The Detergents And Disinfectants For Instruments And Surfaces (Hexanios - Surfanios)

• A normal menstrual cycle usually lasts between 28 ± 7 days and the total bleeding time is less than 7 days. It does not cause anemia unless the total amount of bleeding exceeds 80 ml.

• Anovulation is common in the first 2-5 years after menarche, and the cycle length is often 21-45 days in the adolescence period.

Menstrual menstrual irregularities

• Oligomenorrhea: Bleeding with intervals longer than 35 days and the follicular phase is prolonged. (chronic anovulation)

• Polymenorrhea: Bleeding that occurs at intervals of less than 24 days and the follicular phase is shortened 

• Menorrhagia: It is a large amount (>80 ml), long (> 8 days) long but regular bleeding (adenomyosis, IUD).

• Metrorrhagia: Bleeding with irregular bleeding intervals but normal amount. (endometrial polyps, endometritis).

• Menometrorrhagia; Excessive and prolonged bleeding that occurs at irregular and frequent intervals

• Hypomenorrhea: It is regular bleeding with a small amount (<20ml).

• Hypermenorrhea: It is regular bleeding with a large amount (> 80 ml).

• Intermenstrual bleeding: Bleeding seen in the middle of the cycle (ovulation bleeding).

etiology

• While 30% of abnormal uterine bleedings are due to an organic cause, 70% are not due to an organic cause and used to be called dysfunctional uterine bleeding.

Causes of bleeding by age and frequency
Newborn	prepubertal	adolescent	reproductive	premenopausal	postmenopausal
Withdrawal of maternal estrogen	vulvovaginitis	anovulation	Exogenous hormone use	anovulation	Endometrial atrophy
	Foreign body in vagina	Exogenous hormone use	Pregnancy	fibroids	endometrial polyp
	precocious puberty	Pregnancy	anovulation	Cervical and endometrial polyps	Endometrial cancer
	Tumors (rhabdomyosarcoma, ovarian tumors)	Coagulopathy- Hematological causes	fibroids	thyroid dysfunction	hormone therapy
	Other; Urethral prolapse, lichen sclerosis, trauma, exogenous hormone use		Cervical and endometrial polyps		endometrial hyperplasia
			thyroid dysfunction		tumors, vulvar, vaginal, cervical

The most common gynecological problem in childhood is vulvovaginitis.

Organic Causes of AUB

Gynecological Causes

Gynecological diseases causing AUB

• problems with pregnancy; ectopic pregnancy, abortion, trophoblastic diseases

• gynecological malignancies; Endometrial cancer, cervical dysplasia/cancer, tubal cancer, sex cord stromal ovarian cancers, uterine sarcoma, vaginal cancer

• Uterine leiomyomas

• Adenomyosis

• Endometrial polyp and endometrial hyperplasia

• Genital infections (especially chlamydial cervicitis, chronic endometritis, condyloma)

• Urethral prolapse

• Lichen sclerosis (may be postmenopausal or prepubertal)

• Intrauterine devices, foreign body or trauma

Non-gynecological Causes

• Medication (anticoagulant sex steroids, etc.) and systemic diseases can lead to AUBs.

Systemic diseases causing AUB

1. Diabetes mellitus

2. Hypothyroidism-myxedema

3. Hyperthyroidism

4. Prolactinoma

5. Bleeding diathesis (ITP, vWH)

6. Chronic diseases (Liver diseases, chronic kidney failure, obesity)

Coagulation defects are the cause of 20% of all juvenile bleedings during adolescence, especially after menarche. The most common cause of this is idiopathic thrombocytopenic purpura (ITP) followed by von Willebrand disease.

Dysfunctional Uterine Bleeding

Estrogen Withdrawal Bleeding

0 Sudden discontinuation of exogenous estrogen therapy

0 Bilateral oophorectomy

0 After radiotherapy

0 Ovulation bleeding in the middle of menstruation (intermenstrual bleeding)

0 Neonatal bleeding (withdrawal of maternal estrogen)

Estrogen Breakthrough Bleeding

All anovulatory hemorrhages, such as PCOS, fall into this group (E-03).

Estrogen breakage bleeding is the most common type of IDU in the reproductive period.

Progesterone Withdrawal Bleeding

0 Sudden discontinuation of exogenous progesterone therapy

0 Progesterone withdrawal test (PCT)

0 Corpus luteum insufficiency

Progesterone Breakthrough Bleeding

0 Persistence of corpus luteum

0 During COC use

0 In long-acting progesterone-containing contraception (Depo MPA, implants, LNG-IUD)

0 Minipill usage

The prevalence of anovulatory cycles increases under the age of 20 and above the age of 40.

Palm-Coein Classification in Abnormal Uterine Bleeding

• The most common causes of abnormal uterine bleeding are classified as structural causes (PALM) and non-structural systemic causes (COEIN). Pregnancy-related causes are not included in this classification.

