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DUB is a very common occurrence in routine gynecological
practice. Disturbances of menstrual bleeding are a major
medical problem not only for women but also for their
medical practitioners and for their families and health
services. Dysfunctional Uterine Bleeding (DUB) affects about
5% of menstruating women yet the majority of medical
practitioners who manage the problems do not adequately
understand the underlying pathophysiology nor the principles
involved in appropriate management. (Wren- 1998)
DEFINITION: -
Dysfunctional Uterine Bleeding (DUB) is best defined as
abnormal bleeding from uterus in the absence of organic
disease of the genital tract.
CLASSIFICATION: -
DUB is classified as under:
I) PRIMARY DUB :-
Characterized by dysfunction of uterus ovary, pituitary,
hypothalamus or other part of reproductive system.
II) SECONDARY DUB: -
· Subdivided into :-
a) DUB secondary to use of IUCD or administration of sex
hormones for contraception purpose.
b) DUB secondary to organic disease outside the genital
tract.
Clinical classification of DUB is as under: -
a) Mixed etiology
Short Proliferative & or secretary phase
Midcycle spotting
Polymenorrhea
b) Corpus luteum insufficiency
Luteal phase defect
Menorrhagia
c) Prolonged corpus luteum activity
Persistent corpus luteum activity
Irregular shedding
Menorrhagia
Oligomenorrhea
d) Anovulatory
NORMAL AND ABNORMAL MENSTURATION: -
To diagnose abnormal bleeding attempts
must be made to understand the subtle features of normal
bleeding:
CYCLE: Cycle length may normally vary from 23 to 39 days.
Any menstruation outside these units, any bleeding at other
times in the menstrual cycle & any cyclical premenopausal or
postmenopausal bleeding is regarded as abnormal.
DURATION:- Normal duration varies from
2 to 7 days. Menstruation lasting longer than 8 days in
longer is regarded as excessive.
BLOOD LOSS upto 80 ml is regarded as
normal Menstrual Blood Loss (MBL)
INCIDENCE: -
It is one of the most frequently
encountered conditions in gynecology OPD. It is the
principal diagnosis is atleast 10% of all new patients in
OPD. It is found in 5% of all menstruating women (Wren –
1998). DUB occurs quite frequently in reproductive years and
not only at the extremes. O.C.pills tend to decrease and
IUCD tend to increase MBL. Multiparous women have higher
incidence of DUB.
PATHOLOGY: -
There is little correlation between the gross histology of
the endometrium and the amount & type of uterine bleeding.
Wide varieties of endometria are observed in association
with DUB including many cases with normal secretory
endometrium (60%).
IRREGULAR RIPENING & IRREGULAR
SHEDDING: -
15-25% of case with ovulatory
menorrhagia shows irregular ripening of endometrium on
histology due to deficient progesterone production.
Irregular shedding with a persistent corpus luteum has also
been described, but the true incidence is unknown.
ENDOMETRIAL HYPERPLASIA: -
It is the most commonly diagnosed (30%)
abnormality in DUB and varies from slight exaggeration of
proliferative phase to marked overgrowth approaching
adenocarcinoma of endometrium. Both stroma and glands
increase in number and dilate, producing typical “Swiss
Cheese” endometrium. There is also abnormal vascularization
with numerous thick-walled spiral arterioles and grossly
dilated veins or sinuses just beneath the endometrial
surface. Frequent infarction and thrombosis of blood vessels
with necrosis and shedding of superficial layers of
endometrium results in menorrhagia .The principal
significance of endometrial hyperplasia is the possibility
of progression from benign to aderomatous hyperplasia and
eventually to carcinoma if the condition persists. Increased
endometrial glandular papooses may serve as a morphological
marker of abnormal endometrial development is otherwise
normal biopsy specimen.
ATROPHIC ENDOMETRIUM: -
This is probability the commonest cause
of postmenopausal uterine bleeding. Large dilated venules
are situated superficial under a thin endometrium and may
rupture to cause excessive uterine bleeding.
