Warm Warm GreetingsGreetings

PESIMSR , PESIMSR , KuppamKuppam

By

Dr. L. Krishna Prof of OBGMedical Superintendent PESIMSR, Kuppam

Abnormal uterine bleeding Abnormal uterine bleeding

Organic Dysfunctional Organic Dysfunctional uterine uterine

cause bleedingcause bleeding

Definition of AUB Definition of AUB – Change in the – Change in the frequency of menstruation, duration frequency of menstruation, duration of flow or amount of blood lossof flow or amount of blood loss

Definition of DUB Definition of DUB – when systemic – when systemic or organic pelvic pathology has or organic pelvic pathology has been excludedbeen excluded

1/3 of all outpatient gynecologic visits 1/3 of all outpatient gynecologic visits Affects 50% of menstruating women Affects 50% of menstruating women

worldwide at some time worldwide at some time 4 out of 5 women with AUB have no 4 out of 5 women with AUB have no

anatomic pathologic condition anatomic pathologic condition Accounts for 50% of hysterectomiesAccounts for 50% of hysterectomies

Primary DUB:- Primary DUB:- Dysfunction in the hypothalamus Dysfunction in the hypothalamus pituitary, ovary and uteruspituitary, ovary and uterus

Secondary DUB :- Secondary DUB :- DUB secondary to –DUB secondary to – Bleeding disorders, hypothroidism, SLEBleeding disorders, hypothroidism, SLE Iatrogenic DUBIatrogenic DUB Use of IUCD Use of IUCD Use of sex hormones for contraceptionUse of sex hormones for contraception

Anovulatory:- 80 % Anovulatory:- 80 % Puberty menorrhagiaPuberty menorrhagia Metropathia haemorrhagicaMetropathia haemorrhagica Premenopausal DUBPremenopausal DUB

Ovulatory bleeding:- 20 %Ovulatory bleeding:- 20 % Irregular ripeningIrregular ripening Irregular shedding(Halbans syndrome)Irregular shedding(Halbans syndrome) IUCDIUCD Following sterilisation operationsFollowing sterilisation operations

Cyclical bleeding at normal Cyclical bleeding at normal intervals which is excessive in intervals which is excessive in amount /durationamount /duration

Loss of ≥ 80 mL blood per cycle orLoss of ≥ 80 mL blood per cycle or Bleeding > 7 daysBleeding > 7 days

Generally caused by conditions Generally caused by conditions affecting the affecting the uterus & it’s vascular uterus & it’s vascular

apparatusapparatus

Cyclical bleeding which is normal in Cyclical bleeding which is normal in amount but which occurs at amount but which occurs at frequent intervals of less than 21 frequent intervals of less than 21 days days

The error in cycle is the result of The error in cycle is the result of

disease or functional disturbance of disease or functional disturbance of the the OVARY OVARY

It is cyclical bleeding which is both It is cyclical bleeding which is both excessive and too frequent excessive and too frequent

It implies a disturbance in the It implies a disturbance in the hypothalamic-pitutary-ovarian-hypothalamic-pitutary-ovarian-uterine axis plus the uterus itself uterine axis plus the uterus itself and the endomeyriumand the endomeyrium,,

Pelvic infection and stress Pelvic infection and stress situationssituations

Hypomenorrhea:Hypomenorrhea:

Regularly timed but scanty episodes of bleedingRegularly timed but scanty episodes of bleeding

Hypogonadotropic Hypogonadis(athletes,anorexia)Hypogonadotropic Hypogonadis(athletes,anorexia)

Asherman’s syndromeAsherman’s syndrome

Oligomenorrhea:Oligomenorrhea: • Infrequent , irregularly timed episodes of bleeding Infrequent , irregularly timed episodes of bleeding

usually occuring at intervals of > 35 daysusually occuring at intervals of > 35 days

commonly caused by PCOS, Pregnancy and commonly caused by PCOS, Pregnancy and AnovulationAnovulation

Metrorrhagia:-Metrorrhagia:-

Irregularly timed episodes of bleeding Irregularly timed episodes of bleeding superimposed on normal cyclical superimposed on normal cyclical bleedingbleeding

Menometrorrhagia:-Menometrorrhagia:-

Excessive prolonged bleeding occuring atExcessive prolonged bleeding occuring at

irregularly timed and frequent intervalsirregularly timed and frequent intervals

Causes:- Causes:- InfectionInfection

Submucous fibroidSubmucous fibroid

ca. cervixca. cervix

Endometrial carcinomaEndometrial carcinoma

Vascular ectopy of cervixVascular ectopy of cervix

Cervical endometriosisCervical endometriosis

Amenorrhea: Amenorrhea: Absence of uterine bleeding for > 6 Absence of uterine bleeding for > 6

months / for 3 menstrual cyclesmonths / for 3 menstrual cycles

Postmenopausal bleeding: Postmenopausal bleeding: Uterine bleeding that occurs more than Uterine bleeding that occurs more than

1 year after the last menses in a woman 1 year after the last menses in a woman with ovarian failurewith ovarian failure