• Structural causes (PALM)

► P = Polyp

► A = Adenomyosis,

► L = Leiomyoma; It has two submucosal (L5M) and cavity unrelated (LL0) subgroups.

► M = Malignancy and hyperplasia

• Non-structural causes (COEIN)

► C = Coagulopathy

► O = Ovulatory dysfunction

► E = Endometrial causes

► I = Iatrogenic

► N = Causes not yet classified

• Bleeding classified as dysfunctional uterine bleeding is currently classified as abnormal uterine bleeding due to ovulatory dysfunction or endometrial causes.

• Most anovulatory hemorrhages occur due to estrogen breakdown. Conditions associated with anovulation and abnormal bleeding;

► Eating disorders; Anorexia nervosa and bulimia nervosa

► Extreme exercise

► Chronic diseases

► Primary ovarian failure

► Abuse of alcohol and other drugs

► Stress

► Thyroid diseases; Hypothyroidism, Hyperthyroidism

► Diabetes

► Androgen excess syndromes (like PCOS)

• Endometrial polyp; may cause abnormal uterine bleeding (especially metrorrhagia). Although it may also be associated with dysmenorrhea and infertility, most endometrial polyps are asymptomatic. Its incidence increases in reproductive age. It may also be associated with the use of tamoxifen. It can be visualized by transvaginal ultrasonography, hysteroscopy, hysterosonography, and hysterosalpingography but must be confirmed histologically. There is a possibility of spontaneous regression of asymptomatic and incidentally detected polyps. However, since there is a risk of malignant transformation, some authors recommend polypectomy for all polyps, while others recommend polypectomy only in the presence of risk factors for malignancy (postmenopausal period, greater than 1.5 cm, abnormal bleeding, tamoxifen use). Hysteroscopic resection should be preferred in its treatment.

• Bleeding, which used to be called ovulatory DUB, is now classified as Endometrial AUB (AUB-E). Bleeding due to lack of endometrial local vasoconstrictors or excess vasodilators are included in this group.

• Breakthrough bleeding seen during hormonal contraceptive use is among iatrogenic causes.

Diagnosis

A detailed anamnesis and examination are priority in the diagnosis of AUB. Subsequently, a possible pregnancy should be ruled out. Coagulation tests should be performed in those with severe (abdant) bleeding. Endocrine tests, LFT and BFT are helpful in AUB due to systemic diseases. Imaging techniques (USG, HSG, CT, MRI) are helpful in gynecological AUBs

• Endometrial sampling should be performed in women aged 45 years and older who present with AUB, those with chronic anovulation, obese women, those using tamoxifen, or women with other risk factors for endometrial cancer.

Treatment

• The approach in AUBs with organic cause is the treatment of the underlying disease. hormonal treatment is priority.

Medical Treatment:

► Progesterone Treatment

► Estrogen Therapy: Estrogens also induce clotting at the capillary level, thereby stopping bleeding.

► Combined Oral Contraceptive Therapy: It is a combined treatment that includes both progesterone and estrogen therapy.

► LNG-IUD: The most important advantages are that it is an alternative to surgery and can be used safely in chronic patients. It is the medical method that should be preferred first in women with heavy bleeding and desire for contraception.

LNG IUD is the first choice method in case of abnormal uterine bleeding in patients who use anticoagulants or have coagulation disorders.

► Prostaglandin synthesis inhibitors {mephanemic acid, ibuprofen): They are not used in acute and severe bleeding, but they reduce the amount of bleeding by 30-50% in patients with idiopathic menorrhagia.

The drugs of first choice in idiopathic bleeding are prostaglandin synthesis inhibitors.

► GnRH Analogs: It has no efficacy in acute bleeding.

They are the drugs that should be preferred first in cases that contraindicate hormonal treatments such as chronic kidney failure, after liver transplantation and blood dyscrasias. 

► Danazol: It is not preferred much in practice due to undesirable androgenic side effects.

► Desmopressin: It is a synthetic analogue of vasopressin. It is especially effective in stopping bleeding that occurs in cases of von Willebrand factor deficiency and hemophilia (increases vWF and FS).

► Antifibrinolytic Treatment {Tranexamic Acid): GIS side effects are high. It is very effective in reducing heavy menstrual bleeding. It can also be used in bleeding due to intrauterine devices. Concurrent use with COCs is contraindicated.

Surgical treatment

► Dilatation and Curettage: It is performed for therapeutic as well as diagnostic purposes.

► Endometrial ablation: It is the physical damage of the basal endometrium. It is an alternative treatment method to hysterectomy in patients who have completed their reproductive potential.

Endometrial ablation is strictly contraindicated in women with endometrial hyperplasia, endometrial cancer, expectant fertility, pregnant women, acute pelvic infection status, postmenopausal women, and women at high risk for endometrial cancer (obesity, chronic anovulation, tamoxifen, unopposed estrogen use, DM).

► Hysterectomy: It can be applied as a last resort in treatment-resistant bleeding.