IS BLEEDING TOO HEAVY ?
IRREGULAR BLEEDING
PV
P.D. LIYANAGAMA ,2014 SEP
IDEA OF LEARNING IRREGULAR
BLEEDING
• 1.TO UNDERSTAND THE CAUSES OF IRREGULAR
BLEEDING
• 2. KNOW THE PRINCIPLES OF INVESTIGATION AND
TREATMENT
NORMAL MENSTRUAL CYCLE
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IS A MENSTRUAL CYCLE
WHICH OCCURS EVERY 22 TO 35 DAYS
LASTING NOT MORE THAN 7 DAYS
BLOOD LOSS NOT EXCEEDING 80 ml
AND CYCLE TO CYCLE VARIATION NOT EXCEEDING
7 DAYS
IT MEANS
• ONE WHO GETS CYCLES EVERY 22 TO 24 DAYS ,
DEVELOPS HER CYCLE IN 30 DAYS , THEN ITS
ABNORMAL .
• AND ONE WHO GETS CYCLES EVERY 34 DAYS , GETS
HER CYCLES IN 23 DAYS NEXT TIME , THAT TOO IS
IRREGULAR
BASIC PHYSIOLOGY OF MENSTRUAL
CYCLE
• IT’S CONTROLLED BY HYPOTHALAMO PITUITARY
OVARIAN AXIS [HPO ]
• HYPOTHALAMUS SECRETES GnRH , WHICH
STIMULATES PITUITARY
• ANT. PITUITARY SECRETES FSH, LH ,PROLACTIN
• FSH & LH STIMULATES THE OVARIES TO SECRETE
OESTROGEN & PROGESTOGEN
NORMAL MENSTRUAL CYCLE
ENDOMETRIUM CHANGES IN A
NORMAL MENSTRUAL CYCLE
SOME COMMONLY USED TERMS
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MENORRHAGIA [HYPERMENORRHOEA]
OLIGOMENORRHOEA
HYPOMENORRHOEA
POLYMENORRHOEA [ EPIMENORRHOEA]
METRORRHAGIA
METRORRHAGIA
• IS IRREGULAR ACYCLIC BLEEDING FROM UTERUS
WITH VARIABLE FLOW AT VARIABLE CYCLES.
POLYMENORRHOEA
[EPEMENORRHOEA]
• IS FREQUENTLY OCCURING CYCLES
• ON OTHER WORDS CYCLES OCCURING LESS THAN
21 DAYS BUT GAP REMAIN CONSTANT
HYPOMENORRHOEA
• REDUCED FLOW
MENORRHAGIA
• IS REGULAR BUT HEAVY CYCLES [HEAVY FLOW]
• PROLONGED CYCLES SHOULD NOT BE TERMED AS
MENORRHGIA.
OLIGOMENORRHOEA
• INFREQUENT CYCLES OR
• ON OTHER WORDS ….MENSTRUAL CYCLES
OCCURING MORE THAN 35 DAYS APART.
• SOME MISUSE THIS TERM AS REDUCED FLOW.
FLUCTUATION OF DIFFERENT
HORMONE LEVELS IN A CYCLE
FLUCTUATION OF HORMONES
CAUSES FOR IRREGULAR BLEEDING PV
• ABNORMAL BLEEDING CAN BE A CONSEQUENCE OF
PELVIC PATHOLOGY, INCLUDING MALIGNANT
DISEASE,
• BUT MAJORITY OF WOMEN WHO COMPLAIN
IRREGULAR OR HEAVY FLOW DOESNOT HAVE
UNDERLYING ABNORMALITY.
• CONCERNS ABOUT THE WIDESPREAD USE OF
UNNECESSARY HYSTERECTOMIES IN THIS THIS
SITUATION HAS LED TO A WELL DEVELOPED
EVIDENCE BASED GUIDELINES AND PROTOCOLS
FOR PROPER MANAGEMENT OF IRREGULAR
BLEEDING PV.
• THIS TOGETHER WITH MEDICAL MX AND LESS
INVASIVE SURGICAL METHODS HAS INCREASED THE
RANGE OF OPTIONS AVAILABLE FOR THE RELIEF OF
MENSTRUAL BLEEDING PROBLEMS WORLDWIDE.