VASOCONSTRICTORS VASODILATORS

PGF2αTXA2 LEUKOTRIENES PGD2

PGE2PGI2

PGF2 α > PGE2>PGD2----NORMAL

PGE2>PGF2α>PGD2------AUB

Structural changes in the spiral arterioles and Structural changes in the spiral arterioles and venous sinuses of endometrium venous sinuses of endometrium

Abnormal vascularity of the endometriumAbnormal vascularity of the endometrium Delayed regeneration of endometriumDelayed regeneration of endometrium Excessive endometrial tissue necrosis by Excessive endometrial tissue necrosis by

hydrolytic enzymes from golgi-lysosomal hydrolytic enzymes from golgi-lysosomal complexcomplex

Deficient formation and release of endometrial Deficient formation and release of endometrial vasoconstrictor substancevasoconstrictor substance

How does anovulatory cycles cause AUB?How does anovulatory cycles cause AUB? Unopposed estrogen action – Unopposed estrogen action –

endometrial hyperplasia – fragile due to endometrial hyperplasia – fragile due to lack of progesterone which gives stromal lack of progesterone which gives stromal support and maintain stability – focal support and maintain stability – focal areas breakdown and bleed – these areas areas breakdown and bleed – these areas heal under the effect of estrogen – heal under the effect of estrogen – irregular shedding of endometrium – irregular shedding of endometrium – heavy and prolonged bleedingheavy and prolonged bleeding

How does ovulatory cycles cause AUB?How does ovulatory cycles cause AUB?

Ovulatory DUB – cause not well defined – Ovulatory DUB – cause not well defined – change in endometrial hemostasis – change in endometrial hemostasis – alteration in the synthesis and release of alteration in the synthesis and release of PGs (decreased PGF2a and increased PGs (decreased PGF2a and increased PGE2)PGE2)

Hereditary ( 70 %) Acquired

Von willebrand diseaseGlanzmann’s defectBernard soulier syndromeClotting factor deficiencies- 2,5,7,10,11

Acquired hemophiliaITPSLELiver cell dysfunctionAnti coagulants

Accounts – 10- 20 %

Superficial ulceration of the endometriumSuperficial ulceration of the endometrium Increased vascularity and interstitial red cell Increased vascularity and interstitial red cell

extravasationextravasation High levels of plasminogen activators and High levels of plasminogen activators and

fibrinolytic activity in the endometriumfibrinolytic activity in the endometrium Increased number of heparin producing mast Increased number of heparin producing mast

cellscells Increased leucocytic infiltration of the Increased leucocytic infiltration of the

endometrium which produce leukotrienes endometrium which produce leukotrienes Delayed regeneration of endometriumDelayed regeneration of endometrium

How does endometritis cause AUB?How does endometritis cause AUB? Inflammatory cells produce proteolytic Inflammatory cells produce proteolytic

enzymes – delay normal healing and enzymes – delay normal healing and damage the endometrium – makes it damage the endometrium – makes it fragile and erosivefragile and erosive

Inflammatory cells release PGs and PAF Inflammatory cells release PGs and PAF which are vasodilatorswhich are vasodilators

Incidence -4 %Incidence -4 % Immaturitiy of HPO axis & Immaturitiy of HPO axis &

inadequate positive feedback inadequate positive feedback mechanismmechanism

40 % - 50 % resolve in -2 years40 % - 50 % resolve in -2 years 70 % - 80 % resolve in -10 years70 % - 80 % resolve in -10 years

Anovulation (Puberty menorrhagia)Anovulation (Puberty menorrhagia) Exogenous Hormone use( COCs)Exogenous Hormone use( COCs) Pregnancy complicationsPregnancy complications CoagulopathyCoagulopathy Genital tuberculosisGenital tuberculosis Thyroid disordersThyroid disorders

Genital tuberculosisGenital tuberculosis – menorrhagia in 19% – menorrhagia in 19% of patientsof patients

Fever cough, night sweats, chest pain, Fever cough, night sweats, chest pain, family H/O TBfamily H/O TB

Coagulation disorders Coagulation disorders – accounts for 30%– accounts for 30%

Family history ,frequent epistaxis,bleeding Family history ,frequent epistaxis,bleeding with tooth brushing,excessive bleeding with tooth brushing,excessive bleeding following minor surgery eg,tooth extractionfollowing minor surgery eg,tooth extraction

Hypothyroidism-Hypothyroidism-fatigue,weakness,pedal fatigue,weakness,pedal edema,weight gain,constipation, edema,weight gain,constipation, excessive sleepiness,mental slowingexcessive sleepiness,mental slowing

Systemic illness Systemic illness – leukemia, – leukemia, anticoagulant therapy and anticoagulant therapy and injudicious use of hormonesinjudicious use of hormones

Pallor Pallor LymphadenopathyLymphadenopathy ThyromegalyThyromegaly PetechiaePetechiae SpleenomegalySpleenomegaly Abdominopelvic mass (P/A & Abdominopelvic mass (P/A &

P/R)P/R)

