Management of Abnormal Uterine Hemorrhage Sudhir R Shah, Beena N Trivedi, Dipal D Solanki, Chaitra Sathyanarayana
INDEX
ABCDEFGHILMNOPRSRUVWY
A
Abdominal
hysterectomy surgery 80
pain 15
Abnormal uterine
bleeding 18, 38, 39
hemorrhage 17, 37, 38
Abortion 27
Adenomyosis 22, 46
Adenomyosis of uterus from
inner side 20
outer side 20
Adnexal mass 109
Adolescent age group 35
Adrenal disorders 129
Advantages of laparoscopic surgery 110
Algorithm for evaluation of secondary amenorrhea 139
Ambiguous
external genitalia 125
genitalia 127
Amenorrhea 19, 119, 120
Androgen
insensitivity syndrome 134, 135
secreting tumor 125
Anemia 124
Anorexia 124, 134
Anovulatory
bleeding 44
cycles 14
DUB 31
Asherman's syndrome 133, 149
Atrophic endometrium 22
B
Backache 15
Balloon surgery 74
Blood vessels 9
Body mass index 134
Bone density risk 88
Bradycardia 134
Breast cancer 84
C
Cachexia 134
Carcinoma cervix 47
Cardiovascular risk 87
Carotenemia 134
Catching vaginal wall 94
Causes of
AUH 19
primary amenorrhea 124
secondary amenorrhea 128
Cervical
findings 135
mucosa 2
polyps 46
stenosis and intrauterine adhesions 130
Chronic
illness 124
renal disease 29
Cirrhosis of liver 29
Clamping uterines 101
Coagulation disorders 28
Congenital adrenal hyper-plasia 125
Contraceptive intrauterine devices 30
Cryotherapy 76
Cushing's disease 132
Cut on uterus 102
Cutting
uterus 102
vaginal wall 94
Cyst of ovary 26
D
Dead endometrial tissue 2
Delayed puberty 134, 135
Diabetes mellitus 124
Different phases of menstrual cycle 5
Dilatation and curettage surgery 69
Disadvantages of laparoscopic hysterectomy 117
Disturbance at endometrium 42
Dysfunctional uterine bleeding 30, 44
Dysmenorrhea 15
E
Ectopic pregnancy 27
Embolization 75
Endocrine disorders 150
Endometrial
ablation 72, 74
using urological resectoscope 73
biopsy 53
carcinoma 24
cycle 3, 8
hyperplasia 22
malignancy 26
polyp 21, 47
Endometriosis 23, 25, 85, 108
Endometrium 6
Epimenorrhea 40, 41
Estrogen 6
Ethamsylate 66
Etiology of amenorrhea 124
Evaluation of case of amenorrhea 131
Excessive menstrual flow 39
External genitalia 134
F
Fibroid 157
uterus 19, 22, 105, 157
by NDVH 105
multiples 45
First
clamp 98
pedicle 97
Fixed retroversion 25
Follicular cysts of ovary 27
FSH testing 142
Fundal myoma 159
G
Galactorrhea 134
Genitourinary malformation 124, 125
Gestational trophoblastic neo-plasia 27
Glands 9
Global endometrial ablation devices 73
Gonadal
dysgenesis 134
failure 127
Graafian follicle 8
H
Halban's disease 34
Helps in clotting 66
Hormone replacement therapy 30, 88
Hot
flushes 88
water devices 73
Hypergonadotropic hypogonadism 148
Hypermenorrhea 39
Hyperplastic endometrium 24
Hyperprolactinemia 126, 147
Hypogonadotrophic hypogonadism 125
Hypomenorrhea 40
Hypotension 134
Hypothalamic
amenorrhea 146
dysfunction 124
failure 126
pituitary failure 143
Hypothalamus 6, 38
pituitary ovarian axis 7
Hypothermia 134
Hypothyroidism 29, 125
Hysterectomy 82
Hysterosalpingography 54
Hysteroscopic removal of fibroids 77
Hysteroscopy 54, 71
I
Idiopathic thrombocytopenic purpura 28
Imperforate hymen 135
Intermenstrual bleeding 19
Intramural
fibroid 159
myoma 106
Irregular
ripening 34
shedding 34