ENDOMETRIAL APOPTOSIS: -
This is a relatively new finding described by Stewart
(1999). Routinely processed, haematoxylin and eosin-stained
endometrial biopsies were assessed in 26 patients with
symptomatic menstrual abnormality, mainly menorrhagia, and
in 24 controls. All biopsies were in the proliferative phase
and had been reported as within normal limits and consistent
with the menstrual cycle dates provided. Apoptotic and
mitotic figures were counted in a minimum of 100
transversely sectioned endometrial glands in all cases. In
16 biopsies (12 DUB and four controls) Apoptotic figures
were identified in most control biopsies averaging 5.6/100
glands, and were significantly increased in biopsies from
patients with DUB averaging 13.9/100 glands. There was no
difference in mitotic figure counts. Apoptoses tended to be
clustered within adjacent glands in both groups and
individual glands exhibited both mitotic and apoptotic
activity. Application of the Tunel method gave broad
agreement with morphological assessment although
approximately 20-25% of typical apoptotic figures were not
labeled. They concluded that Endometrial glandular apoptosis
is present in most normal proliferative phase biopsies and
appears increased in some cases of DUB. The significance of
this finding is not known but increased apoptosis may serve
as a morphological marker of abnormal endometrial
development in otherwise normal biopsy specimens (Stewart
CJ-1998).
AETIOLOGY: -
PRIMARY DUB: -
Primary DUB results from disturbances
in Eicosanoid metabolism and in fibrinolytic and lysosomal
enzyme systems of the endometrium. The most common etiology
for DUB is estrogen withdrawal or estrogen break through
bleeding in an anovulatory patient. In absence of
progesterone exposure to cause inhibition of DNA synthesis
and mitosis, the estrogenic proliferative response causes
stream cell growth to exceed the structural integrity of its
stromal matrix, and the endometrium breaks downs with
irregular bleeding. Unopposed estrogen results in vascular
endometrial tissue with relatively scanty stroma, giving
glands a back to back appearance. The endometrium is fragile
and undergoes repetitive spontaneous breakdown. In absence
of normal control mechanism to limit menstrual blood loss,
bleeding can be prolonged and excessive.
Normal menstruation involves the
breakdown, remodeling and repair of the functional
endometrial layers. Endometrial destruction and regeneration
are largely controlled local factors that are dependent on
the levels of estradiol and progesterone. Prostaglandins and
endothelins appear to be powerful vasoactive substances in
the control of menstrual blood loss. The tissue endothelin
concentration may interact with relaxing factors, such as
nitric oxide, prolonging or increasing menstrual blood loss.
(Capdevila C 1997)
Role Of Eicosanoids: -
The role of eicosanoids including
prostaglandin PGE2, PGE2 alpha and the prostanoids
prostacycline PGI2 and Thromboxane TxA2, and leukotrienes
has been well studied. Arachidonic acid is initially
metabolized by cyclooxgyenase into insatiable endoperoxides
which are rapidly converted by specific syntheses into PGF2
alpha (Vasoconstriction and weakly platelet aggregatory),
PGE2 (vasodilator and weakly platelet anti-aggregatory),
PGD2 (a platelet agglutination inhibitor), PGI2 ( a potent
vasodilator and inhibitor of platelet aggregation) and TxA2
( a potent vasoconstrictor and platelet aggregator. In
normal menstruation the ratio of PGF2a: PGE2 in menstrual
fluid is roughly 2:1 so that it is the vasoconstrictor and
platelet aggregator actions that predominate.
Anovulatory DUB: -
In anovulatory DUB, the lack of
progesterone results in a decrease in the PGF2a: PGE2 ratio
and a relative increase in the vasodilator and anti-platelet
aggregators PGE2. This would account for the increased
menstrual blood loss. It also accounts for absence of
uterine contractions and painless periods characteristic of
anovulatory menstruation.
Ovulatory DUB: -
In women with normal MBL, the order of production of
prostaglandin by secretory endometrium is PGF2a/ PGE2/PGD2
but in women with ovulatory DUB, the order of synthesis is
reversed to PGE2/PGD2/ PGF2a. Also increased synthesis of
PGI2 in myometrium causes dilatation of radial arteries and
an increase in MBL.
Role Of Leukotrienes: -
Leukotrienes are eicosanoids produced
by leukocytes, by action of lipoxygenase on arachidonic
acid. MBL is roughly proportional to degree of infiltration
by leukocytes producing leukotrienes.