UPTUPT Complete hemogramComplete hemogram Coagulation profileCoagulation profile Mantoux test, chest X rayMantoux test, chest X ray Thyroid function testThyroid function test Abdomino pelvic USGAbdomino pelvic USG

Menstrual blood for TB PCRMenstrual blood for TB PCR Special haematological investigationsSpecial haematological investigations BM aspirationBM aspiration vWD antigen assayvWD antigen assay vWD ristocetin cofactor activityvWD ristocetin cofactor activity F VIII coagulant activityF VIII coagulant activity Factor assay (VIIII and IX)Factor assay (VIIII and IX) Platelet function studyPlatelet function study

Anovulatory dysfunctional bleeding Anovulatory dysfunctional bleeding

as UPT is negative, investigations for as UPT is negative, investigations for coagulation disorders, tuberculosis coagulation disorders, tuberculosis and thyroid function are normaland thyroid function are normal

Treat anaemiaTreat anaemia Nonhormonal therapyNonhormonal therapy Cyclical progesterone for Cyclical progesterone for

anovulatory bleeding anovulatory bleeding Cyclical OCP for ovulatory cycles for Cyclical OCP for ovulatory cycles for

3-6 cycles3-6 cycles

Complications of PregnancyComplications of Pregnancy Anovulatory bleedingAnovulatory bleeding Focal Uterine lesions( Fibroids, polyps, Focal Uterine lesions( Fibroids, polyps,

adenomyosis)adenomyosis) Diffuse uterine lesions ( Endometrial Diffuse uterine lesions ( Endometrial

hyperplasia and Ca)hyperplasia and Ca) Pelvic Inflammatory Disease(Infections)Pelvic Inflammatory Disease(Infections) Mullerian abnormalitiesMullerian abnormalities IUCD complicationsIUCD complications

Postcoital bleeding – cervical polyp, Postcoital bleeding – cervical polyp, fibroid, ectropion, ca cervixfibroid, ectropion, ca cervix

Intermenstrual bleeding – Intermenstrual bleeding – endometrial polyp or submucous endometrial polyp or submucous fibroidfibroid

PID – pain abdomen, discharge per PID – pain abdomen, discharge per vaginavagina

Hypothyroidism Hypothyroidism

Endometriosis – Endometriosis – dysmenorrhea,dyspareunia, dysmenorrhea,dyspareunia, dyschezia,dysuria,infertility dyschezia,dysuria,infertility

IUCDIUCD Hormonal intake (herbal remedy)Hormonal intake (herbal remedy) Bleeding disorderBleeding disorder

Metropathia Haemorrhagica Metropathia Haemorrhagica (schroder’s disease)(schroder’s disease)

Specialised form of DUBSpecialised form of DUB Age > 40 yearsAge > 40 years

Why bleeding is heavy in CGH?Why bleeding is heavy in CGH? Prolonged estrogen stimulation – proliferation Prolonged estrogen stimulation – proliferation

of glandular epithelium – threshold bleedingof glandular epithelium – threshold bleeding No progesterone – no relaxin – bleeding is due No progesterone – no relaxin – bleeding is due

to haemorrhagic necrosis and not due by to haemorrhagic necrosis and not due by dissolution of reticulum fibres – abnormal dissolution of reticulum fibres – abnormal vascular bed and hyperplastic glandular tissuevascular bed and hyperplastic glandular tissue

Cysitc ovaries secrete more estrogenCysitc ovaries secrete more estrogen Estrogen stimulates fibrinolytic activityEstrogen stimulates fibrinolytic activity Estrogen stimulates proteolytic enzymes – no Estrogen stimulates proteolytic enzymes – no

coagulation and shedding takes place slowlycoagulation and shedding takes place slowly

40% of women with blood loss >80cc considered 40% of women with blood loss >80cc considered their flow to be small or moderatetheir flow to be small or moderate

14% of women with <20cc loss thought their 14% of women with <20cc loss thought their flow was heavy flow was heavy ((Hallberg, et al., 1966)Hallberg, et al., 1966)

One third of light menses were actually >80cc and One third of light menses were actually >80cc and one-half of those believed to be heavy were <80ccone-half of those believed to be heavy were <80cc

(Chimbira, (Chimbira, et alet al., 1980)., 1980)

Does not reflect the actual blood lossDoes not reflect the actual blood loss Changing pads every 1-2 hChanging pads every 1-2 h Changing pads at night (> 1)Changing pads at night (> 1) Passage of moderate - large blood clotsPassage of moderate - large blood clots Tiredness, fatigue or shortness of breath Tiredness, fatigue or shortness of breath

(symptoms of anemia)(symptoms of anemia) Heavy menstrual flow that interferes Heavy menstrual flow that interferes

with regular lifestylewith regular lifestyle

50% of excessive menstruation have normal 50% of excessive menstruation have normal amount of blood loss by objective methodsamount of blood loss by objective methods

Objective:Objective: Iron deficiency anemiaIron deficiency anemia Menstrual calendarMenstrual calendar Admission & pad assessmentAdmission & pad assessment Pictorial blood loss chartPictorial blood loss chart

