Abnormal Uterine Bleeding Abnormal uterine bleeding is a common problem encountered in general practice.
Classification of Abnormal Uterine Bleeding
Abnormal Rhythm
- Irregularity of the cycle
- Inter menstrual bleeding (metorhagia)
- Post coital bleeding
- Postmenopausal bleeding
Abnormal Amount
- Increased amount = menorrhagia
- Decreased amount = hypomenorrhoea
Combination (Rhythm and Amount)
- Irregular and heavy periods = metromenorrhagia
- Irregular and light periods = oligomenorrhoea
Key Facts and Checkpoints
- Up to 20% of women in the reproductive age group complain of increased menstrual loss.
- At least 4% of the consultants in general practice deal with abnormal uterine bleeding.
- Up to 50% of the patients
who present with perceived menorrhagia ( or excessive blood loss)
have a normal blood loss when investigated.
- The possibility of
pregnancy and its complications, such as ectopic pregnancy, abortion
(threatened, complete or incomplete), hydatidiform mole or
chroriocarcinoma should be kept in mind.
- The mean blood loss in a menstrual cycle is 30 –40 ml.
- A menstrual record is a useful way to calculate blood loss.
- Blood loss is normally less than 80 ml.
- Menorrhagia is a menstrual loss or more than 80 ml per menstruation.
- Menorrhagia disposes women to iron efficiency anaemia.
- Various drugs alter menstrual bleeding e.g. anticoagulants , cannabis, steroids.
Defining what is Normal and what is Abnormal
This feature is based on a
meticulous history, an understanding of the physiology and physiopathology of the menstrual cycle and a clear understanding of what
is normal. Most of the girls reach menarche by the age of 13 ( range
10- 16). Dysfunctional bleeding is common in the first 2 –3 years
after menarche due to many anovulatory cycles resulting in irregular
periods and probably dysmenorrhoea.
Once ovulation and regular
menstruation are established the cycle usually follows a predictable
pattern and any deviation can be considered as abnormal uterine
bleeding. It is abnormal if the cycle is less than 21 days, the duration
of loss is more than 8 days or the volume of loss is such that
menstrual pads of adequate absorbency cannot cope up with the flow or
clots.
Relationship of Bleeding to Age
Dysfunctional uterine bleeding
is more common at the extremes of the reproductive era. The incidence
of malignant disease as a cause of bleeding increases with age, being
greatest after the age of 45 , while endometrial cancer is predicted
to be less than 1 in 100 000 in women under the age of 35.
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==========================================
==========================================Menorrhagia
Menorrhagia is cyclical
bleeding at nornal intervals which is excessiue in amount and duration
i.e. 5/28 or 8/28. Is essentially caused by hormonal dysfunction (
e.g.anovulation), local pathology (e.g. fibroids) or medical disorder
(blood dyscrasia). In Menorrhagia the menstrual cycle is unaltered but
the duration and quantity of menstrual loss are increased. Menorrhagia
is essentially a symptom and not in itself a disease. Heavy bleeding,
associated with clots is the major symptom of menorrhagia.
Dysmenorrhoea may accompany the bleeding and, if it does,
endometriosis or pelvic inflammatory disease (PID) should be
suspected. With care 60 – 80% accuracy can be achieved in clinical
assessment.
Etiology: General Diseases Causing Menorrhagia
- Blood dyccrasias i.e leukemia, coagulopathy , thrombocytopenic purpura, severe anaemia.
- Thyroid dysfunction – hypo and hyper thyroidsim in initial stages.
- One of the Commonest causes of menarrhagia in administration of Exogenous estrogen for Climactric symptoms.
Local Causes
- Uterine fibroids, fibroid polyps.
- Chocolate cyst, ovarian feminizing tumours, PCOD, endometriosis, adenomyosis.
- Salpingo – oophoritis , pelvic inflammatory disease, genital TB.
- Immediate puerperal and post abortal periods.
Iatrogenic Causes are
- Oestrogen and progesterone administration ( minipil)
- The Intrauterine Contraceptive Device
- 5 – 10 % of women using the device suffer from menorrhagia in the first few months.
