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Unusual Uterine Bleeding / Abnormal Uterine Hemorrhage

Definition

Abnormal uterine bleeding is defined as vaginal bleeding after 12 months of having stopped the regular cycles (postmenopausal women)

Unpredictable bleeding after 12 months or more of hormone replacement use.

A more general definition includes prepubertal bleeding (before menarche), postmenopausal bleeding, sinusorrhagia (bleeding during sexual intercourse), menorrhagia, and metrorrhagia.

Terminology

Frequency:

  • Amenorrhea: Absence of menstruation for more than 90 days.
  • Oligomenorrhea: Uncommon bleeding, irregular,> 38 days
  • Polimenorrhea: Frequent but regular 24 days or less.
  • Intermenstrual bleeding
  • Criptomenorrhea: Apparent absence of menstruation

Duration:

  • Metrorrhagia: Irregular, not execive,> 7 days
  • Menorragías: Regular, abudante and> 8 days
  • Menometrorrhagia: Usually excessive and prolonged that occurs at frequent and irregular intervals.

Quantity:

  • Hypermenorrhea: regular,> 80 cc
  • Hypomenorrhea: Regular <30 cc

Parameters of a normal menstrual cycle

Frequency in days:

  • Frequent Period <24 days
  • Normal Period 24-38 -days
  • Uncommon Period> 38 days

Duration

  • Prolonged> 8 days
  • Normal 4.5-7 days
  • Shortened <4 days

Regularity

  • Absence: If there is no bleeding
  • Regular: Less than 6 days between periods
  • Irregular: More than 6 days between periods

Volume of loss

  • Abundant> 80 cc
  • Normal 5-80 cc
  • Scarce <5 cc

It must be taken into account that the abnormal uterine bleeding is a SYMPTOM, NOT a diagnosis.

There is no clearly demonstrable pathology

Etiology

  • Systems
  • local
  • Iatrogenic

system PALM- COEIN

Structural (PALM): Polyps, adenomyosis, leiomyomatosis, malignancy or hyperplasia

The characteristics of the structural

  • Visible
  • Measurable
  • Quantifiable
  • Classifiable

These can be diagnosed by means of:

  • Imaging
  • Direct Vision
  • Pathological anatomy

Structural causes (PALM)

  • Cervix
  • Intrauterine
  • Hormonal

Non-structural (COEIN): Coagulopathies, ovarian dysfunctions (These are more related to the Hipotalamo-Hipofisis-Ovary axis), endometrial, Iatrogenic, Not Classified

We refer to Systemic Diseases, it is due more to endocrine problems

  • Molecular control of menstruation
  • Alterations of the Hipotalamo-Hipofisis-Ovario axis (Endocrine problems, its most frequent cause is anovulation)
  • Alterations of hemostasis

Anovulation

  • Excess estrogen
  • There is no peak of LH
  • Hypothyroidism
  • Hyperprolactinemia
  • Polycystic ovaries

Its most frequent cause is polycystic ovarian syndrome

  • Anovulatory 90%: Disruption of E2; Suppression of E2
  • Ovulatory 10% (The duration of the corpus luteum will be shortened by inadequate stimulation): Disruption of P; Suppression of P

Frequency

  • 20-29 years 30%
  • > 40 years 45%

Other causes of Bleeding

  • Vitamin K deficiency: Low levels, defective absorption, inhibition of VK-producing GI flora
  • Drug-induced hemorrhage: Heparin and Warfarin
  • Disproteinemias: Myeloma, Macroglobinemia, Von Willebrand Factor
  • Severe liver disease
  • Primary fibrinolysis

Functional menorrhagia

Altered metabolism of prostaglandins

Cause: We speak of functional menorrhagia when abnormalities in the biochemical process.

  • Increase of prostaglanins that are vasodilators vs prostaglandins that are vasoconstrictors.
  • Increase in factors that decrease platelet adhesiveness.

Whenever we do not find a cause of bleeding, we can say that the patient has abnormal uterine bleeding

If we find any etiology this will be your diagnosis

Differential Diagnostics

  • leiomyoma
  • Endocervical polyp, endometrial
  • Adenomyosis
  • Chronic endometritis
  • Endometrial hyperplasia – malignancy
  • Cervical malignancy – Vaginal

Causes of Bleeding according to your period of fertility

Pre-menarche

  • Neoplasms (Hormone-producing Neoplasms)
  • Trauma (Sexual Abuse)

Fertile age

  • Demonstrable cause?
  • Iatrogenic (Hormones)
  • Systemic diseases
  • Neoplasms: Benign or Malginas. (Utero, Ovaries, etc …)

Postmenopause

  • Iatrogenica (Hormone Replacement Therapy)
  • Atrophy
  • Neoplasms: Benign or malignant

Examples of Postmen Bleeding Causes

  • Ovary
  • Uterine body
  • Cervix
  • Vagina
  • Urethra
  • Vulva

Classification

Aguda: Acute: An episode of uterine bleeding in a woman of reproductive age, who is not pregnant and who requires immediate attention to prevent further blood loss or subsequent heavy bleeding (Make treatment to reduce and prevent bleeding).

Chronic: Abnormal bleeding that comes from the uterine body; with alteration in duration, quantity or frequency (or all three) with a duration of 3 months. (sinusorragia does NOT fall into this classification). This bleeding can make the patient unsteady.

