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Abnormal Uterine Bleeding in Premenopausal Women: Co Pyr Igh T

Jurnal AUB

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Febrina Sylva Fridayanti
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87 views3 pages

Abnormal Uterine Bleeding in Premenopausal Women: Co Pyr Igh T

Jurnal AUB

Uploaded by

Febrina Sylva Fridayanti
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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CASE IN...

Anticoagulants

Abnormal Uterine Bleeding

Abnormal Uterine Bleeding in


Premenopausal Women
Nicholas A. Leyland, BASc, MD, MHCM, FRCSC
Presented at McMaster Universitys Len Lotimer Clinical Obstetrics & Gynecology
Update Day, October 2007.

bnormal uterine bleeding (AUB) can be


Meet Chloe
defined as vaginal bleeding arising from the
reproductive organs. This may include dysfuncChloe is a 42-year-old executive in a large
tional uterine bleeding, that is associated with discorporation. She complains of severe
ruption of the normal pituitary-ovarian endocrinomenorrhagia resulting in anemia and fatigue.
She has nightmares of having an accident
logical balance or bleeding associated with underduring a presentation at work. Chloe came to
lying pathology (Table 1). The goal of the healththe office where she related her menstrual
care provider in the care of such women is to estabhistory, as well as the significant impact of her
problem on her quality of life. Her history was
lish the underlying cause for the bleeding and to
otherwise unremarkable.
tailor the therapy to the patients problem in the
She has no desire for future fertility and
least invasive, most cost-effective way. Such an
requests something to control her bleeding and
approach facilitates the return of the woman to her
to restore her to her previously enjoyed level of
work, her family and her activities of daily living as
health.
expeditiously as possible.
Chloe is otherwise healthy and her physical
A complete history and physical should rule
examination is normal, including her pelvic
examination.
out underlying medical disorders or medications associated with bleeding. Generally, a
Turn to page 12 for more on Chloe.
good menstrual history will differentiate

,
between dysfunctional uterine bleeding (DUB)
load
n
w
o
Uterine
or endocrine issues causing the bleeding and for the Management
n dof uAbnormal
e
a
s
c
1
l
a pelvic examination,
anatomical issues. Most frequently the former Bleeding. Despite
rs a normal
use erson
d
e
p
will be associated with less regular menstrual pelvic
r particularly sonohysterograis ultrasound,
horcanoppick
y foup endometrial cavitary abnormaltphy,
u
flow, the latter heavier but regular menses with
A
c
d.
glerequiring a hysteroscopic surgical approach.
bite a sinities
or without intermenstrual bleeding.hiPhysical
t
pro prinand
examination, in particular u
the
seabdominal
d
n
sedevaluate
pelvic examinations,
w a the patient First-line treatments
e
oriwill
i
v
h
t
au vaginal
lay, or cervical lesions.
for fibroids,
Unlocal
disp
Pap smear and endometrial biopsy should be In the absence of underling pathology, medical
part of the assessment tools of all practitioners therapy should be considered in the first
caring for women. Cervical and endometrial instance (Table 2). If tolerated and in the
pathology, either pre-invasive or invasive neo- absence of contraindications, a combined low
plasia should be ruled out. Blood work should dose of the OC pill can be very effective espebe minimized; the appropriate investigations cially with ovulatory DUB. Many other agents
can be found in Vilos, et al SOGC Guidelines can be used but are not generally tolerated by

t
h
g
yri cia

p
o
C ommer

fo
t
o
N

n
o
i
t
bu
i
r
t
s
l Di

rC
o
le
a
S
r

The Canadian Journal of CME / June 2009 11

Table 1

Table 2

Abnormal uterine bleeding (AUB) pathology

AUB therapies

Fibroids especially cavitary (submucosal


fibroids)
Endometrial polyps
Endometrial hyperplasia/endometrial cancer
Cervical dysplasia/cancer
Cervical polyps

Medical therapy: hormonal, tretinoin, NSAIDs


levonorgestrel-releasing intrauterine system
(LNG-IUS)
Endometrial ablation-hysteroscopic or global
Hysteroscopic myomectomy
Uterine artery embolotherapy
Hysterectomy

Chloes case contd

Take-home message

Chloe underwent her investigations; all were


negative including a sonohysterogram showing
a normal cavity
She underwent an in-office global
endometrial ablation under local anaesthesia
and oral medications
She remains amenorrheic since the procedure
and is very pleased with her new level of
freedom

patients for long periods of time. The levonorgestrel intrauterine system is not yet indicated for the treatment of menorrhagia but clearly is
useful in patients with normal endometrial cavities also requiring effective, reversible contraception and therapy.2