- Post sterilization it is reported in 15 % of cases but the etiology is not clear.
Hormonal: Dysfunction Uterine Bleeding
Clinical Approach for Menorrhagia
History
A detailed history is the key
initial step in the management. A patient’s perception of abnormal
bleeding may be quite misleading and education about normality is all
that is necessary in her management. 30% of Premenopausal women perceive
their menses to be excessive, reports show that only 10% of these
women have clinical menorrhagia. A history should include details of
number of tampons or pads used and the degree of saturation. A
menstrual calendar (over 3 months) can be a very useful guide. A
history of smoking and other psychological factors should be checked.
For unknown reasons cigarette smokers are five times more likely to
have abnormal menstrual cycles.
Questions need to be directed to rule out
- Pregnancy or Pregnancy Complication, e.g. Ectopic Pregnancy, abortion
- Trauma of the Genital Tract
- Medical disorders e.g. bleeding disorders
- Endocrine disorders
- Cancer of genital tract
- Complications of the pill
Physical Examination A general physical examination
should aim at ruling out anaemia, evidence of bleeding disorders and
any other stigmata of relevant medical or endocrine diseases.
Specific Examination Includes:
- Speculum examination - ulcer (cervical cancer)or polyps
- Pap smear
- Bimanual pelvic examination - uterine or adnexal tenderness, size and regularity of the uteru
Vaginal examination is avoided
in selected patients, such as a young virgin girl, as the procedure is
unhelpful and unnecessarily traumatic.
Investigations especially
vaginal ultrasound scans should be selected very carefully and only when
really indicated. Abnormal pelvic examination findings , persistent
symptoms , older patients and other suspicious of disease indicate
further investigation to confirm symptoms of menorrhagia and exclude
pelvic or systemic pathology.
Consider foremost:
Special investigations (only if indicated)
- Pregnancy testing
- Laparoscopy where endometriosis .PID, or other pelvic pathology is suspected
- Serum biochemical screen
- Coagulation screen
- Thyroid function tests
- Tests for SLE: anti nuclear antibodies
Treatment of Menorrhagia
Treatment depends on several factors:
- The age of the patient, her fertility and her desire for children. Under forty, treatment is essentially conservative.
- The degree of anaemia.
- The response to curettage, which is performed primarily as an aid to diagnosis, may be
therapeutically beneficial. There is no scientific explanation why
curettage should benefit dysfunctional bleeding. Curettage should therefore precede hysterectomy in almost every instance.
Conservative Treatment: If the bleeding is not very heavy and the patient’s haemoglobin is
normal, observation and maintenance ofmenstrual chart for a few months
is in order. Sponstaneous cure is possible and can be awaited. In a
patient suffering from severe dysfunctional bleeding, some degree of
anaemia is to be expected. Oral iron should be given and the response to
it checked by serial blood counts. Systemic iron should be given to
those patients where oral iron is not tolerated. Rest, sedative and
reassurance must not be neglected. Blood transfusion is needed in severe
anaemia.
Hormone Therapy
- Oestrogen.
The aim of treatment is to raise the blood oestrogen level
to the super-threshold for bleeding and to achieve this a large initial
dosage is necessary. This means administration of ethinyl oestradiol,
0.25 mg t.d.s . It is, therefore, necessary to continue an artificial
cycle at a fairly high level of blood oestrogen by maintaining
ethinyl oestradial dose of 0.25 mg daily for 21 days. During the last
10 days of this artificial cycle, 10 mg of oral progestational steroid
is given. The 3 weeks cyclical treatment is continued for the next
three to six months, after which the patient is kept under
observation. Today, oestrogen alone is not advocated because of the
cardiovascular side effects of high dosage and the risk of developing
carcinoma of breast and endometrium.
- The newer orally active progestational steroids, such as nor-ethynodrel, nor-ethisterone or lynestrenol are used as an alternative and these are safer than
oestrogen. A high initial dose of 10 to 30 mg a day should arrest bleeding in 24-28 hours, after which 5 mg a day for 20 days is given.
