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DOKTER MUDA
DEFINITION
The evaluation of abnormal uterine bleeding (AUB) requires characterization and quantification of the bleeding,specifically the onset, duration, frequency, amount,and pattern which is occurring both within and outside the menstrual cycle.
MENSTRUAL DIMENSIONS
Normal 24-35 days
Menstrual Frequency
Breakthrough bleeding
Normal 4 to 6 days
b. c. d. e. f. g. h.
Perimenopausal Anovulatory due a. Pregnancy a. Anovulatory to immaturity of related b. Endometrial hypothalamicb. Anovulatory hyperplasia pituitary-ovarian c. Vaginal/pelvic c. Endometrial axis infection polyps Coagulopathy d. Pelvic tumor d. Leiomyomas Pregnancy e. Endocrinopathie e. Adenomyosis Vaginal/pelvic s f. Genital tract infection f. Coagulopathy neoplasm Benign lesions Medications Mllerian anomalies Genetic abnormality
Adolescent
Reproductive
Menopausal a. Atrophy b. Endometrial carcinoma c. Endometrial hyperplasia d. Endometrial polyp e. Leiomyomas f. Hormone replacement therapy
Adapted from Shwayder JM. Pathophysiology of abnormal uterine bleeding. Obstet Gynecol Clin North Am 2000;27:219-234, with permission.
EVALUATION OF AUB
ULTRASONOGRAFI Transvaginal Ultrasonografi (TVUS) TVUS is useful to evaluated for the presens of fibroids, intrauterine pregnancy and ectopic pregnancy. Saline Infusion Sonografi It is the most sensitive non invasive method of diagnosis for endometrial polyps and submucous myomata. But, it does not distinguish between benign and malignant processes. HYSTEROSCOPY The advantage of this procedure is that it provide direct visualization of the endometrial cavity and can be performed in the operating room. MAGNETIC RESONANCE IMAGING (MRI) Can be useful in the diagnosis adenomiosis and can accurately localize and measure fibroids, faciltating determination of the best treatment.
Recommended for a women over age 35 years with anovulatory bleeding and considered in younger women with a history of chronic anovulatory bleeding or risk endometrial carcinoma. The advantage is a rapid, safe, and cost effective. A potential drawback is that the biopsy does not sample the entire endometrium and a localized lesion may be missed.
DILATION and CURRETAGE Can be both diagnostic and therapeutic,but incurs the cost of an operating room and carries the risks of anasthesia. Its also can be indicated in women with nondiagnostic endometrial biopsi.
ETIOLOGY
The predominant causes of DUB are anovulation or oligoovulation. Anovulation is multifactorial and related to alterations of the hypothalamic-pituitaryovarian axis. long-term anovulation estrogen production occurs without the progesterone produced from the corpus luteum thus creating an unopposed estrogen state risk for endometrial hyperplasia Anovulation is also associated with polycystic ovary syndrome, which also places women at risk for endometrial hyperplasia. Morbid obesity Peripheral conversion of androstenedione to estrone occurs in adipose tissue producing elevated estrogen levels Occasionally, DUB may be associated with ovulatory cycles.
Antifibrinolytic
Gonadotropin-releasing hormone (GnRH) agonists
SURGICAL TREATMENT
Endometrial ablation is designed to ablate the full thickness of the endometrium. Before performing endometrial ablation in a woman with anovulatory bleeding, endometrial hyperplasia or carcinoma must be ruled out. overall success rate is 80% to 90%, with 30% to 50% of women reporting amenorrhea 6 months postprocedure. Still, within 5 years, 15% will have a second ablation and 20% will have a hysterectomy. Endometrial ablation is not recommended in women who desire future fertility.
Hormonal Management
a. Oral contraceptives Combined estrogen and b. Transdermal preparations c. Vaginal ring progestins
Androgenic steroids
GnRH agonists
a. Leuprolide (Lupron) 3.75 mg IM/mo or 11.25 mg every 3 mo b. Goserelin (Zoladex) 3.6 mg SQ every 4 wk
Antifibrinolytic Agents
Coagulation Disorders
Menorrhagia during adolescence should be attributed to a coagulation disorder until proven otherwise. Bleeding from multiple sites (e.g., nose, gingiva, intravenous sites, gastrointestinal, and genitourinary tracts) may suggest coagulopathy. There is a higher prevalence of bleeding disorders in women with menorrhagia.
ENDOCRINE DISORDERS
Endocrinopathies can cause anovulation, producing an estrogen without progesteron. the endometrium eventually breaks down, which may or may not lead to the formation of hyperplasia.
Hepatic Dysfunction
Decreased metabolism of estrogen and decreased clotting factor synthesis are common ramifications of liver failure. Anovulation may also ensue. Menometrorrhagia is common. Liver function tests are necessary to make the diagnosis, finding of jaundice, ascites, hepatosplenomegaly, palmar erythema, pruritus, and spider angioma are suggestive of liver failure.
Benign Pathology
Leiomyomata Leiomyomata (fibroids) are the most common uterine neoplasm, and is the number one indication for hysterectomy in the United States. Endometrial Polyps Generally, benign endometrial lesions tend to be asymptomatic but may be present in 10% to 33% of women with complaints of bleeding, typically metrorrhagia.
Endometrial Hyperplasia
Endometrial hyperplasia, a precursor to endometrial carcinoma, is classified into simple or complex, based on architectural features, and typical or atypical, based on cytologic features.
Malignancy
Endometrial Cancer Endometrial carcinoma is rare in patients younger than age 40. Postmenopausal bleeding, should be assumed to represent endometrial cancer until proven otherwise. Cervical Cancer a. Cervical carcinoma is a disease of both the relatively young and the old it cause abnormal bleeding. b. The most common bleeding patterns associated with cervical carcinoma are intermenstrual and postcoital bleeding Ovarian Cancer Estrogen-producing ovarian tumors, such as a granulosatheca cell tumor, can produce endometrial hyperplasia and AUB.
SUGGESTED READINGS
Management of Anovulatory Bleeding. ACOG Practice Bulletin Number 14. American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet 2001;72(3):263-271. Von Willebrand Disease in Women. ACOG Committee Opinion Number 451. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;114:1439-1443. Lacey JV Jr, Chia VM. Endometrial hyperplasia and the risk of progression to carcinoma. Maturitas 2009;63(1):39-44. Casablanca Y. Management of dysfunctional uterine bleeding. Obstet Gynecol Clin North Am 2008;35(2):219-234, viii.