The evaluation of most causes of AUB is within


the scope of practice of primary care providers
There are a number of less invasive options for
the management of AUB
Even hysterectomy can be accomplished using
minimally invasive techniques

n
o
i
t
bud,
i
r
t
is nloa

Uterine artery embolization has a role to play in


women with intramural fibroids associated with
bleeding or
bulk symtomatology.3

t
h
g
D
l
a
treatment
yriDefinitive
i
c

ow
n d use
a
c
al
rs
use erson
d
Hysterectomy
has,
r p in the past, had a significant
ise
hor opy fo
t
u
inc the management of patients with AUB.
. A role
Second-line therapies
gle invasive surgery should be reserved for
ited siSuch
n
b
i
h
pro prihave
nt a treatment failures and for those with additional
Effective minimally, invasive surgical
se therapies
u
d
n
d
wa
riseof vmenorrhagia
been available for treatment
since concomitant diagnoses requiring this approach.
e
o
i
h
,
ut
y
a
a
l
n
the early 1990s.
Hysteroscopic
endometrial
abla- Should hysterectomy be chosen, the least invasive
U
disp

Copommer

fo
t
o
N

rC
o
le
a
S
r

tion is an effective modality for properly selected


patients. Global endometrial ablation technologies
performed under local anaesthesia in a non-hospital
setting are available in Canada, but there are barriers to the access to these outside the hospital setting
and cost containment precludes widespread availability in the hospital environment. It is important to
note that there is no role for dilatation and curettage
in the treatment of abnormal bleeding. Cavitary
abnormalities such as fibroids and polyps are easily
treated hysteroscopically. This can be performed
with an endometrial ablation concurrently.

12 The Canadian Journal of CME / June 2009

approach should be taken. The SOGC Guidelines


on hysterectomy3 recommends the vaginal
approach if feasible, adding the laparoscopic if
this facilitates the vaginal approach.
Laparoscopic total and subtotal hysterectomy
can be utilized in appropriately selected patients.
The open, abdominal approach should be minimized in this algorithm. Choosing the least invasive surgical route allows the patient to return to
her optimal functional level more rapidly.

CASE IN...
Abnormal Uterine Bleeding
Management of Abnormal Uterine Bleeding:
Premenopause
Abnormal uterine bleeding is defined as changes in frequency of menses, duration of flow or
amount of blood loss. The normal menstrual cycle lasts 28 7 days, the flow lasts 4 2 days and
the average blood loss is of 40 20 ml.
History-Physical: Pelvic, PAP, CBC

Rule out: pregnancy, endocrine, coagulation disorder

Yes

persistent irregular bleeding with treatment


obesity > 90 kg
> age 40
other risk factors for neoplasia

No

Endometrial biopsy
Abnormal

Normal

Appropriate management
Normal uterus
(shape and size)

Pelvic Exam Findings

Abnormal uterus
(shape and size)

Transvaginal ultrasound and/or saline sonohysterography


Medical treatment:
Combined oral contraceptive pill
Progestins
Normal
Abnormal
Danazol
Antifibrinolytic agents
Medical treatment:
Non-steroidal anti-inflammatory drugs
Combined oral contraceptive pill
Progestin intrauterine system
Progestins
GnRH Agonists
Danazol
Antifibrinolytic agents
AUB stops
AUB persists
Non-steroidal anti-inflammatory drugs
Progestin intrauterine system
GnRH Agonists
No further
intervention
AUB stops
AUB persists

No further
intervention

Figure 1. Management of AUB.

Dr. Leyland is an Associate Professor of


OB/GYN, University of Toronto; and Medical
Director, the Womens, Childrens and Family
Health Program, St. Josephs Health Centre,
Toronto, Ontario.

Hysteroscopy D&C and


appropriate management

Problem solved

Problem persists

No further
intervention

Hysteroscopy ablation
or hysterectomy

References
1. Vilos G et al: SOGC Clinical Guidelines. Guidelines for the
Management OF Abnormal Uterine Bleeding. J Obstet Gynaecol Can
2001; 23(8):704-9.
2. Hidalgo M, Bahamondes L, Perrotti M et al: Bleeding Patterns and
Clinical Performance of the Levonorgestrel-Releasing System
(Mirena) Up to Two Years. Contraception 2002; 65(2):129-32.
3. Lefebvre G, Allaire C, Jeffrey J, et al: SOGC Clinical Guidelines.
Hysterectomy. J Obstet Gynaecol Can 2002; 24(1):37-61.
The Canadian Journal of CME / June 2009 13

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