ITP 29
L
Lactation 128
Laparoscopic
assisted vaginal hysterectomy 108, 109, 111
hysterectomy 107, 109
removal of uterus 81
supracervical hysterectomy 110
Laparoscopy 54
Large fibroid 160
Laser ablation 72
Leukemia 28
Levonorgestrel intrauterine system 61
Ligation 98
Loss of weight 130
M
Magnetic resonance imaging 55
Malnutrition 124
Management of
amenorrhea 144
DUB 62
Mechanisms of stoppage of menstrual bleeding 13
Medical management of DUB 55
Mefenemic acid 65
Menarche 2
Menometrorrhagia 18
Menopause 2, 128
Menorrhagia 18, 41
Menstrual
cycle 3, 10
flow 4
period 3, 19
symptoms 15
Menstruation 1–3, 12
Metropathia hemorrhagica 32
Metrorrhagia 18, 41
Meyer Rokitansky Kuster Hauser syndrome 135
Microwave endometrial ablation 76
Minimally invasive surgery for
endometrial ablation 71
fibroids 77
Müllerian anomalies 25
Multiple fibroid of uterus 106
Myocardial infarction 13
N
Newborn girls 34
Non-descent vaginal hyster-ectomy 89
Normal uterus 2, 18
Novasure 76
O
Oligomenorrhea 19, 40, 149
Operative
technique 93
trolley 91
Oral contraceptives 29
Organic pelvic pathology 41
Ovarian
cancer 85
cycle 3, 6
cyst 46
dysgenesis 125
failure 142
tumors 135
Ovariohysterectomy 83
Ovulatory
bleeding 43
DUB 33
P
Palmer's point 112
PCO syndrome 146
Pelvic
adhesive disease 108
fullness 135
inflammatory disease 25
Perimenopausal age group 35
menorrhagia 60
Pituitary
disease and hyperprolacti-nemia 130
tumor 134
Placental polyps 27
Polycystic ovarian syndrome 129, 134
Polymenorrhagia 34
Polymenorrhea 19, 34, 40
Post pill amenorrhea 130
Posterior
pouch 99
wall
cut 96
open 97
Postmenopausal age group 35, 62
Pregnancy 128
related complications 27
Premature
menopause 142
ovarian failure 129
Preparation of operative parts 93
Prepubertal age group 35
Primary amenorrhea 123
Principles of LAVH/TLH 113
Progesterone 38
challenge test 140
Pubertal and adolescent menorrhagia 57
Puberty 31
Pubic hair 134
Pulling anterior lip of cervix 94
R
Reflect bladder 96
Regular cycle 38
Reproductive
age group 35
menorrhagia 58
tract 19
lesions 19
Ringer's lactate 116
S
Saline
infusion sonography 72
injection 94
Scanty periods 119, 149
Schematic menstrual cycle date wise 9
Secondary amenorrhea 123
Selective estrogen receptors modulators 56
Septate uterus 24
Sexuality risk 88
Sexually transmitted diseases 52
Sheehan's syndrome 133
Sickle cell anemia 28
Sonography 52
Steps of LAVH/TLH 114
Stroma 9
Surface epithelium 9
Surgical
gallery 151
management of abnormal uterine hemorrhage 67
options for menorrhagia 68
Suturing
vagina angle 103
vaginal vault 103
R
Tamoxifen 30
Testicular feminization 126
Thalassemia major 28
Thermachoice balloon 75
Thyroid dysfunction 148
Total laparoscopic hysterectomy 108, 109
Trauma 25
Trocar entry 112
Trolley for non-descent vaginal hysterectomy 91
Tuberculosis 124
Turner's syndrome 125, 134
U
Urinary bladder 90
Uterine
artery 75
embolization 79
bleeding 19
fibroids 109
findings 135
vessels 101
Uterus 2
V
Vaginal
canal 2
findings 135
hysterectomy 109
removal of uterus 81
von Willebrand disease 28
W
Weight loss 124
Women
with withdrawal bleeding 140
without withdrawal bleeding 141
Y
Yellow skin 134
×
Chapter Notes