Fibrinolytic and Lysosomal Enzymes: -
Progesterone withdrawal causes a
breakdown of hysoymes and release of phospholipase A2 that
causes formation of Arachidonic Acid iron phospholipids and
initiates the prostanoid cascade. There is a marked increase
in both plasminogen activators and in Fibrinohytic activity
in the menstrual fluid in case of DUB.
Endocrine Changes: -
Finding of normal secretory endometrium
in upto 84% of women with DUB is strong evidence against
endocrine abnormalities as a common cause of DUB. It is now
accepted that there is usually no deflectable endocrine
dysfunction in DUB. The occurrence of endometrial
hyperplasia was in upto 30% of women with DUB. This suggests
that endocrine abnormalities are important etiological
factors in a significant minority of cases,
A) Ovulatory DUB:-
This the most common of DUB. Variations
in cycle length are most often associated with disturbances
in proliferative phase: short cycles resulting in
Polymenorrhea, and long cycles in Oligomennohrea. In
adolescence menstrual irregularities are usually due to
impaired response of the hypothalamus and immaturity of the
estrogen feedback system and they nearly always resolve
spontaneously.
· Corpus luteum abnormality :-
I) Corpus luteum Insufficiency:
Inadequate development of corpus luteum may result in
insufficient progesterone production and insufficient
secretory changes in the endometrium with a decrease in
PGF2a: PGE2 ratio in the endometrium and hence in
menorrhagia. Progesterone deficiency can be identified by
plasma progesterone estimation or on histological
examination by irregular ripening of the endometrium in the
second half of the cycle. It may be suspected if there is
premenstrual spotting and/or shortening of the menstrual
cycle.
II) Persistent corpus luteum: A
persistent corpus luteum may result in continued estrogen
and progesterone secretion and absence of the normally sharp
fall in these hormonal levels, which precedes menstruation.
This in turn causes inadequate release of phospholipase A2
and inadequate release of prostaglandins, with irregular
shedding of the endometrium. Persistent corpus luteum may be
suspected if there is an abnormal prolongation of
menstruation and endometrial figments are found in menstrual
discharge more than 48 hours after on set of menstruation.
B) Anovulatory DUB:
It is the most commonly recognized
endocrine abnormality as it results in proliferative
endometrium in the second half of the cycle or endometrial
hyperplasia. There are two types of abnormalities leading to
anovulatory DUB.
· Insufficient follicular Development.
Due to insufficient follicular
development there is inadequate estrogen production and
hence inadequate proliferation of endometrium without any
secretory charge, resulting in a deficient or atrophic
endometrium with large dilated subendothelial vessels
causing excessive bleeding.
· Persistent Ovarian Follicle:-
Anovulation results in persistent
ovarian follicle with adequate estrogen secretion, but since
corpus luteum fails to develop, progesterone secretion is
absent. A continuous unopposed high level of estrogen as in
polycystic ovaries or un-ruptured follicle syndrome results
in endometrial hyperplasia, adenomatous hyperplasia and
eventually carcinoma of endometrium. Bleeding in this
condition occurs either when endometrium outgrows its blood
supply or when there is decrease in estrogen level.
SECONDARY DUB: -
I) SECONDARY TO STEROIDAL
CONTRACEPTIVES AND IUCDS:-
Continuous oral administration of low
dose progestogens, injectable depot progestins and excessive
DUB: Low dose progesterone causes underdevelopment of the
spiral arterioles and degenerative and vascular lesions of
the dilated verges large depot injections of progestogens
produce large superficial dilated venules with atrophy of
the endometrium.
Non-medicated and copper IUDs produce a marked increase in
menstrual loss varying from 26 to 116% with an average
doubling of MBL. Progestogen releasing devices reduce the
volume of MBL by 40-50%. Superficial ulceration of
endometrium and increased vascularity and interstitial red
cell extravasation with absence of platelet fibrin
thrombosis, lead to DUB secondary to IUCD. There is also an
increase number of macrophages which produce PGE2, PGF2a,
plasminogen activator and fibrinolytic enzymes.
II) SECONDARY TO SYSTEMIC DISEASE :-
A) Bleeding Disorders: Bleeding
disorders like thrombocytopenia, thrombocytopathic
afibirogenmia, Von Willebrand’s disease, macroglobinacmia
and factor II,V, VII, X & XI deficiency disorders were
responsible for 30% of teenage DUB cases.