> 25 pads/ > 30 tampons during period

Risk of iron deficient anemia:Risk of iron deficient anemia:When menstrual loss exceeds When menstrual loss exceeds 8080mlml

Saturday 7 14 21 28Sunday 1 8 15 22 29Monday 2 9 16 23 30Tuesday 3 10 17 24 31Wednesday 4 11 18 25Thursday 5 12 19 26Friday 6 13 20 27 . Spotting - Slight loss O Moderate loss Very heavy loss

Menstrual calendarMenstrual calendar

Pad Pad

1 point1 point

5 points5 points

20 points20 points

1p clot 1p clot 1 point1 point5p clot 5p clot 5 points5 pointsFlooding 25 pointsFlooding 25 points

Score >100 = MenorrhagiaScore >100 = Menorrhagia

Days of bleeding ScoreDays of bleeding Score1 2 3 4 5 6 7 81 2 3 4 5 6 7 8

Pictoral blood loss chart (Higham, 1990)Pictoral blood loss chart (Higham, 1990)

Methods Points Degree of staining

Towels 1 Lightly stained

5 Moderately soiled

20 Completely saturated

Tampoon 1 Lightly stained

5 Moderately soiled

10 Completely saturated

Clots 1 Small clot

5 Large clot

Hallberg And Nilsson Method of Alkali Hematin Hallberg And Nilsson Method of Alkali Hematin MethodMethod

Menstrual Pads + 5% NaOH Solution OvernightMenstrual Pads + 5% NaOH Solution Overnight

Alkali Hematin Alkali Hematin

Blood loss is then calucated by Spectrophotometric Blood loss is then calucated by Spectrophotometric analysis of the fluidanalysis of the fluid

Radioisotope labelling of Rbcs and measuring them Radioisotope labelling of Rbcs and measuring them In sanitary padsIn sanitary pads

OC Pills: OC Pills: 1qid for 4d ,1 tds for 3 d, 1 bd for 2 1qid for 4d ,1 tds for 3 d, 1 bd for 2 d, 1 OD for 21 dd, 1 OD for 21 d

MPA:MPA: 20-30 mg/d, 20-30 mg/d, once bleeding stops10 mg / d for 21 daysonce bleeding stops10 mg / d for 21 days Estrogen :Estrogen :IV oestrogen therapy-25mg IV oestrogen therapy-25mg

conjugated equine oestrogen orconjugated equine oestrogen or 1.25 mg conjugated oestrogen /2mg 1.25 mg conjugated oestrogen /2mg

micronised estradiol every 4micronised estradiol every 4thth-6-6thth hrly hrly until bleeding stops/24 hrs , followed by until bleeding stops/24 hrs , followed by

maintainance therapy for 7-10 daysmaintainance therapy for 7-10 days Tranexamic acid : Tranexamic acid : 1 gm QID 1 gm QID

Special investigation (NICE Special investigation (NICE guideline)guideline)

Coagulation disorder – AUB since Coagulation disorder – AUB since menarche(vWD), personal or family menarche(vWD), personal or family historyhistory

Thyroid testing – only if signs and Thyroid testing – only if signs and symptoms are presentsymptoms are present

Samples only 40% of endometriumSamples only 40% of endometrium Sensitivity of detecting intrauterine Sensitivity of detecting intrauterine

pathology: only 65%pathology: only 65% D&C < 35 yr: NNT is 3000 - 4000 to detect D&C < 35 yr: NNT is 3000 - 4000 to detect

one Endometrial CAone Endometrial CA Good TVS excludes intrauterine disease –Good TVS excludes intrauterine disease – role of D & C is questionedrole of D & C is questioned Arrests bleeding (if severe/ persistent) Arrests bleeding (if severe/ persistent)

Dilatation & curettage (D & C)Dilatation & curettage (D & C)

Differential DiagnosisDifferential Diagnosis

Uterine fibroidUterine fibroid

AdenomyosisAdenomyosis

Uterine malignancyUterine malignancy

DUB DUB

Not practical or cost effective to do every Not practical or cost effective to do every testtest

Selection should be tailored to suspected Selection should be tailored to suspected causes from history & physical causes from history & physical examinationexamination

Stepwise process consideredStepwise process considered

TestsTests

Dilatation and curettage Dilatation and curettage – invasive,blind – – invasive,blind – 60% will have less than half of the uterine 60% will have less than half of the uterine cavity curettedcavity curetted

Office endometrial aspiration biopsy Office endometrial aspiration biopsy – – Karman cannula,Pipelle, Vabra aspirator – Karman cannula,Pipelle, Vabra aspirator – 90% sensitive 100% specific – less painful90% sensitive 100% specific – less painful

Hysteroscopic directed biopsy Hysteroscopic directed biopsy – 90 to 97 % – 90 to 97 % sensitive 60 to 97% specific – gold standard sensitive 60 to 97% specific – gold standard – expensive, needs special training– expensive, needs special training