Intermenstrual: A Bleeding that occurs between menstruations clearly defined as cyclical and predictable; it includes the occurrence of random episodes, as well as those that manifest themselves predictably at the same time in each cycle. (Intermenstrual bleeding from ovulation).

Clinical manifestation

  • Age
  • Cycle characteristics (This is important to compare with the control parameters)
  • Bleeding characteristics
  • symptom
  • Signs
  • Other associated pathologies

Laboratories

  • Pelvic / transvaginal ultrasound / HSG
  • Cervical cytology
  • Serology for STIs
  • Thyroid function
  • Liver tests
  • BHCG
  • Blood count
  • Ferritin
  • Coagulation studies
  • FSH / LH
  • Progesterone (requested on day 21 of the cycle)
  • Hysteroscopy- Bx

All measurement of sex hormones must be done in the recruitment phase (Follicular), In the first 5 days of the cycle

Treatment

Objective: To avoid or reduce abnormal uterine bleeding. This management will depend if it is an acute bleeding or a chronic Bleeding

REMEMBER: DO NOT GIVE TREATMENT TO WOMEN GREATER THAN 35 YEARS WITHOUT PREVIOUS ENDOMETRIAL STUDY- SINCE HORMONAL MANAGEMENT WILL REMOVE BLEEDING WITHOUT TREATING THE CAUSE AND WITHOUT MAKING A DIAGNOSIS.

Medical treatments:

  • Hormone (The estrogens cause the endometrium to proliferate and will initially control the bleeding)
  • Antibiotics
  • Antifrinolitics (Each time your period arrives)

Surgical

  • Curetaje
  • Enometrial ablation
  • Hysterectomy

Generalities for handling

  • Pubs
  • Fertile age> 35 years
  • Premenopausal
  • Postmenopausal
  • Acute
  • Chronicle

All these women must have a pathology study that tells us what is happening at that time.

Since if we are going to perform a hormonal treatment we must know if there is a malignant lesion or other cause that is causing bleeding.

Medical Management of Acute Uterine Hemorrhage

Commitment of the general state

  • Hospitalize
  • Stabilize and rule out pregnancy
  • Estrogen IV: 25 mg / 6 hours x 4 doses
  • Concomitant oral estrogen (Viralate estradiol 2mg-21 dragees and Norgestrel 2mg 10 dragees -> This helps to follow the cycle)
  • Continue use with antifibrinolytics 1 gr every 6 hours, NSAIDs or progestins (Do not give more Hormones)
  • No response: Curettage or curettage.

17 Beta-Estradiol is the natural estrogen of women

Post treatment

  • Continue with oral estrogens x 21 days
  • Start progestins on day 16-25 (Medroxyprogesterone acetate 5 mg / day tablets for 10 days)

External consultation

  • Von Willembrand factor (It is the most frequent deficiency)
  • Sangria time
  • Transvaginal echo: endometrial thickness
  • Endometrial biopsy: rule out malignancy

Medications in Outpatient Consultation

  • Oral contraceptives
  • Oral progestins or in IUD
  • NSAIDs: Mefenamic Acid 500mgr c / 6 hours; decreases 30%
  • Tranexamic Acid: Decreases by 50%

Surgical Management

  • Curettage biopsy
  • Hysteroscopy + biopsy
  • Endometrial ablation: thermal or electrical
  • Hysterectomy

Teenagers

Menstruation is a vital sign

  • Menarche 11-14 years
  • Cycles 21-45 days
  • Duration <7 days
  • 3-6 towels or tampons / day

Causes of abnormal Sacred in adolescents

  • Thrombocytopenia is the first cause of bleeding in adolescents.
  • Disorders of platelet function
  • Abnormal collagen
  • Deficiency of coagulation factors
  • Von Willembrand Factor

Clinical history for Von Willembrand

Coagulopathies (Category C)

  • Heavy menstrual bleeding from the menarche
  • One of the following
  • Transfusions- iron substitution
  • Two or more of the following symptoms

Associated Gynecological Pathologies

  • Patient between platelets and the site of injury: Facilitates agglutination and adherence
  • Protects factor VIII from rapid proteolytic degradation
  • Hemorrhagic ovarian cysts
  • Endometriosis

Laboratory exams

  • Sangria time
  • Factor VIII level
  • Analysis of platelet activity
  • Platelet count
  • Specific tests for the von willebrand factor

Control

  • Hormonal
  • No Hormonal

Use of tampons

  • Follow the instructions regarding the insertion.
  • Choose the lowest absorbency level
  • Change your tampon
  • Consider alternating
  • Know the signs of toxic shock syndrome
  • Do not use tampons between periods

Symptoms and signs of Toxico shock syndrome

  • High fever that appears suddenly
  • Muscle pains
  • Diarrhea
  • Dizziness or fainting
  • Rash similar to sunburn
  • Sore throat
  • Redness in the eyes

Monitoring Therapy

Four cycles should be quoted later for “Satisfactory Response”

  • Duration of bleeding <7 days
  • 4 episodes of menstrual bleeding in 4 cycles
  • blood loss <80 cc in each cycle
  • Maximum 1 episode of bleeding> 80 cc
  • No more than 24 days of bleeding in all 4 cycles
  • No increase in the basal number of bleeding days

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