B) Hypothyroidism: - Incidence of
menorrhagia in myxoedema varies from 32 to 80% It promptly
responds to Thyroid replacement.
C) Iron Deficiency Anemia: - Iron
deficiency anemia causes reduction in MBL out of
reproduction to fall in hemoglobin concentration.
CLINICAL PRESENTATION AND DIAGNOSIS: -
Any case of DUB is evaluated on two
grounds, age group and pattern of bleeding.
By Age Group: -
I) Adolescents: Organic disease and
malignancy are very rare in this age group and abnormal
uterine bleeding is almost dysfunctional. Adolescent DUB is
due to immaturity of hypothalamus and inadequate positive
feedback and is often associated with some irregularity of
menstruation due to delayed or failed ovulation. 40-50%
cases resolve within 2 years Prognosis in better in females
in whom DUB starts after a period of normal menstruation
than in those whom DUB started at menarche. Bleeding
disorders must be excluded. These cases are always managed
medically conservatively.
II) Adult (20-39 Yr.)
Benign diseases like pelvic
inflammatory disease and fibromyoma are common causes of
abnormal uterine bleeding in this age group. Most cases are
ovulatory and resolve spontaneously. Organic disease must
always be excluded in a case not responding to conservative
management.
III) Perimenopausal :-
Abnormal uterine bleeding in women 40
yrs. and over is most commonly dysfunctional. It is
mandatory to rule out organic causes such as fibromyoma,
carcinoma endometrium before making diagnosis of DUB.
Hysterectomy is often indicated.
By Bleeding Pattern: -
A) Regular Cyclical Bleeding :-
Menorrhagia may be frequently
associated with some organic disease like fibroid or PID,
but also may be dysfunctional ovulatory. It has a favorable
prognosis.
B) Irregular or Acyclical Bleeding :-
It may be due to organic disease of
genital tract especially carcinoma cervix or endometrium. It
is also dysfunctional frequently and tends to be anovulatory.
Metrorrhagia is unfavorable particularly for perimenopausal
women.
C) Intermenstrual Bleeding:
Cervical and endometrial polyps,
submucons uterine fibroids and carcinoma cervix can cause
such bleeding. It may also be seen in DUB to fall in
estrogen secretion following ovulation.
DIAGNOSIS: -
In clinical practice the diagnosis of
DUB is usually made by exclusion of organic disease of the
genital tract. The main difficulty in the diagnosis of DUB
is deciding the extent of the investigations necessary to
perform reasonably to exclude organic disease of the uterus.
It is now generally accepted that an adequate clinical
examination of the abdomen & pelvis, uterine curettage,
hysteroscopy or an endometrial biopsy are essential to rule
out organic disease of the uterus.
History:-
To be taken as follows:-
· Age, parity, & fertility
· Amount, duration and pattern of uterine bleeding
· Dysmenorrhea, infertility of bleeding disorder or
myxoedema.
· Patients wish regarding contraception, future pregnancies
and possible hysterectomy
· Social and personal background.
Examination: -
Thorough abdominal and pelvic
examination is essential.
Investigations: -
A) Ultrasound: - USG may be used to
exclude pelvic masses or possible pregnancy complications.
TVS is much more informative.
B) Dilatation of cervix and uterine
curettage: It is the commonest investigations resorted to in
cases of abnormal uterine bleeding It helps to:
I) Provide endometrium sample to
differentiate proliferative from secretory, irregular
ripening, shedding or atrophy. Thus helps to judge possible
etiology and decide treatment.
II) Exclude intrauterine organic pathology like endometrial
hyperplasia, carcinoma, tuberculosis, endometriosis,
fibromyoma or endometrial polyps.
III) Arrest bleeding – If it is persistent or excessive
particularly in cases where endometrial hyperplasia is
suspected.
D & C. is essentially a diagnostic & not a therapeutic
procedure, but MBL does decrease is the next cycle.
Commonest pathology defected is fibromyoma, in 20-40% of
cases & endometrial pathology in 2-6% of cases.
C) Hysteroscopy:- With sensitivity of
detecting intrauterine pathology as high as 98% hysteroscopy
is fast replacing curettage. Hysteroscope provides an
excellent view of uterine cavity and polyps, fibromyomas or
any suspicious union however small can be readily diagnosed
by biopsied.