Withdrawal bleeding occurs two to five days after cessation of treatment and a normal loss is to be expected. A second course of 5 mg
daily is given from day 5 for 20 days, after which withdrawal
menstruation should occur. This treatment can be continued for three
to six months and should be stopped to observe the patient. Duphaston
does not suppress ovulation, has no adverse effect on low LDL and is
useful in young women desirous of pregnancy. Medroxyprogesterone
acetate (MDPA) 10 mg tab is also free of adverse effect on
lipoproteins.
Progestogen impregnated IUDs (progestasert), also reduce
blood loss in 97% cases and are as effective as endometrial ablation
done hysteroscopically. Another advantage is the IUD can be left in for a
year, offering one time treatment.
Instead of 3 week cyclical therapy, luteal phase
administration of progestogen minimizes the duration of therapy, though
it may not be as effective.
- Danazol is androgenic and is not recommended as a drug of choice in cases of menorrhagia, more
so in young women. Short term tratment (6 or less)in severe
menorrahagia, given in a doseof 100 – 200 mg daily.
- Combined oral contraceptive pills are useful in menorrhagia if a woman does not
desire a pregnancy. It is more effective than oestrogen or progestogen
alone. It reduces blood loss by 50% and eliminates dysmenorrhoea. The
first line therapy e.g. 50 m g oestrogen 1 mg norethisterone:
norinyl.
- Clomiphene is advocated if pregnancy is desired, and if cycles are anovulatory.
- Ethamsylate reduces the capillary fragility; 500 mg 4 times a day started from 5 days prior to
the anticipated start of the period to 10 days after, reduces
menorrhagia by 50%. No major side effects have be reported.
NSAID:
Mefenamic acid 500 mg t.i.d. taken during meals and given during
menstruation for 5-6 days controls menorrhatgia in 70% cases of
ovulatory cycles or naproxen 500 mg T.I.D. or Ibubrufen 800 mg statum
then 400 mg 8 hourly.
Antifibrinolytic Agents:
Tranexamic acid 1-2 g 4 times a day for 6-7 days during menstruation.
Nausea, vomiting, diarrhoea, headache, visual disturbances and
intracranial thrombosis have been reported.
GnRH: Administration by nasal sprays (synarel) or monthly implants (zoladex) to induce medical “menopause” 3-6 months.
Typical treatment options for acute and chronic heavy bleeding
Acute Heavy Bleeding
- Curettage/hysteroscopy
- Oestrogens (Premarin 25 mg) or oral high-dose progestogens
e.g. norethisterone 5-10 mg 2 hourly until bleeding stops then 5 mg bd otds for 14 days
Chronic Bleeding
- For anovulatory women
- Cyclical oral progestogens for 14 days
- Tranexamic acid
</li>
For ovulatory women
Cyclical prostaglandin inhibitor e.g. mefenamic acid
Oral contraceptive
Antifibrinolytic agent, e.g. tranexamic acid 1 g (o) qid, days 1-4
Progesterone-releasing IUDs
</li>
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==========================================
==========================================Dysfunctional Uterine Bleeding
Dysfunctional uterine bleeding
(DUB), which is a diagnosis of exclusion, is defined as excessive
bleeding, whether heavy, prolonged or frequent of uterine origin, which
is not associated with recognizable pelvic disease, complications of
pregnancy or systemic diseases. If on bi manual examination the uterus
and appendages are found to be normal the term dysfunction uterine
bleeding is used.
The etiology is purely hormonal
and the hypertrophy and hyperplasia of the endometrium are induced
by high titres of oestrogen in circulating blood.
Classification of Dysfunctional Uterine Bleeding |
Anovulatory |
Ovulatory |
| Thereshold bleeding of puberty menorrhagia | Irregular ripening |
| Metropathia haemorrhagica | Irregular shredding |
| Premenopausal dysfunction uterine bleeding | IUCD insertion |
| Following sterilization operation |
Puberty Menorrahagia:
Is a threshold bleeding of
adolescence caused by excessive or un opposed oestrogens and absence of
progesterone in the anovulatory cycle.