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Menstruation—The BasicsChapter 1

2
Menstruation is a monthly experience in every woman from menarche to menopause.
 
DEFINITION
Logically, it is the weeping of the uterus for failure of the ovum to fertilize in that particular cycle. But, as we know, all cycles are not always ovulatory.
In that case, it is the cry of the uterus for not even being capable to produce an ovum.
Medically speaking, menstruation is the cyclical flow of dark blood, dead endometrial tissue, cervical mucosa and few bacteria from the uterus which comes out through the vaginal canal.
It is the visible show of the invisible interactive drama played by different sex hormones inside the body. Figure 1.1 depicts the anatomy of normal uterus.
zoom view
Fig. 1.1: Normal uterus-cervix-fallopian tubes
3
The onset of the first menstrual cycle is called menarche. In India, the average age at menarche is 13 yrs. Menstruation continues cyclically till the age of 45 to 50 years. When this monthly bleeding finally stops, the lady is said to have attained menopause. Table 1.1 gives the characteristics of menstrual period.
Table 1.1   Menstrual period characteristics
Normal
Abnormal
Duration
4–6 days
Less than 2 or more than 7 days
Volume
30–50 ml
More than 80 ml
Interval
24–35 days
 
Menstruation
It is the result of two cycles of the female genital organs:
  1. Ovarian cycle.
  2. Endometrial cycle.
Endometrial cycle in turn depends on the ovarian cycle hormones.
 
MENSTRUATION—THE OVARIAN CYCLE
The hypothalamus which is the master gland of the endocrine orchestra releases GnRH. This acts on the anterior pituitary to release gonadotrophins like FSH and LH. FSH and LH act on the ovarian tissue and cause:
  1. Follicular development-ovulation-fertilization.
  2. Initiates secretions of sex hormones like estrogen and progesterone
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zoom view
Fig. 1.2: Menstrual flow
This estrogen and progesterone act on the endometrium which is the inner mucus lining of uterus (Fig. 1.2).
It develops either to implant the fertilized ovum or results in menstruation.
In short, whatever interplay is played by GnRH-FSH-LH-Estrogen-Progesterone hormones, the result appears at the endometrium. These hormones have a positive and negative feedback on each other (Fig. 1.3). To understand in detail, one can follow Flow chart 1.1:
5
zoom view
Fig. 1.3: Hormones relations
zoom view
Fig. 1.4: Different phases of menstrual cycle
6
zoom view
Flow chart 1.1: The ovarian cycle
Contd…7
Contd…
zoom view
zoom view
Fig. 1.5: Hypothalamus-pituitary-ovarian axis
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Thus, ovarian cycle has:
Development of Graafian follicle under FSH
Secretion of estrogen
Rupture of graafian follicle
Realease of ovum-14th day
Formation of corpus luteum (CL)
Secretion of progesterone from CL
Regression of CL–in the absence of implantation
Withdrawal of estrogen and progesterone
Stimulates FSH from anterior pituitary
Development of Graafian follicle again.
zoom view
Fig. 1.6: Menstrual flow from uterus
 