D) Endometrial Biopsy:- It is useful
procedure to exclude endometrial hyperplasia and carcinoma
Endometrial sampling by vabra aspirator is an outpatient
procedure with less incidences of infection, perforation &
hemorrhage, but has following disadvantages:
· It requires skill & experience to
perform it 7 may fail in postmenopausal women with stenos
cervix.
· Small areas of abnormal endometrium, polyps & submucous
fibroids may be missed.
· It does not remove all the endometrium & is not a curative
procedure.
E) Hematological Investigations:-
Hemoglobin estimation should be carried out in all cases of
DUB. Bleeding time, clotting fine, platelet count &
coagulation profile should be carried out is young patients
with recurrent DUB.
F) Laparoscopy Or Hysterosalpingography
:- To diagnose pelvic tumors, polyps, fibroids or pelvic
inflammatory disease.
G) Day21 Plasma Progesterone to
diagnose corpus luteum insufficiency or involution plasma
follicel stimulating hormone & lutenizing hormone to
diagnose menopause.
H) Plasma Trilodothyronine, Thyroxine
And TSH to exclude myxoedema.
MANAGEMENT: -
There is a wide range of
treatment option fo DUB. Following steps are undertaken
while managing a case of DUB.
I) Exclusion of organic disease of genital tract.
II) Diagnosis of Dysfunction
IV) Assessment of nature and severity of DUB and age, parity
& wishes of patient regarding contraception, future
reproduction & surgery if indicated.
General Measures: -
Reassurance by counseling plays an
important role in the treatment. Pt is advised to keep “
Menstrual Calendar” in which day to day record of amount of
Blood loss is mentioned. This is particularly useful if
amount & pattern of bleeding is uncertain. Oral iron therapy
is often required because menorrhagia makes the patient
anemic and also deflects her iron stores. If DUB is
secondary to IUCD other method of contraception needs to be
reconsidered.
Medical Therapy: -
I) Hormone Therapy: -
Endometrial histology in second half of
cycle helps to choose most appropriate and effective
hormonal therapy.
A) Combined Estrogen – Progestogen:-
Oral contraceptives are most popular &
effective form of hormone therapy. Combined estrogen
progesterone therapy corrects any abnormalities of menstrual
cycle, regularizes the cycle and reduces MBL. Management of
dysfunctional uterine bleeding is determined by the needs of
the patient: oral contraceptives are used for women of
reproductive age with ovulatory uterine bleeding episodes
who also require contraception, they have a strong
progestrogenic effect that is evident as early as the first
week of pill in take. In the perimenopausal patient,
dysfunctional uterine bleeding may be treated by cyclic
progestins with or without conjugated equine estrogens oral
contraceptives can also be used in non-smokers who have no
evidence of vascular disease. (Capdevila C 1997)
B) Progestogen Therapy :-
Can be administered in three ways:
i) Arrest of Hemorrhage: - Norethisterone, 20-30mg daily is
given to arrest severe uterine bleeding for 2-3 days and
then confined at a lower does for 21 days.
ii) Luteal phase treatment: - When corpus luteum
insufficiency with premenstrual spotting is diagnosed
Progestogen therapy is indicated from day 15th to 25th for 3
cycles.
iii) Whole cycle treatment: - When endometrial hyperplasia
is diagnosed potent Progestogen like Norethisterone activate
5mg daily or medroxy progesterone acetate 10 mg daily should
be used from 5th to 25th day for 3 cycles.
C) Estrogen Therapy :-
Estrogen therapy is of value in
breakthrough bleeding and arresting severe hemorrhage
particularly in cases of atrophic endometrium. Estradiol
valerate 4 mg daily or ethinyl estradiol 0.05-mg daily or
conjugated equine estrogen 2.5 mg daily for 5 days is used.
Estrogens are also indicated is cases
of DUB secondary to depot progesterone. In cases of very
severe hemorrhage, a single intravenous injection of
Premarin 25 mg with dilatation & curettage may the best
therapy.
D) Testosterone:
There are best reserved as a third line
agent when other forms of therapy may be contraindicated.
