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Diagnosis & management of DUB

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Diagnosis & management of DUB Dr Manjula M Senior lecturer in O&G SAT Hospital Definition Normal menstruation Pathology Types of DUB Evaluation and diagnosis ... – PowerPoint PPT presentation

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Title: Diagnosis & management of DUB


1
Diagnosis management of DUB
  • Dr Manjula M
  • Senior lecturer in OG
  • SAT Hospital

2
  • Definition
  • Normal menstruation
  • Pathology
  • Types of DUB
  • Evaluation and diagnosis
  • Management

3
DEFINITION
  • abnormal uterine bleeding without any clinically
    detectable organic pelvic pathology
  • Novak-bleeding of uterine origin in the absence
    of pregnancy,tumour or inflammation

4
  • DUB is a diagnosis of
  • exclusion
  • An incorrect and improper diagnosis leads to
    failure of medical management and unnecessary
    surgical interventions

5
Normal menstruation
  • 21-35 days cycle,3-8 days flow,30-60ml
  • Normal HPO axis
  • Decreased OP- decre. BF to endometrium- endo.
    necrosis

6
Pathophysiology of DUB
  • ? PGE2, PGF2 ratio
  • ?tpA - endometrial fibrinolysis
  • Abn. vascularity of endometrium
  • Delayed regn. of endometrium
  • ?endo. tissue necrosis
  • ?Prostacycline,TxA2 ratio

7
DUB-Diag of exclusion.
  • Organic disease of the genital tract
  • Pregnancy and its related complications
  • Organ failure
  • Genital injury, FB
  • Pathology of outflow tract

8
TERMS
  • Menorrhagia
  • Metrorrhagia
  • Polymenorrhea
  • Oligomenorrhea
  • Amenorrhea

9
Classification
  • Aetiological
  • Primary
  • Secondary
  • Iatrogenic
  • Types
  • Anovulatory
  • Ovulatory

10
HISTORY
  • Full menstrual history,medical history
  • Asso. mens. symptoms,h/o PID
  • Symptoms of endocrine / organic diseases
    /bleeding disorder
  • Stress,psych abn.
  • Drugs,IUCD
  • Family history
  • Future preg , contraception

11
Examination
  • Built
  • Pallor,icterus,hirsuitism
  • Petechial rashes,LNE
  • Thyroid,breast,abdomen
  • L/E- lesions ,FB,injury,anomalies
  • P/V-uterus ,adnexa
  • P/R- unmarried

12
Investigations
  • Hb, CBC,BT ,CT ,PS
  • LFT,RFT
  • PT,APTT
  • TFT
  • UPT
  • PAP smear
  • USG-TAS,TVS
  • Prolactin

13
  • RBS
  • R/O CAH ,Cushing synd.
  • F C ,D/C,endom. biopsy
  • Lap, hysteroscopy, sonohysterography

14
Endometrial Assessment
  • Array of methods
  • Dilatation and curettage
  • Hysteroscopy and endometrial
  • Endometrial sampling
  • Ultrasonography

15
  • CURETTAGE-primarily diagnostic,rarely therapeutic
  • In adolescents-deferred until severe bleeding
  • In reproductive postponed till 3 months
  • Perimenopausal-done immediately
  • Postmenopausal-mandatory

16
Timing of curettage
  • Cyclic menorrhagia-5-6 days prior to onset of pds
  • Irregular shedding-5-6 days after pds start
  • Irregular ripening-soon after pds start
  • Acyclic-soon after pds start
  • Continuous-anytime

17
DC
  • Rarely indicated in lt40yrs with regular heavy
    periods
  • 3000 4000 DC to detect 1 END Ca
  • Only 50 of uterine cavity is samples
  • 50 of endo Ca may be missed by DC alone

18
ROLE OF USG
  • Uterine architecture
  • Endometrial thickness
  • Impt adjunct to sampling
  • TVS better sensitivity 89
  • specificity 96
  • Endometrial thickness 5mm
  • Exclude endo. Ca (Goldstein 1990)
  • After menopause
  • USG endo biopsy when endogt5mm