PELVIC PATHOLOGIES RESPONSIBLE
FOR IRREGULAR OR HEAVY BLEEDING
ANY UTERINE PATHOLOGY THAT COULD CAUSE
VASCULAR CONGESTION OR INCREASED SURFACE
AREA OF THE ENDOMETRIUM CAN CAUSE SUCH
BLEEDING.
Ex ; UTERINE FIBROIDS
ADENOMYOSIS / ADENOMYOMA
ENDOMETRIAL POLYPS
ENDOMETRIAL HYPERLASIA
ENDOMETRIAL CARCINOMA
UTERINE FIBROIDS ..TYPES
HYSTEROSCOPIC VIEW OF ENDO POLYP
US FEATURES OF ENDO POLYP
US FEATURES OF ENDO POLYP
US ENDO POLYP
CERVICAL PATHOLOGIES
• CAN ALSO CAUSE SUCH BLEEDING
• Ex: 1. EXTENSIVE CERVICAL ECTROPION
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SOME MISUSE THE TERM CERVICAL EROSION
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2. CERVICAL GROWTHS
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3. CERVICAL POLYPS
MANAGEMENT FOR SUCH
• IS TO REMOVE THE PATHOLOGY IN CASES OF
FIBROIDS / POLYPS/ ADENOMYOSIS ETC
• ENDOMETRIAL HYPERPLASIA ,.
• IF SIMPLE HYPERPLASIA WITHOUT ATYPIA
• MANAGEMENT IS MODERATELY HIGH DOSES OF
PROGESTOGENS INTO 2 CYCLES OF 21 DAYS WITH A
7 DAY GAP ,…AND REPEAT ENDOMETRIAL BIOPSY,
• IF PATHOLGY PERSISTS EVEN WITH MEDICAL Mx.. ,
THEN CONSIDER SURGICAL OPTION.
DUB [ DISFUNCTIONAL UTERINE
BLEEDING]
• IS ABNORMAL BLEEDING PV WITHOUT ANY
DEMONSTRABLE PATHOLOGY IN THE GENITAL TRACT,
• AND ALSO WITH THE EXCLUSION OF ANY BLEEDING
DYSCRASIAS LIKE VONWILL-BRAND DISEASE ,
CERTAIN CLOTTING FACTOR DEFICIENCY
• 7/8/9/11 , CHRISTMAS DISEASE ETC,
• AND SYSTEMIC DISORDER LIKE HYPOTHYROIDISM.
THEN WHAT CAUSES THIS IRREGULAR
BLEEDING
• MENSTRUAL BLOD LOSS IS CONTROLLED WITH THE
HELP OF ANTIFIBRINOLYTIC SYSTEM.
• ANY IMBALANCE IN THE ABOVE SYSTEM COULD
CAUSE IRREGULAR OR HEAVY BLEEDING.
• ENDOMETRIUM IS SECRETING CERTAIN FACTORS ,
WHICH ALSO CAUSE SUCH BLEEDING,
• EX: PROSTAGLANDINS , INTRLEUKIN, TNF [ TUMOUR
NECROSIS FACTOR] ETC.
INVESTIGATIONS
• 1. GOOD HISTORY TAKING
• 2. ABDOMINAL -PELVIC EXAMINATION
• 3. TVS / TAS
MANAGEMENT
• 1. ANTIFIBRINOLYTIC DRUGS LIKE TRANEXAMIC ACID.
• 2. DRUGS WHICH ACT AGAINST THOSE CHEMICAL
FACTORS SECRETED BY ENDOMETRIUM, Ex; ANTIPROSTAGLANDINGS [mefenamic acid] ,NSAIDS
CAN ALSO REDUCE BLOOD LOSS.
• 3. ANY MEDICAL DRUG OR INVASIVE TECHNIQUE
WHICH CAN INACTIVATE ENDOMETRIUM CAN ALSO
REDUCE BLOOD LOSS.
• 1.MEDICAL MANAGEMENT
• 2. INVASIVE TECHNIQUES
• 3. SURGICAL OPTIONS
MEDICAL MANAGEMNT
• Non hormonal therapy
• Hormonal therapy
NON HORMONAL THERAPY
• For women with menorrhagia requiring non
hormonal Rx, antifibrinolytic agents …
• Such as TRANEXAMIC ACID
• And
• NSAIDS like mefenamic acid …
• Are the first line drugs…
• As both these drugs have different mechanisms of
action in menorrhagia, they may be more effective
when used in combination.