Methyl testosterone is given 10 mg daily for 7 days
preceding menstruation in cyclical menorrhagia. It
should not be given for more than 3 months danazol is
peripherally converted into testosterone and acts
as an androgen .it effectively reduces MBL in dosage of 200
mg for 12 weeks
II) Prostaglandin Synthetase
Inhibitors:-
Prostaglandin syntheses inhibitions
like diclofenac, ibuprofen mefenamic acid & naproxen act by
blocking cyclo-oxygenase which converts arachidonic acid to
endoperoxides & thence to prostanoids.
These agents may be particularly
beneficial in ovulatory DUB associated with dysmenorrhea.
They can be used as first line agent. Their effectively is
demonstrated on Colour Doppler studies. It is shown that
tranexamic acid significantly reduces uterine artery
vascular resistance in women with dysfunctional uterine
bleeding. This effect is unlikely to be a mechanism for the
action of tranexamic acid in reducing menstrual blood loss
but may have important implications for women taking this
treatment in the long term(Lakhani KP 1998).
IV) Antiflbrinolytic Agents :-
Aminocaproic acid, paraaminomethyl benzoic acid and
tranexamic acid are potent inhibitors of fibrinolysis and
their use reduce MBL below 80 ml in 50% of cases in
essential & IUCD related menorrhagia recommended dose is
upto 6gms for first four days & than smaller dose for next
four doses.
Surgery:-
Endometrial Ablative Procedures;-
Such techniques are regarded as
alternatives to hysterectomy when it is derived to preserve
the uterus. Good results wear obtained by TCRE -Transcervical
Resection of Endometrium using 26 F gauge resectoscope and
by hysteroscopic laser photo vaporization by many workers.
The surgical treatment outcome
prospects for dysfunctional uterine bleeding were studied in
a randomized trail designed to compare endometrial ablation
against hysterectomy (Strabinsky 1999). Available data from
studies with admittedly incomplete. Follow-up suggest that
upto one quarter of patients treated with endometrial
ablation require repeat ablation or infrequently
hysterectomy to stop DUB. Best results in ablative
procedures can be obtained by suppressing endometrium for
4-6 weeks with high dose of progestins or GnRH against or
danazol.
In the past the treatment of benign
uterine lesions and DUB required, in many instances, a
hysterectomy. These days most cases can be successfully
treated by hysteroscopy. To be reliable, this technique must
lead to a significant reduction in the number of
hysterectomies performed for these conditions. The
electro-resection technique is preferred to that using the
Nd-YAG laser because of its lower cost and its equivalent
efficacy. By using the uterine perfusion pump device, the
risk of resumption syndrome can be reduced to its minimum.
Submucosal myomas<1cm, benign endometrial hyperplasia and
adenomyosis are the commonest benign lesions treated.
Dysfunctional uterine bleeding can also be treated by an
endometrectomy. A preoperative work-up includes a
transvaginal ultrasound and a biopsy. This ensures that only
benign lesions that are accessible to a hysteroscopy will be
submitted to this technique and that no cases of endometrial
cancer or atypical hyperplasia would be ignored. One good
study presents 270 cases of operative hysteroscopy with a
follow-up to 4 years. 82.8% of myomatous lesions were
treated with success. The results for patients with benign
endometrial polyps or benign endometrial hyperplasia are
also excellent with only 4.6% and 5.6% rate of secondary
surgery respectively. Adenomyosis does not appear to be a
good indication for hysteroscopy as only 37% of patients did
not definitive hysterectomy. Rates of operative
complications ( post-operative bleeding , uterine
perforation resumption syndrome and difficulty of access)
are acceptable and get less frequent as the surgeon
experience increase(Herman P-1998).
Postoperative granulomas have been described in the uterine
cervix, fallopian tube, and other sites after various
procedures, as well as in the endometrium after endometrial
ablation procedures. Endometrial ablation is a procedure
increasingly used by gynecologists to relieve symptoms
associated with dysfunctional uterine bleeding.
Occasionally, patients will not have a satisfactory result,
and some will require subsequent hysterectomy. One study
describes the pathological findings in the hysterectomy
specimens from 15 patients who had previously undergone
endometrial ablation. Indications for subsequent
hysterectomy included Dysmenorrhea (7 patients), Menorrhagia
( 7 patients), dysfunctional uterine bleeding ( 5 patients),
and pelvic pain ( 4 patients). All patients had varying
degrees of fibrous tissue. Histological examination revealed
fibrosis with varying degrees of granulomatous inflammation.