19
Management
  • Medical
  • Non-hormonal
  • Hormonal
  • Surgical
  • Conservative
  • Hysterectomy

20
  • Non-hormonal
  • NSAIDs
  • Inhibits cyclooxygenase,blocks PGE2
  • 20-30redn in bld loss ovulatory DUB
  • Antifibrinolytics EACA,Tranexamic A
  • Inhibits tpA
  • 50 redn in bld loss
  • IUCD related menorrhagia

21
  • Hormones
  • Progestogens
  • Norethisterone
  • MPA
  • Dydrogesterone
  • IU Progestogens
  • LNG IUS (Mirena)
  • Progestasert

22
  • Hormones
  • Combined O/P
  • OCP
  • HRT
  • OTHERS
  • Danazol
  • Gestrinone
  • GnRH analogues

23
Surgical therapy
  • Curettage
  • E A /RESECTION
  • HYSTERECTOMY

24
Management
  • Puberty and adolescent -lt20 yrs
  • Reproductive-20-40 yrs
  • Perimenopausal-gt40 yrs

25
Pubertal
  • 75- Primary DUB
  • Anovulatory (90)
  • 15 - Coaguln. defects
  • 10 -condns like ovarian trs

26
  • Life style modificn, diet ,exercise ,wt. redn
  • Mild-reassurance, iron and vitamin
    supplementation,menstrual calender,periodic
    reevaluation

27
  • Moderate
  • PROGESTINS for 3-6 months
  • Progestogens reverses the effect of
    unopposed estrogens due to anovulation
  • In married women-contraceptive action also

28
  • Severe-hospitalisation,exclude coagulative
    pathology rapidly ,blood transfusion,iron and
    vitamin supplementation,
  • Trt CCF if present

29
Role of progestogens
  • NEA 10mg 1-1-1 3days till bleeding stops
    .taper over 3 days_
  • Withdrawal bleed _
  • Restart from 5th day of menstrual bleed

30
  • If progestogens fail
  • Can start on parenteral estrogens(premarin 25 mg
    4th hrly,max 6 doses
  • After achieving haemostasis give progestogens
    concurrently
  • DC-very rarely indicated
  • Helps to know hormonal status,and tissue
    diagnosis of tuberculous endometritis

31
  • Majorily return to normal pattern within 3-4 yrs
    of menarche
  • If anovulation exceeds 4 yrs,increased risk of
    PCOD,infertility, Ca endometrium

32
REPRODUCTIVE AGE GROUP
  • 80 OVULATORY
  • 20 ANOVULATORY
  • Take a careful h/o,detailed general and pelvic
    examination,r/o pregnancy complications,USS,r/o
    PID,irregular hormone intake/r/o malignancy,DC

33
  • OPTIONS AVAILABLEmedical and surgical therapy

34
Prescribing practically
  • Progesterones-androgenic progesterones mainstay
    of treatment in anovulatory cycles. Produces
    MEDICAL CURETTAGE
  • Used to
  • Arrest hge in endometrial hyperplasia
  • Luteal phase trt in C L insufficiency d15-d25
  • Whole cycle trt in endometrial hyperplasia d5-d25
  • Give for 6 months and reevaluate.

35
Estrogen and Progesterone
  • Cyclical therapy
  • COC
  • 2 4 tab 6 12 hrly for 5 7 days
  • withdrawal bleed
  • Low dose pill from 5th day
  • COC may be tapered
  • (4 times, 3 times, 2 times)
  • Over 3 6 days and 1 everyday

36
  • ESTROGENS - limited use to arrest acute
  • haemorrhage uncontrolled
  • by progesterones
  • Acts as a stimulus to clotting at capillary level
  • CONTRAINDICATIONS