AUB >45 yrsAUB >45 yrs Not responding to medical therapyNot responding to medical therapy Persistent intermenstrual bleedingPersistent intermenstrual bleeding With other risk factors for endometrial CAWith other risk factors for endometrial CA Obese adolescents after 2-3 yrs of Obese adolescents after 2-3 yrs of

anovulatory bleedinganovulatory bleeding Abnormal endometrial morphology on Abnormal endometrial morphology on

USG / ET >12mm in premenopausal womenUSG / ET >12mm in premenopausal women

Pipelle curette

AccuretAccurettete

Method of choiceMethod of choiceIndications: Indications: Erratic menstrual bleedingErratic menstrual bleeding Failed medical treatmentFailed medical treatment Suspected intrauterine pathology Suspected intrauterine pathology

Hysteroscopic Hysteroscopic endometrial biopsyendometrial biopsy

Endometrial histology Percentage

Normal endometrium 50%

Endometrial hyperplasia 30-35%

Irregular shedding 10%

Irregular ripening 3-4%

Atrophic endometrium 3-4%

Chronic endometritis 1-2%

Type of endometrial hyperplasia

Malignant potential

Simple hyperplasia without atypia

1%

Simple hyperplasia with atypia

3%

Complex hyperplasia without atypia

8%

Complex hyperplasia with atypia

29%

Non HormonalNon Hormonal

Prostaglandin synthetase Prostaglandin synthetase inhibitors(NSAIDS)inhibitors(NSAIDS)

AntifibrinolyticsAntifibrinolytics

ProgestogensProgestogens Progesterone IUSProgesterone IUS Injectable progesterone : DMPAInjectable progesterone : DMPA OCPsOCPs OestrogenOestrogen DanazolDanazol GnRH analoguesGnRH analogues

SERMSSERMS

Mechanism of action-Mechanism of action- Inhibits prostaglandin synthesisInhibits prostaglandin synthesis Alters balance between thromboxane Alters balance between thromboxane

A2 and prostacyclin (PGI2 )A2 and prostacyclin (PGI2 ) Direct inhibitory effect of fenamates Direct inhibitory effect of fenamates

on PGE receptor bindingon PGE receptor binding

Plasminogen Plasminogen Plasminogen Plasminogen →→ ↓ ↓

activator Plasmin activator Plasmin Plasminogen Plasminogen inhibitor inhibitor ↓↓

Metalloproteinase Metalloproteinase familyfamily ↓ ↓ Matrix degradationMatrix degradation

Nonhormonal methods Nonhormonal methods First line of drug First line of drug NSAIDs(efficacy 20-30%)NSAIDs(efficacy 20-30%) Tranexamic acid (reduces blood loss by Tranexamic acid (reduces blood loss by

50%)50%)

Halts endometrial growth and Halts endometrial growth and

allows for an organised sloughing of allows for an organised sloughing of endometriumendometrium

PGF2a/PGE increasedPGF2a/PGE increased

Inhibits DNA synthesis and cell Inhibits DNA synthesis and cell proliferationproliferation

Stimulates 17Stimulates 17 -hydroxysteroid β-hydroxysteroid βdehydrogenase and sulfotransferase dehydrogenase and sulfotransferase activity,which convert oestradiol to activity,which convert oestradiol to oestrone sulfate.oestrone sulfate.

Inhibits oestrogen receptorsInhibits oestrogen receptors Suppresses oestrogen mediated Suppresses oestrogen mediated

transcription of oncogenestranscription of oncogenes

Maturation of endometriumMaturation of endometrium Healing of superficial breaksHealing of superficial breaks Enhancement of the stromal matrix with Enhancement of the stromal matrix with

increased structural stability and increased structural stability and cessation of bleedingcessation of bleeding

( ( MEDICAL CURETTAGE MEDICAL CURETTAGE – arrest of severe – arrest of severe bleeding with high doses of bleeding with high doses of progestogens)progestogens)

Anovulatory cycle -Anovulatory cycle - Cyclical progestins ––MPA 10mg Cyclical progestins ––MPA 10mg

OD for 15 days 3 cyclesOD for 15 days 3 cycles

Endometrial hyperplasia & ovulatory DUB Endometrial hyperplasia & ovulatory DUB – 21 days – 21 days

6 cycles6 cycles

Who cannot tolerate heavy withdrawal bleeding and Who cannot tolerate heavy withdrawal bleeding and

are anaemic are anaemic - Continuous progestins - Continuous progestins

Reduction in the blood loss :40-50%Reduction in the blood loss :40-50%

If menses does not follow progestin If menses does not follow progestin withdrawalwithdrawal

↓↓

Profound ovulatory dysfunction associated Profound ovulatory dysfunction associated with grossly low oestrogen levelwith grossly low oestrogen level

Failed progestin treatment requires further Failed progestin treatment requires further diagnostic evaluationdiagnostic evaluation

Mirena – Mirena –

LNG-52mg-20mcg/d-5yrs- LNG-52mg-20mcg/d-5yrs- effective in both ovulatory effective in both ovulatory and anovulatory bleeding – and anovulatory bleeding – 94% reduced blood loss in 3 94% reduced blood loss in 3 mths – decidualisation of mths – decidualisation of stroma and atrophy of glandsstroma and atrophy of glands