Premenopausal Menorrhagia:
Is seen in women in anovulatory
cycle. It is essential to rule out endometrial carcinoma by
dilatation curettage, uterine aspiration or hysteroscopic directed
biopsy.
Features
- It is a working clinical diagnosis based on the initial detailed history, normal physical
examination and normal initial investigation.
- Very common: 10-20% incidence of women at some stage.
- Peak incidence of ovulatory DUB in late thirties and forties (35-45 years).Anovulatory
DU B has two peaks: 12-16 years and 45-55 years.
- Anovulatory DUB has two peaks: 12-16 years and 45-55 years.
- The majority complains of menorrhagia.
- Up to 40% with the initial diagnosis of DUB will will have other pathology (e.g.
fibroids, endometrial polyps) if detailed pelvic endoscopic
investigations are undertaken.
Symptoms
- Heavy bleeding: saturated pads, frequent changing, ‘accidents’, ‘flooding’, and ‘clots’.
- Prolonged bleeding – menstruation > 8 days Or heavy bleeding > 4days.
- Heavy bleeding- periods occur more than once every 21 days.
- Pelvic pain and tenderness are not usually prominent features.
Management Principles
- Establish diagnosis by confirming symptoms and exclude other pathology.
- If no evidence of iron
deficiency or anaemia, and significant pathology has been excluded,
prospective assessment of the menstrual pattern is indicated using a
menstrual calendar.
- Conservative management is usually employed if the uterus is of normal size and there is no evidence of anaemia.
- Drug therapy is indicated if symptoms are persistently troublesome and surgery is
contra-indicated or not desired by the patient.
- Provide reassurance about the absence of pathology, especially cancer, and give counseling to
maximize compliance with treatment.
- Consider surgical management if fertility is no longer important and symptoms cannot be
controlled by at least 3-4 months of hormone therapy.
General rule: < 35 years – medical treatment
- 35 years – hysteroscopy and direct endometrial sample (diagnostic-sometimes Therapeutic)
Treatment Treatment is governed by factors such as age, amount of bleeding, associated conditions.
I. General
When bleeding is heavy advise
bed rest, sedatives if necessary, advocate normal activity between
episodes of bleeding, treat anemia if present.
II. Medical Management
- Non-hormonal methods
- Prostaglanding synthetase inhibitors:
Mefanamic acid 250 – 500 mg tid is effective in reducing menstrual
loss by 25% other agents that can be used are Diclofenac Ibuprofen and
Naproxen.
- Antifibrinolytic agents EACA 3gms 4
times daily or Tranexamic acid lgm 2-4 times a day. These agents can
reduce menstrual loss by 50%. These may be tried when hormonal
treatment is contraindicated.
- Hormones
Play a very important role in women of reproductive age and rarely used after the age of 40.
The drugs used are estrogens, progestogens and estrogen – progestogen combination.
- Estrogens: indicated when bleeding is
very heavy and unresponsive to progestogens and in anovulatory
bleeding conjugated equine estrogen (CEE) 12.5 mg IV to stop bleeding
and repeat after 12hrs if necessary. Subsequently use OC pills or
progestogens.
- Progestogens: Oval synthetic
progestogens or injectable progestogens can be used in avovulatory DUB
in girls and young women. “This is known as medical curettage”
hyperplastic endometrium converted into secretary endometrium to
precipitate shedding when treatment stopped.
10-30mg of Norethistorone acetate daily is given in
heavy bleeding till it stops then treatment is stopped, withdrawl
bleeding starts in 2-3 days and stops on its own accord.
If prolonged heavy bleeding occurs then repeat the cycle.
To avoid relapses usually dehydro progesterone a
medroxyprogesterone is given from 16-25 days of cycle, this is continued
for 3-6 cycles.
- Oestrogen – Progestogens Combination:
Combined oral contraceptive pills can be used in
ovulatory DUB. This treatment may not control bleeding in 20% of cases,
in these cases its advisable to use pill with higher estrogen content.
