ABNORMAL UTERINE BLEEDING.docx | Menstruation | Mammal ...

ABNORMAL UTERINE BLEEDING (AUB) The very 1st of all, we should know about normal uterine bleeding !

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Frequency of menses – 21 days (0.5%) to 35 days (0.9%) • Age 25, 40% are between 25 and 28 days • Age 25-35, 60% are between 25 and 28 days • Teens and women over 40’s cycles may be longer apart Duration of menses – 2 days to 8 days • Usually 4-6 days Flow/amount of menses – Normal volume of menstrual blood loss is 30 cc

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Polymenorrhea Interval less than 21 days Another classification based on etiology?

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Definition :

Bleeding that is outside the normal parameters of the menstrual cycle (volume, duration, or interval). -

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Classification : Menorrhagia Regular intervals, excessive menstrual blood loss (amount >80mL) -

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Ovulatory Menorrhagia with regular, cyclic bleeding, PMS symptoms, often have structural abnormality. Abnormal PG ratios. Anovulatory Erratic bleeding, both in timing and volume, may have times of amenorrhea. Absence of cyclic progestin causes fragile unstructured endometrium prone to breakage and bleeding Etiology : Cara mengetahui ada kelainan pada struktur

Metrorrhagia Irregular intervals, excessive flow and duration

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Menometrorrhagia Heavy and irregular bleeding

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Oligomenorrhea Interval longer than 35 days

anatomi? 1. Polip The lesions are usually benign but a small minority may have atypical or malignant features. Polyps are categorized as being either present or absent, as defined by 1 or a combination of ultrasound and hysteroscopic imaging with or without histopathology.

2. Adenomyosis These criteria have been based on histopathologic evaluation of the depth of “endometrial” tissue beneath the endometrial– myometrial interface, as determined via hysterectomy. There exist both sonographic and magnetic resonance imaging (MRI)based diagnostic criteria.

2. Uterine evaluation (lanjutan dari initial evaluation)

3. Leiomyoma Determining the presence of leiomyomas would require only sonographic examination confirming that 1 or more such lesions are present. 4. Malignancy dan Hiperplasia Combination of ultrasound and hysteroscopic imaging with or without histopathology. -

Diagnosis :

Ada 2 evaluasi yang direkomendasikan oleh ACOG : 1. Initial evaluation Requires the patient to have experienced 1 or a combination of unpredictability (excessive duration, abnormal volume, or abnormal frequency of menses for at least the previous 3 months). Patients should undergo a structured history designed to determine ovulatory function, potential related medical disorders, medications, and lifestyle factors that might contribute to AUB.

Tambahan diagnosis :  Pelvic Exam Menilai : -Cervical and vaginal lesions -Size, shape of uterus  Laboratory -Urine pregnancy test -CBC with platelets -Coagulation studies -Thyroid studies (TSH, T4) -Prolactin  Diagnostic Procedures -Pap smear -Endometrial biopsy (EMB) -Transvaginal ultrasound -Hysteroscopy -Saline-infusion sonography (SIS) -

Treatment :

OVULATORY AUB 􀂋 OCPs Untuk manajemen acute bleeding, dikasih IV premarin 25mg IV selama 4 jam. Disambung

dengan pemberian progestin 7-10 days setelah pemberian premarin. 􀂋 Progestins, IUD Yang paling banyak digunakan adalah norethindrone atau MDPA. Tinggal pilih siklik (secara oral) atau kontinu (dengan IUD).

􀂋 Tranexamic Acid Reduces flow better than progestins dan NSAIDs, termasuk antifibrinolitik. Dosis 1 gr/day, diminum pada hari ke 1-4 saat haid. Risiko thromboembolik? Jurnal study shows no increase in risk. 􀂋 NSAIDs Best option : Ibuprofen selalu  􀂋 GnRH with addback Sangat efektif mengatasi amenore jenis apapun. Banyak side effects, contohnya hot flushes, depresi, osteopenia. Bila dicombine dengan progestins akan mengurangi seide effects, loooh... 􀂋 Danazol Dikasih 200-400 mg/day Lebih efektif daripada NSAIDs dan progestins, tapi side effectnya tidak mengenakkan. Contoh : weight gain dan acne. ANOVULATORY AUB 􀂋 OCs 􀂋 Cyclic progestins 􀂋 GnRH agonists (penjelasan sda) Perlukah surgical treatments? Dilakukan apabila pengobatan dengan medikamentosa GAGAL. Option? 1. Hysterectomy Definitive therapy 2. Hysteroscopy Good for structural causes, myomectomy, polypectomy etc. 3. Endometrial ablation Hysteroscopic or nonhysteroscopic techniques Now the question is..........

Apakah ada perbedaan antara AUB dan DUB? Menurut ACOG, ternyata signifikan dari AUB dan DUB.

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perbedaan

AUB = klasifikasi etiologi dibagi berdasarkan kriteria terbaru PALM & COEIN DUB = etiologinya harus exclude 9 etiologi dari AUB, karena definisinya sendiri adalah “Abnormal uterine bleeding with no attributable underlying illness or pathology, must exclude all other causes of AUB”. -

Etiologi dari DUB :

a. Polycystic ovary syndrome (PCOS) b. Obesity c. Adrenal hyperplasia d. Luteal phase defect (rare) -

Klasifikasi dan diagnosis dari DUB dan AUB sama saja, hanya yang perlu digarisbawahi dan yang menjadi pembeda adalah etiologi!

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Treatment dari DUB :

Selain mengobati penyakit dasar dan perubahan life style, ada beberapa medikamentosa yang direkomendasikan (treatment ini juga bisa diberikan pada pasien AUB, karena pasien DUB dan AUB punya klasifikasi yang sama) :  Massive Intractable Bleeding  Conjugated Estrogens 25 mg IV  Continued Management after Massive Bleeding  Conjugated Estrogens 2.5 mg po daily x 25 days  Medroxyprogesterone acetate 10 mg for the last 10 days  Allow 5-7 days for withdrawal bleed  Administer Mirena IUD  Management of Moderate Menometrorrhagia 1. Estrogen-Progestin Combination  Conjugated Estrogen 1.25 mg po daily x 25 days + Medroxyprogesterone acetate 10 mg po for last 10 days

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OCP x 21 days, with 7 day

withdrawal 2. Cyclic Progestin  Medroxyprogesterone acetate 10 mg po daily x 10-15 days ea. month  Norethindrone acetate 5 mg po daily x 1015 days ea. month

 5 – 7 days menstrual withdrawal should follow cessation ea. month 3. Mirena IUD By : Tamara Ayu Widyasuri