Efficacy of Mirena:Efficacy of Mirena:

- - MBL reduction : 90%-95%MBL reduction : 90%-95%

- Amenorrhoea : 20% at 1 yr- Amenorrhoea : 20% at 1 yr

-Cancelled hysterectomy-64%-Cancelled hysterectomy-64%

DMPA : 150mg IM / 3monthsDMPA : 150mg IM / 3months Initially - irregular bleedingInitially - irregular bleeding

Prolonged use-amenorrhoea (40-50%)Prolonged use-amenorrhoea (40-50%)

Useful maintenance therapy in whom OC pills Useful maintenance therapy in whom OC pills are contraindicated, and those who are not are contraindicated, and those who are not compliantcompliant

Mechanism of action-Mechanism of action-

Induces endometrial atrophyInduces endometrial atrophy

Indication-Indication-

Prolonged episodes of heavy bleeding Prolonged episodes of heavy bleeding

ovulatory DUBovulatory DUB

Dosage-Dosage- 3-4 tab till bleeding stops, BD 3days,OD till 3-4 tab till bleeding stops, BD 3days,OD till

pack finishespack finishes When OCs cannot be used-Progestins can be When OCs cannot be used-Progestins can be

given in higher dosesgiven in higher doses

For eg.-MPA-20mg dailyFor eg.-MPA-20mg daily If treatment fails further evaluation is If treatment fails further evaluation is

neededneeded

Advantages-Advantages-

Effectiveness to reduce heavy menstrual bleedingEffectiveness to reduce heavy menstrual bleeding

Predictability Predictability

Contraceptive effectContraceptive effect

Reduced withdrawal bleeding episodesReduced withdrawal bleeding episodes

Reduces dysmenorrhoeaReduces dysmenorrhoea

MBL reduction : 50% MBL reduction : 50%

Mechanism of action-Mechanism of action- Promotes rapid endometrial growth to Promotes rapid endometrial growth to

cover denuded endometrial surfacescover denuded endometrial surfaces Causes vasospasm of uterine arteries Causes vasospasm of uterine arteries

and initiates coagulation related and initiates coagulation related functions which decreases uterine functions which decreases uterine bleedingbleeding

Indications-Indications- Acute heavy bleeding episodesAcute heavy bleeding episodes Progesterone breakthrough bleedingProgesterone breakthrough bleeding

For best results-For best results- Therapy should be f/b treatment with Therapy should be f/b treatment with

progestins or OC pills to stabilize the progestins or OC pills to stabilize the oestrogen stimulated endometrial oestrogen stimulated endometrial growthgrowth

Mechanism of actionMechanism of action

Competes with oestradiol for binding with Competes with oestradiol for binding with

receptors receptors

Prolonged depletion of receptors and has Prolonged depletion of receptors and has

long-lasting post withdrawal effectlong-lasting post withdrawal effect

Drug-Drug- OrmeloxifeneOrmeloxifene

Prevents bone lossPrevents bone loss Cardioprotective Cardioprotective Relief of PMSRelief of PMS ContraceptionContraception Reduces risk of breast cancerReduces risk of breast cancer No risk of uterine cancerNo risk of uterine cancer

Dose : Dose : 60 mg.twice a wk. for 12 wks60 mg.twice a wk. for 12 wks..

60 mg.once a wk. for 12 wks.60 mg.once a wk. for 12 wks.

Side effects:Side effects: Delay in menstrual cycleDelay in menstrual cycle Ovarian cystOvarian cyst

Endometrial ablationEndometrial ablation

Endometrial destruction by application of various forms of energy directly to the endometrium

Menorrhagia resistant to medical Menorrhagia resistant to medical therapytherapy

Uterus Uterus 12 wks or uterine cavity 12 wks or uterine cavity << 10 cms10 cms

Endometrial histology – normal \ low Endometrial histology – normal \ low riskrisk

Completed familyCompleted family CounsellingCounselling

Acute PIDAcute PID Abnormal pap smearAbnormal pap smear Malignant pathologyMalignant pathology History of gynecologic malignancy in past 5yrsHistory of gynecologic malignancy in past 5yrs Intramural fibroidIntramural fibroid Previous endometrial ablation procedurePrevious endometrial ablation procedure PregnancyPregnancy Desire for future fertilityDesire for future fertility

Methods:Methods: GnRH analogues (most preferred)GnRH analogues (most preferred) DanazolDanazol ProgesteronesProgesterones

Advantage:Advantage: ↓↓ OT timeOT time ↓↓ Blood lossBlood loss ↓↓ Absorption of distending mediaAbsorption of distending media Better intraoperative environmentBetter intraoperative environment Higher rate of post-op amenorrheaHigher rate of post-op amenorrhea

11stst generation generation--

Hysteroscopic Laser Ablation (HLA)Hysteroscopic Laser Ablation (HLA) Transcervical Resection of Endometrium Transcervical Resection of Endometrium

(TCRE)(TCRE) Rollerball Endometrial AblationRollerball Endometrial Ablation

TCRE reduces failure rate when adenomyosis is TCRE reduces failure rate when adenomyosis is present?present?