- 1UCD: Intrauterine progesterone and
Levonorgestrel 1UCD have also been found to be effective. This has the
advantage of avoiding daily intake of tablets and side effects are
low.
- Androgens: These compounds are useful
in all types of DUB but avoided due to unpleasant side effects like
virilization. Mostly used in women more than 40 years age drugs used
are methyl testosterone 5-10mg daily for 2 months.
Mixed preparations of Androgen and estrogen and androgen and progesterone are used for hemostatic purpose.
Another useful drug is Danazole 200-400mg for 12 weeks, effective in reducing blood loss by 50%.
- GnRH Analogues:
Used in anovulatory DUB and endometrial hyperplasia.
</li>
III. Surgical Treatment:
The determining factor for
surgical modality of treatment in DUB is age, last resort, in young
patients and can be considered in women above 40 years of age.
- D & C: D&C is primarily done for diagnostic purpose and same times may have Curative benefit in some cases.
- Endometrial Ablation:
Endometrial layer of uterus is ablated by using
electrocautery.The procedure is relatively simple, used mainly in cases
where patient desires to retain uterus and has no desire for
pregnancy, can be used in cases where there are medical
contraindications for surgery.
- Hysterectomy:
This surgical remedy is used in patients above 40 years and
in cases where simple treatment has failed to give respite. Can be
done vaginally or by abdominal route.
IV. Radiotherapy:
In rare cases where surgery is
contraindicated and medical measures are ineffective DUB can be
controlled by external irradiation.
Cycle Irregularity
For practical purposes, patients with irregular menstrual cycles can be divided into those under 35 and those over 35 years.
Patients under 35:
- The cause is usually hormonal, rarely organic, but keep malignancy in mind
- Management options
- Explanation and reassurance (if slight irregularity).
- COC pill for better cycle control – any pill can be used.
- Progestogen-only pill (especially anovulatory cycles) norethisterone (Primolut N) 5-15 mg/day from day 5 –25 of cycle.
Patients over 35 should be
referred for investigation for organic pathology, usually endometrial
sampling and / or hysteroscopy. If normal, the above regimens can be
instituted.
Intermenstrual Bleeding and Postocaital Bleeding
These bleeding problems are due
to factors such as cervical ecotropion (often termed cervical
‘Erosion’), cervical polyps, the presence of an IUCD and the oral
contraceptive pill. Cervical cancer and intrauterine cancer must be
ruled out. Hence there is importance of a Pap smear in all age groups
and endometrial sampling, especially in the over 35 age group. Refer
women with bleeding problem associated with abnormal smear. Those with a
friable ectropion that is causing persistent symptoms should also be
referred. Thus inter menstrual bleeding should always be investigated.
Cervical ectropion, which is
commonly found in women on the pill and post partum, can be left
untreated unless intolerable discharge or moderate post coital bleeding
is present. An IUCD should be removed if causing significant symptoms
and the causative pill should be changed to one with a higher
oestrogen dose (e.g. from 30 ug oestrogen to 50 ug oestrogen).
Amenorrhea
Amenorrhea is the absence of menstrual bleeding. It is a normal feature in prepubertal, pregnant, and postmenopausal females.
False Amenorrhea
It is a condition where there
is absence of menstrual flow due to outflow obstruction at the level of
the cervix, vagina or vulva. It presents as amenorrhea although
menstruation is taking place. This is also known as cryptomenorrhea.
True Amenorrhea
It is the condition in which menstrual function is suppressed due to physiological or pathological causes.
- Physiological
- Before puberty
- Adolescence
- Pregnancy
- Lactation
- Menopause
</li>
Pathological
Primary
Secondary
</li>
Physiological Amenorrhea
Before puberty Amenorrhea is normal during
childhood. Menstruation is usually established by the age of 16 years
but may not appear until the age of 18 years without any abnormality.
Adolescence Initial menstrual cycles are
often anovulatory and therefore irregular. Periods of amenorrhea lasting
for 2-12 months after menarche for 1-2 years are regarded as normal.
