 months
Side effects
hot flushes, sweats, headache, irritability,
loss of libido, vaginal dryness, lethargy,
reduced bone density.
GnRH analog

61. Surgical treatment
1. Endometrial ablation
Destruction of the basal layer of the endometrium
So little or no remaining endometrium can
regenerate

62. I.Hysteroscopic:
1. Laser
2. Electrosurgical
a.Roller ball
b.Resection
II.Non-hysteroscopic:
1. Thermal ut. balloon
2. Microwave.
3. Heated saline
Surgical treatment
1. Endometrial ablation
Methods:

63. Indications
1. Failure or contraindication of medical treatment
2. Family is completed
3. Uterine cavity <10 cm
4. Submucos fibroid <5 cm
5. Endometrium is normal or low risk hyperplasia.
1. Endometrial ablation

64. 2. Hysterectomy
Indications:
1. Failure of medical treatment
2. Failure of endometrial ablation
3. Family is completed
Routes:
1. Abdominal
2. Vaginal
3. Laparoscopic
Surgical treatment

65. Advantages
1. Complete cure
2. Avoidance of long term medical treatment
3. Removal of any missed pathology
Disadvantages
1. Major operation
2. Hospital admission
3. ↑ Mortality & morbidity
2. Hysterectomy