Superficial resection of myometriumSuperficial resection of myometrium

Endometrial electrosurgical vaporisation ?Endometrial electrosurgical vaporisation ? Large electrode with multiple edges or elevators – Large electrode with multiple edges or elevators –

generate current – vaporisation of endometriumgenerate current – vaporisation of endometrium

Fluid deficit Fluid deficit 1000ml – measure S.Na+ & give 1000ml – measure S.Na+ & give frusemidefrusemide

Fluid deficit 2000ml & S.Na+125 – stop the Fluid deficit 2000ml & S.Na+125 – stop the procedureprocedure

Why Nd:YAG is preferred?Why Nd:YAG is preferred? Cooking laser – better hemostasisCooking laser – better hemostasis Can be delivered through 0.6mm fibre Can be delivered through 0.6mm fibre

inserted through operative channel of inserted through operative channel of hysteroscopehysteroscope

Distension medium when Nd:YAG laser is Distension medium when Nd:YAG laser is used?used?

Low viscosity sodium containing fluidLow viscosity sodium containing fluid CO2CO2

Two ways of endometrial ablation?Two ways of endometrial ablation? Direct contact with tissue (Dragging)Direct contact with tissue (Dragging) Non touch technique (Blanching)Non touch technique (Blanching)

Anterior wall followed by rest of the Anterior wall followed by rest of the uterine cavity is ablated?uterine cavity is ablated?

Debris and bubbles float up and obscure Debris and bubbles float up and obscure anterior wallanterior wall

Argon laser?Argon laser? Photocoagulator but very superficialPhotocoagulator but very superficial

KTP/532 laser?KTP/532 laser? Not a coagulator and superficialNot a coagulator and superficial

CO2 laser?CO2 laser? Beam is assorted by water – no liquid Beam is assorted by water – no liquid

distension mediumdistension medium

Fluid Balloon – Cavaterm, Thermachoice. Fluid Balloon – Cavaterm, Thermachoice.

Hydrothermal ablator,Enabl system Hydrothermal ablator,Enabl system

Microwave – MEAMicrowave – MEA

Cryotherapy – Cryogen, HerchoiceCryotherapy – Cryogen, Herchoice

Electrode : Mesh – Vesta ( triangular silicon Electrode : Mesh – Vesta ( triangular silicon inflatable electrode carrier) inflatable electrode carrier)

Balloon – Novasure (three Balloon – Novasure (three dimensional fan shaped expandable dimensional fan shaped expandable bipolar ablation)bipolar ablation)

Unipolar electrodeUnipolar electrode Insterstitial Laser : ELITTInsterstitial Laser : ELITT Photodynamic therapyPhotodynamic therapy Radiofrequency probeRadiofrequency probe Diode LaserDiode Laser

Advantage:Advantage: Do not require hysteroscopy – less skill requiredDo not require hysteroscopy – less skill required Lesser complications (e.g. fluid overload, Lesser complications (e.g. fluid overload,

hemorrhage)hemorrhage) ↓↓ OT timeOT time ↓↓ Need for GANeed for GA

Disadvantage:Disadvantage: Blind procedures – direct visualization of Blind procedures – direct visualization of

endometrium & detection of abnormal pathology endometrium & detection of abnormal pathology not possiblenot possible

System Thermachoice Cavaterm

Balloon Latex Silicone

Thermal

source

Hot 5% Dextrose

Hot glycine

Catheter diameter

4.5mm 8mm

(dilatation

required)

Rx time 8 min 15 min

Postablation tubal sterilisation Postablation tubal sterilisation syndrome?syndrome?

Previous tubal sterilisation – Previous tubal sterilisation – regeneration of endometrium in cornual regeneration of endometrium in cornual area – blood flows back into the proximal area – blood flows back into the proximal portion of tube due to extensive scarring portion of tube due to extensive scarring of LUS – proximal haematosalpinx causes of LUS – proximal haematosalpinx causes symptoms similar to those of an ectopic symptoms similar to those of an ectopic pregnancypregnancy

Extensively evaluatedExtensively evaluated Utilizes 9.24Hz microwave frequencyUtilizes 9.24Hz microwave frequency Meantime – 132 secsMeantime – 132 secs Complication rate is 0.7/1000Complication rate is 0.7/1000 Success rate is 90%Success rate is 90% Previous LSCS –Previous LSCS –

scar thickness >8mmscar thickness >8mm

USG guided procedure:USG guided procedure: Cryogen system:Cryogen system:

5.5mm cryoprobe tip5.5mm cryoprobe tip Probe surface temp -90 to110Probe surface temp -90 to110ooCC Mean time: 8-10minMean time: 8-10min Complication – earlier reports of uterine Complication – earlier reports of uterine

abscessabscess Depth 9-12mmDepth 9-12mm

Soprano system:Soprano system: Ongoing phase III trialOngoing phase III trial Adv:Cryotip 3mm, Adv:Cryotip 3mm, Probe surface temp. –70Probe surface temp. –70ooCC

