case 7 : Treatments Offered

Abnormal Uterine Bleeding

Definition:
 
Abnormal uterine bleeding (AUB) is irregular menstrual bleeding that is longer or
heavier than usual or does not occur at your regular menstrual time interval.
Abnormal uterine bleeding is seen as early as in young girls i.e. bleeding before
menarche (the first period in a girl's life) , reproductive,premenopausal and
postmenopausal age groups . It is hormonal in origin and hence is a condtion
diagnosed after excluding the following commonly thought of Gynaecological diseases.
 
Common Gynaecological Diseases to be excluded are:
 
1. Fibroid / Adenomyosis
2. Endometriosis
3. Endometrial polyp
4. Cervical polyp or lesion in vaginal tract
5. Adnexal mass
6. Abnormal pregnancy
7. Medical condition : Thyroid hormone dysfunction ,Haemotological causes
8. Iatrogenic cause( drug induced)
 
Symptoms:
 
Any change from the existing menstrual pattern noticed over more then 3 menstrual cycles should
consult a gynaecologist.
The common presentations are : Vaginal bleeding that occurs more often than every 21
days or farther apart than 35 days.
Vaginal bleeding that lasts longer than 7 days (normally lasts 4 to 6 days).
If you are passing more blood clots that soak your pad more than usual, your bleeding is
considered severe and a gynaecologist opinion must be taken.
Pain in abdomen.
 
Diagnosis:
 
Since AUB is diagnosed after exclusion ,before investigations a good history obtained from the
patient helps reach probable diagnosis
 
Investigations
 
1.Pregnancy test
2.BHcg
3. Thyroid function test
4.Coagulation profile
5.Ca125
6.Endometrial Biopsy
7. Ultrasound
8. Operative Hysteroscopy
 
Treatment
 
Medical Management
Progesterone oral and or injectable preparations is the first line of treatment for AUB.
Surgical intervention is to be considered if the lady fails to respond to medical management of minimum of 3 months.
 
Surgical Management
 
1.Hormonal intrauterine
device :Progesterone intrauterine device
2.Hysterectomy
 
Post Menopausal Bleeding
 
Definition:
It is defined as irregularity in menstrual bleeding pattern seen in menopausal women
who has had amenorrhoea for 1 year and more.

Causes of Postmenopausal bleeding:

1. Polyps: These are abnormal growth that develop in the linning of the uterus,
cervix , or inside the cervical canal. They tend to cause erratic bleeding and
present as postmenopausal
bleeding.
2. Endometrial Cancer
3. Certain medication like Hormone therapy, blood thinners etc cause
postmenopausal bleeding.

Symptoms:

1. Spotting or bleeding after not having any menstrual cycle for more than a
year.
2. Pain in the abdomen.
3. Lower back ache

Tests to be done:

1. Ultrasound Abdomen and pelvis.
2. Hysteroscopic Endometrial biopsy: This procedure is done under general
anaesthesia and under vision endometrial tissue is biopsied

Treatment:

Depending on the cause of the postmenopausal
bleeding, the treatment shall vary.
If biopsied tissue is negative for malignancy then lady is asked for regular follow ups.In
rare cases bleeding is troublesome and in such cases Hysterectomy is planned.
Treatment in malignancy cases varies .
Medications are administered to maintain the endometrial lining that has fluctuation
due to hormonal imbalance.
 
Fibroids

Definition:

Fibroids are noncancerous or benign type of tumor that tends to grow in the muscular wall of
the uterus. They are of various sizes and can either occur in multiples or solitary (single).
Depending on the location of the fibroid within the uterine musculature they are classified as:
 
1. Serosal Fibroid: This is seen as a tumor that extends outwards through the uterine
wall which gives a knob like appearance to the uterus. It can either be connected to a
stock or stem ( like a flower connected to the stem) hence being called as
pedunculated.
 
2. Intramural Fibroid: These develop in the lining of the uterus and expand inwards
and therefore pose the maximum discomfort and cause heavy menstrual bleeding.
 
3. Submucosal Fibroid : They are seen just under the lining of the uterus. Since they are
in such close proximity to the uterus any increase in size; even if it’s a small change
would pose heavy menstrual flow along with pelvic pain and prolong periods.

Symptoms:

Menstrual complaints :
Heavy prolonged menstrual bleeding with or without pain and clots.
Pressure symptoms:
In huge fibroid which present as abdominal lump there are pressure symptoms like urinary
frequency or retention of urine.
Some might have constipation or bloating.
Fibroids are also incidentaly diagnosed on sonography as not all fibroids are symptomatic.

Investigations:

Sonography is the best diagnostic tool for fibroids. Rarely 3D
sonography or MRI pelvis is
performed for mapping the exact location of fibroid.

Treatment:

Factors which need to be considered before planning the treatment for fibroid are :
child bearing age group,infertility,site ,size and number of fibroid.
Those fibroids which are symptomatic need to be treated according to its symptoms .

Medical management :

1.Progesterone preparation has a limited role in the management of fibroid
2.GnRh analogues helps in temporarily decreasing the size of the tumor and hence
has a very few indications for its use.

Surgical management :

Laparoscopic Myomectomy It is a minimally invasive surgery / keyhole surgery with the advantages of early recovery,minimal pain,minimal blood loss and tissue damage.
This procedure is performed under general anaesthesia .A minimum of 34 small cuts less
then half cm are made on the abdomen .Laparoscope is a main optical equipment which is
inserted through the belly button and connected to videomonitor for visualisation of the
surgery on the screen .The rest of the ancillary cuts are used for enucleating the fibroid from
its location and delivering it out of the abdomen.
 
Hysteroscopic Myomectomy Hysteroscopicsurgery is performed under general anaesthesia and is a day care surgery indicated for submucous fibroids .The procedure is performed through the birth passage but not cuts are made in this area.Through the vagina hysteroscope enters the cervix ,and after visualisation of the fibroid it is resected out from the uterine cavity.
 
Laparoscopic Myomectomy and Hysteroscopic Myomectomy are procedures in which uterus
is conserved and hence proper patient selection is of prime importance .
Laparoscopic HysterectomyHysterectomy is removal of the uterus along with the cervix in those select few cases where family is complete and there are multiple and/or huge fibroids.

Dr Nandita Dubey

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