Undiagnosed DUB H/o thromboembolism,
thrombophlebitis Suspected pregnancy Breast Ca
37
  • DANAZOL
  • 200mg/d decreases MBL
  • Antiestro,antiprogesto,androgenic
  • 800mg/d produces amenorrhoea
  • Used in cases of recurrent
    bleed,awaiting hysterectomy

38
  • GESTRINONE-2,5 mg twice a week for 3 months
  • CLOMEPHINE citrate-used in anovulatory DUB with
    infertility ,wanting pregnancy
  • GnRH analogues-produces hypoestrogenic state and
    decreases MBL.These are indicated only in cases
    with adverse effects to sex steroid
    therapy,failure of sex steroid therapy,in
    haematologic disorders

39
  • PG SYNTHETASE INHIBITORS-decreases MBL by 20-30
  • Used in ovulatory DUB
  • given during menses
  • ANTIFIBRINOLYTIC AGENTS-tranexamic acid used in
    IUCD induced menorrhagia and ovulatory DUB. CI in
    patients with h/o thrombosis

40
  • DESMOPRESSIN-increases factor VIII levels used
    in DUB PATIENTS WITH COAGULOPATHY
  • LNG IUD decreases MBL by 96 after 12 months of
    use

41
HPR
  • proliferative endometrium and pregnancy
    desired-CC
  • proliferative endometrium and pregnancy not
    desired-prog 2nd half12 days
  • Secretory endometrium and pregnancy desired-PG
    synthetase inhibitors
  • Secretory endometrium and pregnancy not
    desired-OCP 6 mths
  • Atrophic endometrium-est dominant OCP
  • Hyperplastic endometrium-prog dominant OCP

42
Surgical treatment
  • Conservative
  • ABLATIVE PROCEDURES-Thermal,roller ball
  • RESECTION
  • Radical
  • vaginal hysterectomy
  • TAH

43
Indications for endometrial ablation
  • Heavy menstrual loss
  • Endometrial atypia excluded
  • Uteruslt12 weeks size
  • No pelvic infection
  • Completed family
  • Fit for surgical procedure
  • Willing for hysterectomy if reqd

44
Indications for hysterectomy
  • If conservative treatment fails
  • Blood loss impairs health
  • Younger age group with completed family and with
    symptoms uncontrolled on medical management

45
ROLE OF RADIOTHERAPY
  • External beam radiation to induce
  • menopause in patients with intractable DUB
  • when hysterectomy is indicated but patient
  • is unfit for surgery

46
Perimenopausal group
  • Cause- functional ageing of HPO axis
  • Pituitary produces more FSH ,the ovaries become
    refractory to it-anovulatory cycles
  • Unopposed endogenous estrogens from
    fatendometrial hyperplasia---persistent
    hyperplasia---adenomatous hyperplasia---atypical
    hyperplasia---CIS

47
EVALUATION
  • Detailed history
  • Clinical examination
  • Diagnostic procedures
  • Hormones-progestins tried for a few cycles may
    reverse dysplastic changes

48
h/o examination
PAP SMEAR,COLPOSCOPY
MALIGNANCY (APPROP TRT)
HYSTEROSCOPY----N ENDOMETRIUM (LOOK FOR
MYOMA,POLYP)
FC
Proliferative endometrium Simple hyperplasia
Adenomatous/atypical hyperplasia
progestins
hysterectomy
Follow up after 6 months Endometrial sampling
Ablative therapy is indicated in carefully
selected cases
49
Post menopausal
  • No place for hormones
  • Rule out adnexal mass,malignancy,organic lesions
    by USG
  • FRACTIONAL CURETTAGE is mandatory
  • If bleeding stops-can wait
  • If recurs-hysterectomy

50
Take home messages
  • Hysterectomy for DUB should be made a last
    resort.
  • The liberal use of hysterectomy to treat DUB
    reflects failure in establishing a correct
    diagnosis
  • When the diagnosis is correct , medical
    management or limited surgical management is a
    better option if facilities are available

51
thank you
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