Transcript menstrual irregularities and abnormal uterine bleeding

Definition:
is a gynecological medical condition in women in
which endometrial-like cells appear and flourish in
areas outside the uterine
, most commonly on the ovaries. The uterine cavity
is lined by endometrial cells, which are under the
influence of female hormones. These endometriallike cells in areas outside the uterus
(endometriosis) are influenced by hormonal
changes and respond in a way that is similar to the
cells found inside the uterus. Symptoms often
worsen with the menstrual cycle.
Endometriosis is typically seen during the
reproductive years; it has been estimated that
endometriosis occurs in roughly 5-10% of women.
Symptoms may depend on the site of active
endometriosis. Its main but not universal symptom
is pelvic pain in various manifestations.
Endometriosis is a common finding in women
with infertility.
Signs and symptoms
Pelvic pain
A major symptom of endometriosis is recurring pelvic
pain. The pain can be mild to severe cramping that
occurs on both sides of the pelvis, in the lower back
and rectal area, and even down the legs. The amount of
pain a woman feels is not necessarily related to the
extent or stage (1 through 4) of endometriosis.
Some women will have little or no pain despite having
extensive endometriosis or endometriosis with
scarring. On the other hand, women may have severe
pain even though they have only a few small areas of
endometriosis. However, pain does typically correlate
to the extent of the disease. Symptoms of
endometriosis-related pain may include:
dysmenorrhea
painful, sometimes cramps
during menses; pain may get worse
overtime (progressive pain), also
lower back pains linked to the pelvis
chronic pelvic pain – typically accompanied by lower
back pain or abdominal pain
dyspareunia
– painful sex
dysuria
–sometimes painful voiding
dragging pain to the legs are reported more commonly
by women with endometriosis. Those with sever
disease appears to be more likely to report shooting
rectal pain. Individual pain areas and pain intensity
appears to be un related to area of endometriosis
Other symptoms may be present,
including:
Constipation
chronic fatigue
heavy or long menstrual periods with small or large blood clots
gastrointestinal problems including diarrhea, bloating and
painful defecation
extreme pain in legs and thighs
back pain
mild to extreme pain during intercourse
extreme pain with or without the presence of menses
premenstrual spotting
mild to severe fever
headaches
depression
hypoglycemia (low blood sugar)
anxiety
Cause
the exact cause of endometriosis remains
unknown, many theories have been presented to
better understand and explain its development.
These concepts do not necessarily exclude each
other.
Cause
1. Estrogens: Endometriosis is a condition that
is estrogen-dependent and thus seen primarily
during the reproductive years.
In experimental models, estrogen is necessary to
induce or maintain endometriosis.
Medical therapy is often aimed at lowering
estrogen levels to control the disease.
2. Retrograde menstruation:
The theory of retrograde menstruation, first proposed
by John A. Sampson, suggests that during a woman's
menstrual flow, some of the endometrial debris exits the
uterus through the fallopian tubes and attaches itself to the
peritoneal surface (the lining of the abdominal cavity) where
it can proceed to invade the tissue as endometriosis.
While most women may have some retrograde menstrual
flow, typically their immune system is able to clear the debris
and prevent implantation and growth of cells from this
occurrence. However, in some patients, endometrial tissue
transplanted by retrograde menstruation may be able to
implant and establish itself as endometriosis.
2. Retrograde menstruation:
The theory of retrograde menstruation, first proposed
by John A. Sampson, suggests that during a woman's
menstrual flow, some of the endometrial debris exits the
uterus through the fallopian tubes and attaches itself to the
peritoneal surface (the lining of the abdominal cavity) where
it can proceed to invade the tissue as endometriosis.
While most women may have some retrograde menstrual
flow, typically their immune system is able to clear the debris
and prevent implantation and growth of cells from this
occurrence. However, in some patients, endometrial tissue
transplanted by retrograde menstruation may be able to
implant and establish itself as endometriosis.
Factors that might cause the tissue to grow in
some women but not in others need to be
studied, and some of the possible causes
below may provide some explanation, e.g.,
hereditary factors, toxins, or a compromised
immune system.
3. Müllerianosis
A competing theory states that cells with the
potential to become endometrial are laid down in
tracts during embryonic development
and organogenesis. These tracts follow the female
reproductive (Mullerian) tract as it migrates caudally
(downward) at 8–10 weeks of embryonic life.
Primitive endometrial cells become dislocated from
the migrating uterus and act like seeds or stem
cells. This theory is supported by fetal autopsy
4. Coelomic Metaplasia:
This theory is based on the fact
that coelomic epithelium is the common ancestor
of endometrial andperitoneal cells and
hypothesizes that later metaplasia (transformation)
from one type of cell to the other is possible,
perhaps triggered by inflammation. This theory is
further supported by laboratory observation of this
transformation.
5. Genetics:
Hereditary factors recognized that daughters or
sisters of patients with endometriosis are at higher
risk of developing endometriosis themselves; for
example, low progesterone levels may be genetic,
and may contribute to a hormone imbalance.
There is an about 10-fold increased incidence in
women with an affected first-degree relative. One
study found a link between endometriosis and