The majority of the granulomas were associated with
refractile brown hematoidin-like pigment, and most were also
associated with uniform black pigment. In 8 cases, areas of
faintly eosinophilic, homogenous, hyalinized material was
present within the endometrium. Comparison is made to
granulomas due to other causes, because the postoperative
granulomas of the endometrium differ morphologically from
granulomatous inflammation caused by other etiologies. As
endometrial ablation gains popularity among gynecologists
and their patients, it is likely that the practicing
pathologist may encounter these sequelae with increasing
frequency. (Silvernagel SW 1997)
Hysterectomy: -
Hysterectomy offers advantages like
complete cure of the condition and removal of any missed
pathology e.g. unsuspected undiagnosed malignancy besides
avoidance of continued long-term medical therapy. It is a
major operative procedure, necessitating hospital admission
patient pain & inconvenience, morbidity and sometimes
mortality are also associated. Principle deciding factors
are severity & persistence of abnormal bleeding, age and
parity & wishes of patient regarding future reproduction. In
younger women of reproductive age group it should be the
last resort & virtually should never be profound. In women
over 30 years it should be performed with reluctance, when
medial therapy has failed & family is complete. In women of
40 years or more, hysterectomy should be considered in all
cases of persistent or recurrent bleeding and of incomplete
response to medical therapy. In this age group missed
organic disease are more likely & spontaneous remission is
unlikely. Removal of uterus is also psychologically more
acceptable to patient of this age.
Many gynecologists are reluctant to do this surgery in
luteal phase. But this may not be with any evidence. To
determine the relationship between the timing of a
hysterectomy performed during the menstrual cycle phase and
the postoperative complication rate in women who had
undergone surgery for dysfunctional uterine bleeding, the
authors examined the charts of 24 patients for the 3 –month
period immediately after the hysterectomy. Twelve of the
women were in the follicular phase, and 12 were in the
Luteal phase at the time they had undergone the
hysterectomy. Operative pathology, preoperative and
postoperative hemoglobin levels, operation time, blood loss
classified patients, days before return to full functioning
days in hospital, and uterine morphology. Further
prospective studies with longer follow-up time are needed to
obtain more conclusive indications regarding the optimal
timing of hysterectomy during the menstrual cycle (Baron DA,
1999).
Radiotherapy: -
External irradiation of the ovaries is
performed & amenorrhea results. It has no immediate risks
but leaves behind a potentially damaged organ that may
develop pyometra, haematometra or carcinoma. It is only
resorted to when hysterectomy is indicated but patient is
unfit for operation. In the 1940s, 1950s and 1960, low doses
of radiotherapy were used to treat benign uterine bleeding.
The cases of two women who received this from of therapy and
later developed gynecological malignancies and had high dose
pelvic radiotherapy were recently published. A 76-years-old
women with an International Federation of Gynecology and
Obstetrics (FIGO) stage-IIB squamous cell carcinoma of the
cervix received external beam radiotherapy and intra-uterine
brachytherapy and a 77-year –old women with a FIGO stage-IB
endometrial adenocarcinoma received adjuvant postoperative
pelvic radiotherapy. Both women had a significant past
history of low-dose rate intra uterine irradiation for
dysfunctional uterine bleeding. Therefore the theoretical
question of carcinogenesis was raised, and also the
practical question of what dose had previously been given
and what further dose could be safely given with regard to
normal tissue tolerance(MacLeod C 1999)
REFRENCES
1. Wren BG: Aust Fam Physician
1998-May,27(5):371-7,
2. Stewart CJ: Sydney Menopause Centre,
RHW, Histopathology 1999 Feb, 34(2):99-105
3. Capdevila C: Eur J Contracept.
Reprod Health Care 1997 Dec:2(4) 229-37
4. Lakhani KP: Marsh MS, Purrcel W:
Ultrasound Obstet Gynecol 1998, April,11(4)283-5
5. Stabinsky S S: Modern treatment of
menorrhagia attributable to DUB 1999, Jan,54(1): 61-72
6. Herman P Rev Med. liege 1998 Dec,
53(12) : 756-61,
7. Silvernagel SW: Ann. Diag. Pathol
1997-Dec,(2):82-90
8. Baron DA, Hardie T: J Am Osteopath
Assoc. 1999 Jan, 99(1):25-7
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