Principle : Free flowing normal saline at 80-Principle : Free flowing normal saline at 80-9090ooC instilled into uterine cavityC instilled into uterine cavity

Mean time – 10 minMean time – 10 min Advantages:Advantages:

Useful for irregular uterine cavityUseful for irregular uterine cavity Cheaper: no balloon requiredCheaper: no balloon required

Photosensitising agent – 5-Photosensitising agent – 5-Aminolevulenic acid / photophrin II Aminolevulenic acid / photophrin II + monochromatic light - resulting + monochromatic light - resulting photosensitiser molecule reacts photosensitiser molecule reacts with tissue oxygen – produce single with tissue oxygen – produce single oxygen molecule that is cytotoxic – oxygen molecule that is cytotoxic – produce local tissue necrosisproduce local tissue necrosis

Device Pre-

treatment

Hysteroscopy Rx time

(min)

FDA approval

Thermachoice No 8-12

Hydrothermal ablation

Yes 12

First option (Cryogen)

No (USG required) 10-20

MEA No 3/unknown Investiga-tional

ELITT No 7/unknown Investiga-tional

Novasure system No No 1.5/5

Obstet Gynecol Survery, 2003

Reduced bleeding 80-90%Reduced bleeding 80-90% Amenorrhoea 25-50%Amenorrhoea 25-50% Reduced menstrual pain 70-80%Reduced menstrual pain 70-80% Satisfaction 75-90%Satisfaction 75-90% No additional therapy 80%No additional therapy 80%

(surgery) up to 5yrs(surgery) up to 5yrs

Surgical option is more effective in treatment Surgical option is more effective in treatment of menorrhagia compared to medical therapyof menorrhagia compared to medical therapy

(Grade B)(Grade B)

LNG-IUS is a reasonable alternative to surgical LNG-IUS is a reasonable alternative to surgical therapy provided patients are aware of therapy provided patients are aware of possible need for further surgical treatment possible need for further surgical treatment

(Grade B)(Grade B)

While D &C may have a diagnostic role,it is not While D &C may have a diagnostic role,it is not effective therapy for women with menorrhagiaeffective therapy for women with menorrhagia

(Grade A)(Grade A)

Endometrial destruction procedure provides an Endometrial destruction procedure provides an alternative treatment option to hysterectomyalternative treatment option to hysterectomy

Women undertaking endometrial destruction Women undertaking endometrial destruction procedure must be aware that one third of them procedure must be aware that one third of them may need hysterectomy latermay need hysterectomy later

Surgeon must be well-trained and aware of Surgeon must be well-trained and aware of the limitations of each procedurethe limitations of each procedure

The operating time is longer when LAVH is The operating time is longer when LAVH is compared to VH but recovery period was compared to VH but recovery period was similar.The cost of LAVH is likely to be similar.The cost of LAVH is likely to be doubled when compared to VHdoubled when compared to VH

(Grade B) (Grade B)

Thin pedicle Thin pedicle – avulsion– avulsion

Broad pedicle and can be reached Broad pedicle and can be reached – –

clamp pedicle and cutclamp pedicle and cut

Broad pedicle but cannot be reached Broad pedicle but cannot be reached – –

enucleation followed by transfixation of enucleation followed by transfixation of

the pediclethe pedicle

Indications Indications Other treatment options have failed/ Other treatment options have failed/

contrindicated/declined by womencontrindicated/declined by women

CounsellingCounselling Major risks:Major risks: Bladder/ureter injury – 7/1000Bladder/ureter injury – 7/1000 Bowel injury – 4/10000Bowel injury – 4/10000

Haemorrhage requiring blood transfusion – Haemorrhage requiring blood transfusion –

23/100023/1000

Bleeding /wound dehiscence – 7/1000Bleeding /wound dehiscence – 7/1000

Pelvic abcess/infection – 2/1000Pelvic abcess/infection – 2/1000

Venous thrombosis or pulmonay embolism – Venous thrombosis or pulmonay embolism –

4/10004/1000

Mortality within 6 weks – 32/100000 (pulmonary Mortality within 6 weks – 32/100000 (pulmonary

embolism, cardiac disease)embolism, cardiac disease)

Frequent risksFrequent risks

Wound infection,pain,bruising,delayed wound Wound infection,pain,bruising,delayed wound

healing,keloid formationhealing,keloid formation

Numbness,tingling or burning sensation Numbness,tingling or burning sensation

around the scararound the scar

UTIUTI

Ovarian failareOvarian failare

Atrophic endometriumAtrophic endometrium

Endometrial carcinomaEndometrial carcinoma

Exogenous hormonesExogenous hormones

ET <4mm (Specificity 60%, PPV 25%, NPV 100%)ET <4mm (Specificity 60%, PPV 25%, NPV 100%)

Gull, et al., 2003Gull, et al., 2003

ET 4-8mm in women on cyclic HRT and about ET 4-8mm in women on cyclic HRT and about 5mm if they are receiving combined HRT5mm if they are receiving combined HRT

Good, 1997Good, 1997