chromosome effect . The female siblings of patients
with endometriosis the relative risk of endometriosis
is about 5.7:1 versus a control population.
6. Immune system:
Research is focusing on the possibility that
the immune system may not be able to cope with
the cyclic of retrograde menstrual fluid.
In this context there is interest in studying the
relationship of endometriosis toautoimmune
disease, allergic reactions, and the impact of toxins.
It is still unclear what, if any, causal relationship
exists between toxins, autoimmune disease, and
endometriosis.
7. Environment:
There is a growing suspicion that environmental
factors may cause endometriosis, specifically some
plastics and cooking with certain types of plastic
containers with microwave ovens. Other sources
suggest that pesticides and hormones in our food
cause a hormone imbalance.
8. Birth Defect:
In rare cases where imperforate hymen does not
resolve itself prior to the first menstrual cycle and
goes undetected, blood and endometrium are
trapped within the uterus of the patient until such
time as the problem is resolved by surgical incision.
By the time a correct diagnosis has been made,
endometrium and other fluids have filled the uterus
and fallopian tubes with results similar to retrograde
menstruation resulting in endometriosis.
Endometriosis in postmenopausal women does
occur and has been described as an aggressive
form of this disease characterized by complete
progesterone resistance.
In less common cases, girls may have
endometriosis symptoms before they even reach
menarche.
Complications of endometriosis include:
Internal scarring
Adhesions
Pelvic cysts
Chocolate cyst of ovaries
Ruptured cyst
Blocked bowel (bowel obstruction)
Infertility can be related to scar formation and
anatomical distortions due to the endometriosis;
however, endometriosis may also interfere in more
subtle ways: cytokines and other chemical agents may
be released that interfere with reproduction.
Other complications of endometriosis include bowel
and ureteral obstruction resulting from pelvic
adhesions. Also, peritonitis from bowel perforation can
occur.
Ovarian endometriosis may complicate pregnancy by
decidualization, abscess and/or rupture, It is the most
common adnexal mass detected during pregnancy,
being present in 0.52% of deliveries as studied in the
period 2002 to 2007. Still, ovarian endometriosis during
pregnancy can be safely observed conservatively.
The only way to diagnose
endometriosis is by laparoscopy or
other types of surgery with lesion
biopsy. The diagnosis is based on
the characteristic appearance of the
disease, and should be corroborated
by a biopsy. Surgery for diagnoses
also allows for surgical treatment of
endometriosis at the same time.
possible locations of endometriosis
various stages show these findings:
Stage I (Minimal)
Findings restricted to only superficial lesions and
possibly a few filmy adhesions
Stage II (Mild)
In addition, some deep lesions are present in
the cul-de-sac
Stage III (Moderate)
As above, plus presence of endometriomas on the
ovary and more adhesions
Stage IV (Severe)
As above, plus large endometriomas, extensive
adhesions.
Treatments
Hysterectomy
hormonal medication
presacral neurectomy
Advantages of medicinal interventions
Decrease initial cost
Empirical therapy (i.e. Can be easily modified as
needed)
Effective for pain control
Disadvantages of medicinal interventions
Adverse effects are common
Not likely to improve fertility
Some can only be used for limited periods of time
Advantages of surgery
Has significant efficacy for pain control. Has increased
efficacy over medicinal intervention for infertility
treatment
Combined with biopsy, it is the only way to achieve a
definitive diagnosis
Can often be carried out as a minimal invasive
(laparoscopic) procedure to reduce morbidity and
minimalize the risk of post-operative adhesions
Disadvantages of surgery
Cost
Risks are "poorly defined... and probably
underestimated."
In one study, 3-10% experienced major complications
from surgery.
Efficacy is questionable.
In the same study, substantial short-term pain relief was
experienced by approximately 70-80% of the subjects.
However, at 1 year follow-up, approximately 50% of the
subjects needed analgesics or hormonal treatments
HEALTH ASSESSMENT
HISTORY TAKING/HEALTH HISTORY
Ensure the baseline history and identify problem.
Midwife must access:
- General health and family history of patient.
- Age of menarche (first menstruation).
- Patient’s last menstrual period (LMP), description of menstrual
pattern and flow.
- Risk for sexually transmitted disease (STD’s).
- Pregnancy history : number of pregnancies, live births, stillborn
births, type of fetal abnormalities.
- Abortion history.
- Drug, allergy, substance abuse, and smoking history.
- Symptoms of present disorder, such as painful intercourse or
characteristic of vaginal discharge, and duration.
PHYSICAL EXAMINATION
Perform the gynecologic examination (pelvic examination), an
inspection, and palpation of pelvic reproductive system.
Obtains examination gloves, lubricant, several sizes of
bivalve speculums and light source.
Firstly inspect the external genitalia and adjacent structures,
following inspection of the vaginal wall and cervix by using a
bivalve speculum.
Next, one or two fingers of a lubricated, gloves hand are placed into
vagina.
Do the vaginal-abdominal palpitation, structures beyond the vaginal
orifice are examined.
Access the position, size, and contour of the uterus, ovaries, and
other pelvic structures.
At the end of examination, a gloved finger is inserted into the
rectum to palpate the posterior surface of the uterus.
Examination of uterus, vagina, ovaries, fallopian
tubes, bladder, and rectum for any changes in their
shape or size.
 Speculum is used to widen the vagina so that the
upper part of the vagina and the cervix can be seen