• Mefenamic acid reduces mean blood loss by about
20 %...
• And Tranexamic acid reduces mean blood loss by
about 50%
HORMONAL CONTRACEPTIVES
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Combined oral contraceptives
Oral Progestogens
IM progestogens
Progesterone releasing IUCDs
Other medical therapies
COMBINED OCPS
• For women nrequiring contraception or for whom
hormonal agents are acceptable cocp
preparations are effectice and reduce mean blood
loss by about 50%.
• They also control cycle irregularities and relieve
menstrual pain.
• In women after the age of 40 , COCP must be used
very CAUTIOUSLY as it could grow an endometrial
cancer faster if given to a undiagnosed patient
with endometrial carcinoma.
PROGESTOGENS
• Cyclical progestogens were used comonly in the
past ,but current evidence does not support their
use for menorrhagia when given only during LUTEAL
PHASE.
• They are effective when given at high doses
between day 5 to day 26. [total 21 days]
• Oral medroxyprogesterone 10 bd
• Or … norethisterone 5 mg tds
• Oral progestogens are in fact use to treat
ENDOMETRIAL HYPERPLASIA WITHOUT ATYPIA.
IM PROGESTOGENS
• DMPA MAY BE HELPFUL IN CONTROLLING HEAY
• BLEEDING PV , WHEN NOT RESPONDING TO OTHER
MEDICAL THERAPIES,
• BUT THEIR USE IS LIMITED BY SIDE EFFECTS.
PROGESTOGEN RELEASING IUCD
• Mirena is an IUCD which releases LEVENOGESTROL
20 mcg per 24 hours ,for 5 years duration
• Reduce mean blood loss by 80-85 %.
• Very effective long term drug.
• Short term Expensive
• Irregular spotting is common during first 6 months,
and patients to be councelled before inserting.
• Breast tenderness is the other side effect.
OTHER MEDICAL THERAPIES
• Second line drugs are available for the control of
severe bleeding when simpler measures have
failed.
• As they reliably induce amenorrhoea , are useful in
the management of severe anemia or in the
presence of medical disorders when surgery may
be contraindicated.
• Androgens such as DANAZOL and GESTRINONE
• Induce amenorrhoea by a combination of negative
feedback and direct effect on endometrium.
GNRH ANALOGUES
• THEY INDUCE HYPOGONADAL STATE VIA THEIR
CENTRAL ACTION.
• WHILE USEFUL , THEY ARE LIMITED TO SHORT TERM USE
BECAUSE OF THEIR SIDE EFFECTS.
• THEY ARE ALSO VALUED AS ENDOMETRIAL THINING
AGENTS PRIOR TO HYSTEROSCOPIC AGENTS.
• IN CASES OF SEVERE MENORRHAGIA, IN WHICH
SIMPLE MEASURES FAILED, LONG TERM GNRH WITH
ADD BACK THERAPY CAN BE CONSIDERED.
OTHER INTERVENTION METHODS
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ENDOMETRIAL RESECTION
THERMAL BALOON ABLATION
LASER ABLATION OF ENDOMETRIUM
MICROWAVE ABLATION
TCRE
TRANSCERVICAL RESECTION OF ENDOMETRIUM
USING ELECTROCAUTERY LOOP
OR … ROLLER BALLER DIATHERMY .
OBJECTIVE OF ALL ABLATIVE TECHNIQUES IS TO
ACHIEVE COMPLETE DESTRUCTION OF
ENDOMETRIUM , THOUGH NOT 100% POSSIBLE .
• ONLY 20 -30 % WILL GET AMENORRHOEA.
• REST WILL HAVE SOME DEGREE OF BLEEDING PV.
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TRANS-CERVICAL RESECTION OF
ENDOMETRIUM
ROLLER BALL
ROLLER BALL TYPES
THERMAL BALOON ABLATION
• BALON IS INSERTED INTO UTERINE CAVITY
CONNECTED TO A MACHINE.
• SALINE IS HEATED TO 80 DEGREES FOR 15 TO 20 MIN.
• ENDOMETRIUM IS THEN DESTROYED BY THERMAL
ACTION.