Pregnancy It is the most common cause of
secondary amenorrhea. The amenorrhea is due to continuous production
of estrogen and progesterone by the chorion.
Lactation Menstruation is suppressed for a varying period of time due to production of prolactin by the hypothalmo-pituitary system.
Menopause It is the cessation of
menstruation as the ovaries cease to react to the gonadotrophic stimulus
and stop production of the hormones estrogen and progesterone.
Primary Amenorrhea Primary amenorrhea can be
diagnosed if a patient has normal secondary sexual characteristics but
no menarche by 16 years of age. If a patient has no secondary sexual
characteristics and no menarche, primary amenorrhea can be diagnosed as
early as 14 years of age.
Causes
- Hyperprolactinemia
(Prolactin = 100 ng per mL)
- Altered metabolism
- Liver failure
- Renal failure
</li>
</li>
<li>Ectopic production
- Bronchiogenic (e.g. carcinoma)
- Gonadoblastoma
- Hypopharynx
- Ovarian dermoid cyst
- Renal cell carcinoma
- Teratoma
Breast feeding
Breast stimulation
Hypothyroidism</li><li>Medications
- Oral contraceptive pills
- Anti psychotics
- Anti depressants
- Anti hypertensives
- H2 receptor blocker
- Opiates
Prolactin >100ng/mL
- Empty sella syndrome
- Pituitary adenoma
</li><li>Hypergonadotropic hypogonadism
- Gonadal dysgenesis
- Turner's syndrome
- Other
</li>
Postmenopausal ovarian failure
Premature ovarian failure
Autoimmune
Chemotherapy
Galactosemia
Genetic
17-hydroxylase deficiency syndrome
Idiopathic
Mumps
Pelvic radiation
</li>
</li><li>Hypogonadotropic hypogonadism
- Anorexia or bulimia nervosa
- Central nervous system tumor
- Constitutional delay of growth and puberty
- Chronic illness
- Chronic liver disease
- Chronic renal insufficiency
- Diabetes
- Immunodeficiency
- Inflammatory bowel disease
- Thyroid disease
- Severe depression or psychosocial stressors
</li>
Cranial radiation
Excessive exercise
Excessive weight loss or malnutrition
Hypothalamic or pituitary destruction
Kallmann syndrome
Sheehan's syndrome
</li><li>Normogonadotropic
- Congenital
- Androgen insensitivity syndrome
- Müllerian agenesis
- Hyperandrogenic anovulation
- Acromegaly
- Androgen-secreting tumor (ovarian or adrenal)
- Cushing's disease
- Exogenous androgens
- Nonclassic congenital adrenal hyperplasia
- Polycystic ovary syndrome
- Thyroid disease
- Outflow tract obstruction
- Asherman's syndrome
- Cervical stenosis
- Imperforate hymen
- Transverse vaginal septum
</li><li>Other
 |
| Evaluation of a Case of Primary Amenorrhea |
Secondary amenorrhea
Secondary amenorrhea is the
absence of menstruation for three months in women with previously normal
menstruation and for nine months in women with previous
oligomenorrhea. Secondary amenorrhea is more common than primary
amenorrhea.
