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8/10/2019 A Quick Overview on Menstrual Irregularity... A Newer Approach (AUB)
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A quick
overview onMenstrual
irregularity
And a newer approach to
abnormal uterine
bleeding
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Menstruation
Menstruationis the periodic discharge of bloodand mucosal tissue from the inner lining of theuterus through the vagina due to, orderly cyclichormone production and parallel proliferation of
the uterine lining preparing for implantation of theembryo.
The time frame from the start of one menstrual
episode to the start of next menstrual episode iscalled Menstrual Cycle.
The number of days the menstrual bleedingpersists is called menstrual Period.
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The parameters of Normal
Menstruation
Duration of flow 3-7 days (average 4 days)
Cycle length 21 - 35 days (average 29 days)(28 days +/- 7 days}
Blood loss < 80 ml (average 30-35 ml)
ny deviation from this
normal parameter is
abnormal menstruation
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When will we call it Abnormal
Menstruation??
Duration of flow more than 7 days (If flow is normal) or
more than 5 days (if flow is heavy)
Less than 2 days
Menstrual cycle is Less than 21 days
More than 35 days
Flow is heavy blood loss of greater than 80 ml
Passing of large blood clot during menstruation
Enough flow to soak a pad or tampon every hour for 3consecutive hours. (Each soaked tampon holds 5ml of blood)
Night time bleeding that requires getting up to change pads or
tampons
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Here are the
Classic
Terminologies
we used toDescribe
AbnormalMenstruation
Dysmenorrhoea
Menorrhagia
Polymenorrhea
Polymenorrhagia
Oligomenorrhoea
Hypomenorrhoea
Metrorrhagia
Metropathia
Haemorrhagica
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Parameters of Classic terminologies
Description Cycle Period
Normal
menstruation
Normal period of
menstruation
2135 days 37 days
Dysmenorrhoea Painful menstruation
as to hamper day today life
2135 days 37 days + PAIN
Menorrhagia Normal Cycle with
Excessive amount /
Period of bleeding
2135 days >7 days + normal flow
>5 days + heavy flow
Polymenorrhoea Decreased Cycle
with normal period
Less than 21 days 37 days
Polymenorrhagia Decreased cycle with
Excessive amount /
Period of bleeding
Less than 21 days >7 days + normal flow
>5 days + heavy flow
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Description Cycle Period
Oligomenorrhoea prolonged Cycle with
normal period
more than 35 days 37 days
Hypomenorrhoea prolonged Cycle with
Decreased period
more than 35 days Less than 2 days
Metropathia
Haemorrhagica
A special type of
anovulatory uterine
bleeding
6 - 8 weeks of
amenorrhoea
followed by
28 weeks of
bleeding which is
painless and life
threatening
Metrorrhagia Irregular, acyclical
bleeding
Can not be specified
into definative cycle
Can not be specified
into definative
period
Parameters of Classic terminologies
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Classic approach to diagnose a case of
Menstrual Irregularity
Fibroid
PID
Adenomyosis
Endometrosis
DUB
Painless
To diagnose exclude
Pubertal age Hypothyroidism
(TSH, T4)
Bleeding disorder(BT, CT)
Reproductive ageAbortion
Ectopic PregnancyMolar Pregnancy
IUCD in utero
Break through bleeding
Peri menopausal ageCa cervix
Endometrial polyp
Endometrial carcinoma
HRT treatment if
Stopped abruptly
Dysmenorrhoea
Menorrhagia(Regular/Cyclical) Metrorrhagia(Irregular/Acyclical)
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The problems of Classic terminology And the
move to refine it
Over the past decade it has become
abundantly clear that many terms used todescribe menstrual symptoms and causes of
abnormal menstrual bleeding are ill defined
and confusing.
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So, a formal initiative was established with aninternational workshop in Washington, D.C., in
2005, Which yielded the FIGO (InternationalFederation of Gynecology and Obstetric)Classification in 2009 at Cape town.
This Classification looks to refine the Illdefined Terminologies to a better defined welldemarcated territory of Newer TerminologyThat Is,
BNORM L UTERINE BLEEDING
The problems of Classic terminology And the
move to refine it
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BNORM L UTERINE
BLEEDING
Abnormal Uterine Bleedingis defined as
bleeding from the uterine corpus that isabnormal in regularity, volume, frequency, or
duration and occurs in the absence of
pregnancy in women of reproductive age.
