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Women’s H ealth

Women’s H ealth. Dr.Jameela Al-Qahtani Obstetrician and Gynecologist Kuwaiti Board Maternity H ospital. Abnormal uterine bleeding. Abnormal uterine bleeding. Abnormal uterine bleeding is a term which refers to menstrual bleeding of abnormal quantity, duration, or schedule )

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Women’s H ealth

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  1. Women’s Health Dr.Jameela Al-Qahtani Obstetrician and Gynecologist Kuwaiti Board Maternity Hospital

  2. Abnormal uterine bleeding

  3. Abnormal uterine bleeding • Abnormal uterine bleeding is a term which refers to menstrual bleeding of abnormal quantity, duration, or schedule) • A common gynecologic complaint, accounting for one-third of outpatient visits to gynecologists 

  4. Abnormal uterine bleeding • Can be caused by a wide variety of local and systemic diseases or related to medications • FIGO classification system for causes of abnormal uterine bleeding (PALM-COEIN)

  5. Abnormal uterine bleeding

  6. Abnormal uterine bleeding PALM-COEIN Polyp

  7. Abnormal uterine bleedingEndometrial polyp • Endometrial polyps are one of the most common etiologies of abnormal genital bleeding in both premenopausal and postmenopausal women • They are hyperplastic overgrowths of endometrial glands and stroma that form a projection from the surface of the endometrium (lining of the uterus) • They may also be asymptomatic • The great majority of endometrial polyps are benign, but malignancy occurs in some women 

  8. Abnormal uterine bleeding Endometrial polyp

  9. Abnormal uterine bleeding Endometrial polyp

  10. Abnormal uterine bleeding Endometrial polyp

  11. Abnormal uterine bleeding Endometrial polyp

  12. Abnormal uterine bleeding PALM-COEIN Adenomyosis

  13. Abnormal uterine bleedingAdenomyosis • It is a disorder in which endometrial glands and stroma are present within the myometrium (uterine musculature) • Women with symptomatic adenomyosis present with uterine enlargement, abnormal uterine bleeding, and painful menses

  14. Abnormal uterine bleedingAdenomyosis

  15. Abnormal uterine bleedingAdenomyosis

  16. Abnormal uterine bleedingAdenomyosis • Heavy menstrual bleeding and dysmenorrhea are the typical symptoms of adenomyosis, occurring in approximately 60 and 25 percent of women, respectively • Chronic pelvic pain may also occur • Heavy menstrual bleeding is possibly related to the increased endometrial surface of the enlarged uterus, while pain may be due to bleeding and swelling of endometrial islands confined by myometrium • Approximately one-third of women are asymptomatic

  17. Abnormal uterine bleedingAdenomyosis • Symptoms are typically reported to develop between the ages of 40 and 50 years; however, this may reflect the fact that most adenomyosis has historically been diagnosed at hysterectomy, and younger women are less likely to undergo definitive reproductive surgery

  18. Abnormal uterine bleedingAdenomyosis • History:Heavy menstrual bleeding or pelvic pain should be included. • Pelvic examination: The bimanual pelvic examination in women with adenomyosis typically shows a mobile, diffusely enlarged (often referred to as "globular" enlargement), soft (often referred to as "boggy"), and globular uterus

  19. Abnormal uterine bleedingAdenomyosis • Transvaginal ultrasound

  20. Abnormal uterine bleedingAdenomyosis • MRI

  21. Abnormal uterine bleedingAdenomyosis- Management • Hysterectomy: Total hysterectomy is the definite treatment of adenomyosis • Hormonal medications: Hormonal treatment may be effective for reducing heavy menstrual bleeding and dysmenorrhea • Uterus-conserving procedures: • Uterine artery embolization • Uterus-sparing resection

  22. Abnormal uterine bleeding PALM-COEIN Leiomyoma

  23. Abnormal uterine bleedingLeiomyoma • Leiomyomas of the uterus (also referred to as myomas or uterine fibroids) are benign neoplasms of smooth muscle of the myometrium

  24. Abnormal uterine bleedingLeiomyoma • Risk Factors: • Race • Parity • Early menarche • Hormonal contraception • Obesity • Diet

  25. Abnormal uterine bleedingLeiomyoma • Symptoms are classified into three categories: • Heavy or prolonged menstrual bleeding • Bulk-related symptoms, such as pelvic pressure and pain • Reproductive dysfunction ( infertility or obstetric complications)

  26. Abnormal uterine bleedingLeiomyoma Physical examination • Abdominal and Bimanual pelvic examination to check the size, contour, and mobility of the fibroid • An enlarged, mobile uterus with an irregular contour is consistent with a leiomyomatous uterus

  27. Abnormal uterine bleedingLeiomyoma • Pelvic ultrasound is the imaging study of choice for uterine leiomyomas

  28. Abnormal uterine bleedingLeiomyoma- management • Hormonal therapies • Hysterectomy • Myomectomy • Endometrial ablation • Uterine artery occlusion