MENSTRUATION—THE ENDOMETRIAL CYCLE
Endometrium is the lining epithelium of the uterus. It consists of
  1. Surface epithelium.
  2. Stroma.
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zoom view
Fig. 1.7: Schematic menstrual cycle date wise
  1. Glands.
  2. Blood vessels.
Surface epithelium has 2 layers:
  • Outer 2/3 layer which is functional and is sensitive to estrogen and progesterone.
  • Inner 1/3 layer which is the basal layer has more stroma and fewer glands-for regeneration.
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Endometrial cycle has 4 stages:
  1. Regeneration.
  2. Proliferative.
zoom view
Fig. 1.8: Menstrual cycle-hormone influence
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  1. Secretory.
  2. Menstruation.
    1. Regeneration
      • It starts from the second day of menstruation.
      • New blood vessels start from the stump of blocked vessels in the basal layer.
      • Stroma and glands increase in size and shape.
      • This is under the influence of estrogen secreted by next developing follicles in the ovary.
    2. Proliferation
      • Proliferation starts from day 5 to day 14.
      • Under estrogenic effect, glands becomes tubular-epithelium becomes columnar with nucleus at the base
      • Blood vessels increase in length and become spiral
      • Stroma increases in size and shape
      • Total thickness of endometrium is about 3–4 mm.
    3. Secretory Phase
      • Under the effect of progesterone from day 14 to day 25.
      • Estrogen creates receptors of progesterone in the endometrium. Thus progesterone acts only if endometrium is primed with estrogen.
      • Glands increase in size and become convoluted.
      • Surface epithelium becomes more columnar and ciliated.12
      • Appearance of glycogen secretion between nucleus and basement membrane-called sub nucleolar vacuolation-first histological sign of ovulation.
      • Blood vessels grow rapidly and become more and more spiral.
      • Stroma becomes swollen and large polyhedral cells are seen.
      • Total thickness of endometrium is 5–6 mm.
      • Now, 7 days have passed after ovulation, i.e. day 21.
      • In the absence of implantation-No HCG-Corpus luteum degenerates-reduces proge-sterone.
      Already there is reduced estrogen-this causes degeneration of endometrium
      It starts decreasing in size suddenly.
    4. Menstruation
      • Day 25-With shrinkage of endometrium from 5 mm to 2–3 mm, glands becomes more convoluted.
      • Blood vessels become more and more spiral.
      • Stasis of blood occurs-amount of blood in the vessels decreases and spasm of vessels occurs to such an extent that it causes ischemia of the vessel wall and surrounding tissues (like myocardial infarction)-Bleeding occurs from arteriolar end to necrosed endometrial tissue.13
      • This blood+necrosed endometrial tissue goes to the endometrial cavity-Cervix-Vagina and menstruation starts.
      • Now this degenerated endometrial tissue has prostaglandins of 3 types:
PGF2alpha-causes vasoconstriction and contraction of myometrial muscles.
PGE2-causes vasodilatation and contraction of myometrial muscles.
PGI2-causes vasodilatation and relaxation of myometrial muscles.
Their relative concentrations in blood and balance with each other decides the amount of menstrual flow.
 
Mechanisms of Stoppage of Menstrual Bleeding
  • As bleeding starts-prothrombin is released-acts on thrombin–converts fibrinogen to fibrin-clot forms.
  • Endometrium also activates plasminogen activator-converts plasminogen to plasmin.
  • Plasmin act on fibrin-and causes fibrinolysis-clots liquefy-bleeding continues through vagina.
  • Here is the role of prostaglandin F2 alpha. It causes prologed vasoconstriction and strong myometrial contraction+local aggregation of platelets-blocks open vessels and bleeding begins to STOP.
    So prostaglandin F2alpha has a positive role.
If PGE2 and PGI2 is more-no blocks and bleeding continues.
14
 
In Anovulatory Cycles
  • There is no rupture of graafian follicle-estrogenic environment continues-more proliferation of endometrium-more thickness-more blood in vessels.
  • Follicle grows up to some extent till day 25 to day 30 and then regresses on its own. This decrease in estrogen is responsible for the estrogen with-drawal bleeding. As the cycle is anovulatory-no progesterone secretion. So, proportion of the prostaglandin PGF2α is lesser compared to PGI2. Hence, there is less vasoconstriction leading to painless but excessive periods.
Thus, the amount and duration of menstrual bleeding depends on:
  • Ovulatory or anovulatory cycle.
  • Balance of different prostaglandins.
  • Limited action of plasminogen activator.
  • Availability of platelets to form block.
  • Condition of capillary wall.
  • Enough clotting factors in blood.
  • Resumption of estrogen from graafian follicle in ovary.
 
Menstrual Symptoms
  • There are no symptoms in majority of women except flow of blood from the vagina giving some mental and hygenic disturbance.15
  • In young girls and nulligravida, there may be pain due to myometrial contraction and narrow cervical canal.
  • Heaviness in the lower abdomen due to pelvic congestion of blood in the uterus.
  • Occasionally, there may be severe abdominal pain and backache due to spasm and congestion called dysmenorrhea.