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Caution
Abnormal Uterine Bleeding excludes thefollowing situations:
AUB Excludes Gravid patients. A pregnancy test is amust before trying out for AUB.
AUB deals only with women of reproductive age thatis from definitive onset of Menstruation tomenopause. So, pre-pubertal bleeding or post
menopausal bleeding is not included in AUB. Lower genital tract bleeding due to any cause is
opted out of AUB. So, cervical or vaginal tears ormalignancies must be excluded first.
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Types of AUB
Heavy Menstrual Bleeding Acute
AUB is defined as an episode of heavy bleeding that, in theopinion of the clinician, is of sufficient quantity to require
immediate intervention to prevent further blood loss Chronic
chronic AUB is defined as bleeding from the uterine corpusthat is abnormal in volume, regularity, and/or timing, and
has been present for the majority of the past 6 months Intermenstrual Bleeding
occurs between clearly defined cyclic and predictablemenses.
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Differential Diagnosis of AUB
AUB
Structural
P-Polyp (AUB-P)A-Adenomyosis (AUB-A)L- Leiomyoma (AUB-L)
M-Malignancy &Hyperplasia (AUB-M)
Non-Structural
C-Coagulopathy (AUB-C)O-Ovulatory dysfunction(AUB-O)
E-Endometrial (AUB-E)I-Iatrogenic (AUB-I)N-Not yet classified (AUB-N)
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P-Polyp (AUB-P) Polyps are epithelial proliferations
comprised of a variable vascular,glandular, and fibromuscular andconnective tissue components and
are often asymptomatic.
Yet, it is generally accepted that atleast some polyps contribute to thegenesis of AUB.
For the basic classification system,polyps are categorized as beingeither present or absent.
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A-Adenomyosis (AUB-A) The relationship between
adenomyosis and thegenesis of AUB is unclear,
though undeniable. As there exists both
sonographic and magneticresonance imaging (MRI)-
based diagnostic criteria,adenomyosis has beenincluded in theclassification system
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L-Leiomyoma (AUB-L) An Important cause
of AUB I has its own
primary, secondary
and tertiaryclassification system
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M-Malignancy & Hyperplasia (AUB-M) Although relatively
uncommon, atypicalhyperplasia and
malignancy areimportant potentialcauses of, or findingsassociated with AUB
and must be consideredin nearly all women ofreproductive age
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C-Coagulopathy (AUB-C) coagulopathy
encompasses the spectrumof systemic disorders of
hemostasis that may beassociated with AUB.
Coagulation Disorders
Inherited
von willibrands
haemophilia
Acquired
ITP
DIC
Leukemia
Drug Induced
Heparin
Warferin
Aspirine
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O-Ovulatory dysfunction (AUB-O) Ovulatory dysfunction can contribute to the genesis
of AUB.
Although most ovulatory disorders elude a defined
etiology, many can be traced to Endocrinopathies(e.g. polycystic ovary syndrome, hypothyroidism,
hyperprolactinemia, mental stress, obesity, anorexia,
weight loss, or extreme exercise such as that
associated with elite athletic training).
Also, unexplained ovulatory disorders frequently
occur at the Extremes of reproductive age.
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E-Endometrial (AUB-E)
When AUB occurs in the context of predictable and cyclicmenstrual bleeding, typical of ovulatory cycles, andparticularly when no other definable causes areidentified, the mechanism is probably a primary disorderof the endometrium.
Indeed, high-quality evidence has demonstrateddeficiencies in local production of vasoconstrictors suchas endothelin-1 and prostaglandin F2, and/oraccelerated lysis of endometrial clot because of excessive
production of plasminogen activator. the diagnosis of endometrial disorders should probably
be determined by exclusion of other identifiableabnormalitiesin women of reproductive age who seemto have normal ovulatory function.
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I-Iatrogenic (AUB-I) Drugs that may contribute to
AUB:
Hormonal therapy (estrogen,progesteron, androgens, Etc )
the use of anticoagulant drugssuch as warfarin, heparin, andlow molecular weight heparin
Systemic agents that interferewith dopamine metabolismhave the potential to cause AUB
Tricyclic antidepressants
phenothiazines
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N-Not yet classified (AUB-N)
Chronic endometritis
Arteriovenous malformations
Myometrial hypertrophy, Etc
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Notation for FIGO Classification
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Notation for FIGO Classification
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So, FIGO Notation for our patient
would be.
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