THERMAL BALOON ABLATION
THERMAL BALOON ABLATION
INVASIVE TECHNIQUES
• LASER ABLATION:
• IS LIMITED BY IT.S COST TO VERY LIMITED CENTRES
MICROWAVE ABLATION
• PROBE WHICH INTRODUCE MICROWAVES IS
INSERTED INTO UTERINE CAVITY AND THE PROBE IS
MOVED UP AND DOWN WHILE EMITTING
MICROWAVES
ENDOMETRIAL ABLATION
ENDOMETRIAL ABLATION
SURGICAL OPTIONS
• IN FAILURE OF ALL THE ABOVE TECHNIQUES ,
HYSTERECTOMY IS THE FINAL OPTION.
• DRAW BACKS ARE , HIGH MORBIDITY, LONGER
RECOVERY TIME , GREATER COSTS.
POST MENOPAUSAL BLEEDING PV
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CAUSES
1. ATROPHIC ENDOMETRITIS
2. ENDOMETRIAL HYPERPLASIA
3. ENDOMETRIAL CARCINOMA
ENDOMETRIAL TRIPLE LINE OR LAYER
TRIPLE LAYER CONSISTS OF
• OUTER LAYER BASALIS
• INNER LAYER FUNCTIONALIS
• MEDIAN LAYER COMPOSED OF MUCUS
LUTEAL PHASE ENDOMETRIUM
CA ENDOMETRIUM
CA ENDOMETRIUM US FEATURES
CA ENDO US FEATURES
CA ENDO US FEATURES
CA ENDO. PATHOLOGICAL SPECIMEN
ENDOMETRIAL CANCER
• USUALLY ARISE IN POST MENOPAUSAL WOMEN
• HOWEVER ANY WOMAN PRESENTING WITH
IRREGULAR BLEEDING PV MUST BE INVESTIGATED TO
EXCLUDE THE POSSIBILITY OF CA ENDOMETRIUM.
• IN UK SECOND MOST COMMON GYNAECOLOGICAL
CA
• …AND 5 TH MOST COMMON CANCER IN WOMEN
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AETIOLOGY
• WOMEN WITH RELATIVELY HIGH LEVELS OF
CIRCULATING OESTROGENS , OR PROLONGED
EXPOSURE TO OESTROGENS ARE HIGH RISK.
• THEREFORE DO NOT ABUSE OESTROGEN
CONTAINING PILLS AFTER THE AGE OF 40.
• OBESITY : DUE TO PERIPHERAL CONVERSION OF
ANDROGENS IN ADIPOSE TISSUE …ARE HIGH RISK
• EARLY MENARCHAE AND LATE MENOPAUSE
• PCOS
• TAMOXIFEN THERAPY
• OESTROGEN THERAPY UNOPPOSED BY
PROGESTERONES
PRESENTATION
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IRREGULAR BLEEDING PV
HEAVY PROLONGED BLEEDING PV
MENORRHAGIA[ HEAVY BUT REGULAR CYCLES]
INTERMENSTRUAL BLEEDING
DISCHARGE PV
INVESTIGATIONS
• US PREFERABLY TVS WHEN BLEEDING PV STOPS
• ENDOMETRIAL THICKNESS LESS THAN 4 mm IS TAKEN
AS NORMAL AFTER MENOPAUSE & UNLIKELY TO
HAVE CA , AND ANYTHING ABOVE 4 MM SHOULD
BE ARRANGED WITH ENDOMETRIAL SAMPLING.
• IN PERIMENOPAUSAL AGE ENDOTHICKNESS IS
VARYING UPTO 15 mm and still could be normal.
• ONE PATIENT WITH 7 mm ENDO. THICKNESS CAN
HAVE CA ,WHILE THE OTHER PERSON WITH 14 mm
may not have CA.
THEREFORE
• ENDO BIOPSY IS IMPORTANT AFTER THE AGE OF 40
YEARS IN PATIENTS WITH IRREGULAR OR HEAVY
CYCLES, IN ORDER TO EXCLUDE CA ENDO.