Sound waves that shows organs and structures in
the pelvis; bladder, ovaries, uterus, cervix, and
fallopian tubes
 Abnormalities : small ovarian cysts, leiomyoma,
endometrial carcinoma.
 Evaluation of endometrium : thickness.
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Procedure used to examine the vagina, uterus, fallopian
tubes, ovaries, and bladder.
Transducer (probe) is inserted into the vagina that causes
sound waves to bounce off organs inside the pelvis.
Creates a sonogram.
Diagnostic Investigations
Hysteroscopy is the examination of the whole
endometrial cavity, lower segment and cervical
canal ; to detect small polyps or sub-mucous
fibroids.
 Hysteroscopy alone (without biopsy) is not very
accurate in diagnosing endometrial hyperplasia
and carcinoma.
 Endometrial biopsy or aspirate is to exclude
endometrial pathology like hyperplasia, endometrial
disorders or malignancies.

Diagnostic Investigations
These tests can rule out hyperthyroidism or
hypothyroidism and hyperprolactinemia.
 These conditions cause ovarian dysfunction
leading to possible menorrhagia.

MEDICAL &
SURGICAL
MANAGEMENT
In patients in the reproductive years, endometriosis
is merely managed: the goal is to provide pain relief,
to restrict progression of the process, and to restore
or preserve fertility where needed. In younger
women, surgical treatment attempts to remove
endometrial tissue and preserving the ovaries
without damaging normal tissue.
In women who do not have need to maintain their
reproductive potential, hysterectomy and/or removal
of the ovaries may be an option; however, this will
not guarantee that the endometriosis and/or the
symptoms of endometriosis will not come back, and
surgery may induce adhesions which can lead to
complications.
Treatments for endometriosis in women who do
not wish to become pregnant include:
1. Progesterone or Progestins: Progesterone
neutralizes estrogen and inhibits the growth of
the endometrium.
Such therapy can reduce or eliminate
menstruation in a controlled and reversible
fashion. Progestins are chemical alternatives
of natural progesterone
 Avoiding products with xenoestrogens, which
have a similar effect to naturally produced
estrogen and can increase growth of the
endometrium.
2.
Hormone
contraception
therapy:
Oral
contraceptives reduce the menstrual pain associated
with endometriosis. They may function by reducing
or eliminating menstrual flow and providing estrogen
support. Typically, it is a long-term approach.