Causes
After pregnancy, thyroid
disease, and hyperprolactinemia are eliminated as potential diagnoses,
the remaining causes of secondary amenorrhea are classified as
- Normogonadotropic amenorrhea
- Hyperandrogenic anovulation
- Acromegaly
- Androgen-secreting tumor (ovarian or adrenal)
- Cushing's disease
- Exogenous androgens
- Nonclassic congenital adrenal hyperplasia
- Polycystic ovary syndrome
- Thyroid disease
- Outflow tract obstruction
- Asherman's syndrome
</li>
</li>
<li>Hypogonadotropic hypogonadism
- Anorexia or bulimia nervosa
- Central nervous system tumor
- Chronic illness
- Chronic liver disease
- Chronic renal insufficiency
- Diabetes
- Immunodeficiency
</li>
Excessive exercise
Excessive weight loss or malnutrition
Hypothalamic or pituitary destruction
Sheehan's syndrome
</li><li>Hypergonadotropic hypogonadism
- Gonadal dysgenesis
- Postmenopausal ovarian failure
- Premature ovarian failure
- Autoimmune
- Chemotherapy
- Galactosemia
- Genetic
- 17-hydroxylase deficiency syndrome
- Idiopathic
- Mumps
- Pelvic radiation
</li>
Treatment
Special Investigations to Corroborate Clinical Diagnosis |
Probable diagnosis
|
Investigations
|
Findings
|
| Mullerian agenesis | Laparoscopy
Karyotype
IVP
| Uterus- absent
Tubes-present
Ovaries-normal
46XX
Urinary tract abnormalities
(30%) |
| Unresponsive endometrium | Progesterone challenge test
HSG | Negative
Normal uterine activity |
| Uterine synechiae | Progesterone challenge test
HSG
Hysteroscopy | Negative
Honeycomb appearance
Direct visualization |
| Tuberculosis | Blood-ESR
Chest X Ray
Mantoux test
Endometrial biopsy | Raised
Positive findings
Usually positive
Positive lesion may be detected |
| Hypogonadotropic Hypogonadism | Progesterone challenge test
Serum gonadotropins | Positive
Low<5mIU/mL |
| Primary ovarian failure | Karyotype
Serum gonadotropins
Ovarian biopsy | 46XX
Elevated >40mIU/mL
Follicle(-) or ( )
-resistant ovarian syndrome |
| Turner syndrome | Karyotype
Laparoscopy | 45XO or 45 XO/46XX
Streak gonads |
| Androgen insensitivity syndrome | Karyotype
Gonadal biopsy | 46 XY
Testicular structure |
| Androgenital syndrome | Karyotype
Serum hydroxyl progesterone
Urinary preganetriol | 46 XX
Elevated (>8ng/Ml) |
| Thyroid dysfunction | Serum TSH
T3, T4 | Elevated
Lowered |
| Diabetes | Blood sugar | Elevated |
The general treatment includes
correction of errors in diet, working conditions, home environment,
the use of leisure and reduction of weight in case of obesity. In a
large number of cases in which the cause of amenorrhea is not an
organic disease, it cures itself spontaneously. Such an outcome should
always be awaited before starting hormonal therapy or other special
treatment. Hormonal therapy is instituted depending on the underlying
disorder.
| Hormone |
Disorder |
| Thyroid | Hypothyroid |
| Cortcosteroid | Congenital adrenal hyperplasia |
| Cyclical estrogen and progesterone | Primary amenorrhea, Premature ovarian failure |
| Clomiphene | PCOS, post pill amenorrhea, Chiari frommel syndrome |
| Gonadotrophins | Infertility due to failed pituitary function and responsive ovaries |
| GnRH agonists | Hypothalmic cause or cause in cerebral cortex |
| l-dopamine | Hyperprolactenemia |
| Bromocriptine | Hyperprolactenemia, Pitutary tumor |
Surgical Treatment
Wedge resection or laproscopic
laser ablation of ovaries is practiced in patients with PCOD who do
not respond to medical treatment.
Postmenopausal Bleeding
Postmenopausal bleeding is
vaginal bleeding of any amount occurring six months or more after the
menopause. It suggests cervical or uterine body cancer (up to 25%).
Other causes include polyps, atrophic vaginitis, endometrial hyperplasia
and urethral caruncle. Care has to be taken with women on HRT who
have irregular bleeding – they require investigation.
Early referral is usually
indicated with a view to a diagnostic procedure. If bleeding recurs
despite curettage, hysterectomy should be performed since early cancer
of the uterus may be missed.
When to Refer
- To exclude intrauterine pathology.
- The patient does not respond to initial therapy.
- There is evidence of underlying disease, e.g. endometriosis, SLE.
- Surgery is indicated (minor or major).
Practice Tips:
References:
1. General practice by Dr. John Murtagh
2. Shaws text book of gynaecology
============
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Subject: Abnormal Uterine Bleeding (RCGP) 
Thu May 03, 2012 1:12 am