ENDO BIOPSY METHODS
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D&C
PIPELLE [OFFICE PROCEDURE]
VABRA SAMPLING
HYSTEROSCOPIC ENDO SAMPLING [NOT FREELY
AVAILABLE IN MANY CENTRES & MORE TIME
WASTING AND COSTY]
D&C
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SAMLING AREA IS MORE OR LESS 50%
BUT DETECTION RATE IS LOW ,AROUND 50%
NEED ANESTHESIA
COST IS MORE
NEED HOSPITAL STAY
INVESTIGATIONS PRIOR TO ANESTHESIA
PIPELLE
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ENDOMETRIAL SAMPLING AREA IS AROUND 5%
BUT DETECTION RATE FOR CA ENDOMETRIUM
OR ENDO. HYPERPLASIA IS HIGH AROUND 80 TO 85 %
IF PERFORMED BY EXPERIENCED PERSON.
OFFICE PROCEDURE
DOES NOT NEED ANESTHESIA
NO HOSPITAL STAY
CHEAP
NO NEED OF INVESTIGATIONS
• FOR MEDICALLY UNFIT HIGH BLOD PRESSURES,
THYROTOXIC, UNCONTROLLED DM OR HIGH RISK
FOR GA PATIENTS ,THIS IS A VERY USEFUL
TECHNIQUE.
• UNFORTUNATELY IN DEVELOPING COUNTRIES
ACCEPTANCE IS POOR AND MANY PATIENTS PREFER
D&C.
IRREGULAR BLEEDING PV
IMMEDIATELY AFTER MENARCHAE
• COMMON AMONG YOUNG GIRLS AND SCHOOL
GIRLS
• NO PATHOLOGICAL LESION IN OVER 99% PATIENTS
• IMMATURE H-P-O AXIS IS THE CAUSE.
• COMBINED OCP IS THE DRUG OF CHOICE
• IT TRAINS THE HPO AXIS TO SECRETE HORMONES IN A
REGULAR FASHION
• FEW CYCLES WOULD DO THE JOB
• ONLY IN A FEW , LONGER USE IS NECESSARY
IRREGULAR BLEEDING PV FOLLOWING
DMPA OR JADEL
• CAUSE FOR THE BLEEDING IS DECENSITISED
OESTROGEN RECEPTORS DUE TO LONG TERM USE OF
PROGESTERONES.
• DON’T EVER TREAT SUCH PATIENTS WITH ANOTHER
PROGESTOGEN.
• DRUG OF CHOICE IS COMBINED OCP WHICH
CONTAINS BOTH OESTROGEN AND PROGESTOGENS.
• FEW DAYS MEDICATION WOULD SETTLE THE PROBLEM
USE OF ORAL PROGESTOGENS
ANOVULATORY BLEEDING :
tds for 14 -21 days .
NORETHISTERONE 5 mg
• TO DELAY PERIODS : start at least 3 days before
your scheduled period and continue until the day
you want free of periods ,but not exceeding 21
days.
IN IRREGULAR INTERMENSTRUAL
BLEEDING
• Norethisterone 5 mg tds from day 5-26 [total 21
days]
• TO PREVENT RECURRENCE: NORETHISTERONE 5mg
daily or bd from day 16- 25
ENDOMETRIOSIS
• NORETHISTERONE SHOULD COMMENCE BETWEEN
DAY 1 – 5 OF THE CYCLE WITH 5 mg bd.
• TREATMENT TO BE CONTINUED FOR 4 =6 MONTHS AT
LEAST.
• Dose can be increased to 5 mg tds or 10 mg bd ,in
the event of irregular spotting.
• Once the spotting stops ,go back to 5 mg bd dose
• With uninterrupted daily intake ,ovulation and
menstruation does not occur ,therefore the pain
settles or significantly reduce .
CONCLUSION
• Idea behind this lecture is to educate medical
persons to identify the causes for irregular bleeding
patterns, and to properly investigate them and
provide correct treatment when requires.
• IN CA ENDOMETRIUM , EARLY DETECTION CAN
BRING CLOSE TO 100% SURVIVAL RATES….
• WHILE LATE DETECTION WILL DRASTICALLY REDUCE
THE 5 YEAR SURVIVAL RATE …
• SO PLEASE DON’T MISS THESE PATIENTS ..
• YOU CAN PLAY A BIG ROLE
THANKYOU
• CRITISISM AND CORRECTIONS AND ANY NEW IDEAS
ARE VERY WARMLY WELCOME …
• PLEASE DISCUSS IF ANY….
TREAT YOUR IRREGULAR HEAVY
BLEEDING PROBLEM AND BE HAPPY