  29. Abnormal uterine bleeding PALM-COEIN Malignancy and hyperplasia

  30. Abnormal uterine bleedingMalignancy and hyperplasia • Seventy-five to 90 percent of women with endometrial carcinoma present with abnormal uterine bleeding • Women with a clinical presentation suspicious for endometrial carcinoma or hyperplasia should undergo a pelvic examination to evaluate the size, mobility, and axis of the uterus and do endometrial sampling

  31. Abnormal uterine bleedingMalignancy and hyperplasia Risk factors: - Age >45 - Unopposed estrogen therapy - Tamoxifen therapy - Early menarche - Late menopause (after age 55) - Nulliparity - DM - Polycystic ovary syndrome - Obesity -Estrogen-secreting tumor - Lynch syndrome (hereditary nonpolyposis colorectal cancer) - Family history of endometrial, ovarian, breast, or colon cancer

  32. Abnormal uterine bleeding

  33. Abnormal uterine bleeding PALM-COEIN Coagulopathy

  34. Abnormal uterine bleedingPALM-COEIN- coagulopathy • Bleeding disorders are common in reproductive-age women. • Up to 15 to 24 percent of women presenting with menorrhagia may have some type of bleeding diathesis (eg, von Willebrand disease, immune thrombocytopenia, or platelet function defect)

  35. Abnormal uterine bleeding PALM-COEIN- coagulopathy • A bleeding disorder should be suspected if: • heavy or prolonged menses began at menarche • Associated with a family history of coagulopathy • The patient has signs of a bleeding diathesis (eg, easy bruising or prolonged bleeding from mucosal surfaces) • Patient is taking medications associated with an increased bleeding tendency

  36. Abnormal uterine bleeding PALM-COEIN Ovulatory Dysfunction

  37. Abnormal uterine bleedingPALM-COEIN- Ovulatory dysfunction • Ovulatory dysfunction occurs when a woman is not ovulating, or having infrequent ovulation • Women typically experience some combination of irregularity of bleeding and a variable volume

  38. Abnormal uterine bleeding PALM-COEIN- Ovulatory dysfunction • It can be related to: • Psychological stress • Weight loss or gain • Excessive exercise • Medications that affect dopamine metabolism • An endocrine abnormality that impacts the hypothalamic-pituitary-ovarian axis, such as hyperprolactinemia, thyroid disease, and polycystic ovary syndrome

  39. Abnormal uterine bleeding PALM-COEIN Endometrial

  40. Abnormal uterine bleeding PALM-COEIN- Endometrial • In women with predictable and cyclic menses suggestive of normal ovulation who have AUB, particularly the symptom of HMB but can also include intermenstrual bleeding, and absent other definable causes, the patient is classified as having AUB-E • Most often, the cause of such bleeding is a primary disorder of the endometrium.

  41. Abnormal uterine bleeding PALM-COEIN- Endometrial • If the symptom is HMB, the patient may have a primary disorder of mechanisms regulating local endometrial hemostasis. • There are no available tests for these disorders. • AUB-E is assigned after excluding other etiologies of AUB in women of reproductive years. • There may exist other causes of AUB-E, such as endometritis secondary to, for example, Chlamydia trachomatis

  42. Abnormal uterine bleedingPALM-COEIN Iatrogenic

  43. Abnormal uterine bleeding PALM-COEIN- Iatrogenic • Medications that may cause AUB-I include: • Gonadal steroids (eg, estrogens, progestins, androgens) • Gonadal steroid-related therapy • Anticoagulants • Systemic agents that contribute to disorders of ovulation • Intrauterine devices

  44. Abnormal uterine bleedingPALM-COEIN Not yet classified

  45. Abnormal uterine bleedingPALM-COEIN- Not yet classified • These have either been poorly defined, inadequately examined, and/or are extremely rare

  46. Heavy menstrual bleeding (HMB)

  47. Heavy menstrual bleeding (HMB) • Take a history from the woman that covers: • The nature of the bleeding • Related symptoms, such as persistent intermenstrual bleeding, pelvic pain and/or pressure symptoms Impact on her quality of life • Other factors that may affect treatment options (such as comorbidities or previous treatment for HMB)

  48. HMB • Carry out a physical examination • Carry out a full blood count test for all women with HMB • Testing for coagulation disorders (for example, von Willebrand's disease) should be considered for women who: have had HMB since their periods started and have a personal or family history suggesting a coagulation disorder • Offer ultrasound • Consider hysteroscopy and endometrial biopsy

  49. HMB • Treatments for women with no identified pathology • LNG-IUS should be the first line treatment for HMB • If a woman with HMB declines an LNG-IUS or it is not suitable, consider the following pharmacological treatments: - Non-hormonal: Tranexamic acid and/or NSAIDs - Hormonal: Combined hormonal contraception or Cyclical oral progestogens

  50. VAGINAL DISCHARGE

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