Recently Seasonale was FDA approved to reduce
periods to 4 per year. Other OCPs have however been
used like this off label for years. Continuous
hormonal consists of the use of combined oral
contraceptive pills eliminates monthly bleeding
episodes.
3. Danazol (Danocrine) and gestrinone are suppressive
steroids with some androgenic activity. Both agents
inhibit the growth of endometriosis but their use
remains limited as they may cause hirsutism and
voice changes.
4. Gonadotropin Releasing Hormone (GnRH) agonist:
These agents work by increasing the levels of
GnRH. Consistent stimulation of the GnRH
receptors results in down regulation, inducing a
profound hypoestrogenism by decreasing
FSH and LH levels. While effective in some patients,
they induce unpleasant menopausal symptoms, and
over time may lead to osteoporosis. To counteract
such side effects some estrogen may have to be
given back (add-back therapy). These drugs can
only be used for six months at a time.
5. Lupron depo shot is a GnRH agonist and is used to lower the
hormone levels in the woman's body to prevent or reduce
growth of endometriosis. The injection is given in 2 different
doses a once a month for 3 month shot or for 6 month shot
with the dosage of according to dr. prescription.
6. Aromatase inhibitors are medications that block the formation of
estrogen and have become of interest for researchers who are
treating endometriosis.

NSAIDs Anti-inflammatory. They are commonly used in
conjunction with other therapy. For more severe cases narcotic
prescription drugs may be used. NSAID injections can be helpful
for severe pain or if stomach pain prevents oral NSAID use.
7. Morphine sulphate tablets (MST) and other opioid painkillers
work by mimicking the action of naturally occurring painreducing chemicals called "endorphins". There are different
long acting and short acting medications that can be used alone
or in combination to provide appropriate pain control.
8. Diclofenac suppository or pill form to reduce inflammation and
as an analgesic reducing pain.
Surgery
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Procedures are classified as
1. conservative when reproductive organs are retained,
semi-conservative when ovarian function is allowed to continue,
radical when the uterus and ovaries are removed.
removal, excision (called cystectomy) or ablation of
endometriosis, adhesions, resection of endometriomas, and
restoration of normal pelvic anatomy as much as is possible.
2. Radical therapy in endometriosis removes the
uterus (hysterectomy) and tubes and ovaries
(bilateral salpingo-oophorectomy) and thus the
chance for reproduction. Radical surgery is
generally reserved for women with chronic
pelvic pain that is disabling and treatmentresistant. Not all patients with radical surgery
will become pain-free.
3. Semi-conservative therapy preserves a healthy
appearing ovary, and yet, it also increases the
risk of recurrence.

For patients with extreme pain, a presacral
neurectomy may be indicated where the nerves to
the uterus are cut. neurectomy is more effective in
pain relief if the pelvic pain is midline concentrated,
and not as effective if the pain extends to the left and
right lower quadrants of the abdomen.

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Women who had presacral neurectomy have higher
prevalence of chronic constipation not responding
well to medication treatment because of the potential
injury to the parasympathetic nerve.
Proper counseling of patients with endometriosis
decisions about therapy and desire for childbearing
need to be explained.
 Not all therapy works for all patients. Some patients
have recurrences after surgery or pseudomenopause. In most cases, treatment will give
patients significant relief from pelvic pain and assist
them in achieving pregnancy.
 This is a disease without a cure but with the proper
communication, a woman with endometriosis can
attempt to live a normal, functioning life. Using
cystectomy and ablative surgery, pregnancy rates are
approximately 40%.

2.
Endometrial destruction or ablation
○ Destroy or remove the endometrial tissue.
○ Performed for women who has been diagnosed
with menorrhagia and cannot or do not want to
have hysteroscopy procedure.
○ Endometrial ablation destroys a thin layer of
the lining of the uterus and stops the menstrual
flow.
○ In some women, menstrual bleeding does not
stop but is reduced to normal or lighter levels.
Surgical Management
THANKS
Dr.Areefa