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🐳  Dr. SABA
🐳 Monday Lecture


🌨Signs of heavy Bleeding =>

     ❄️Number of pads > 4 /Day
     ❄️ Presence of clots
     ❄️ Interference with her daily activities
     ❄️Symptoms of Anemia
     ❄️ Associated with::
            ☆ Pain
            ☆ Dysmenorrhea
            ☆Swelling
            ☆Intermenstrual bleeding
            ☆ Post_coital bleeding



🌨In case of  Watery discharge , think about  cervical or endometrial abnormality .


🌨 Causes of AUB :
     
           ❄️Structural :
                 [PALM]
                  P:olyp
                  A:denomyosis 
                  L:eiomyoma
                  M:alignancy

          ❄️Non _ structural :
                 [COEIN ]
                 C:oagulation disorders
                 O:varian Diseases
E:ndometrial
                 I:atrogenic
                 N:non classified DUB



🌨High estrogenic state, could  occur due to ;

           ❄️PCOS
           ❄️Anovulation



🌨Examination , for pt with Heavy bleeding:

       ❄️ General examination :

               🧊 Face ;
     🫧Acne
     🫧 Abnormal hair grown on face (on androgen dependent areas)
     Exophthalam( Hyperthyroidism)
    🫧 Pallor (Anemia)


         🧊 Neck ;
                 🫧Thyroid swelling
                 🫧Enlarged LNs
                   

        🧊 Breast ;for Galactorrhea

       🧊Abdominal Examination
[As usual, but pay attentionto any swelling & detect if it is abdominal or pelvic swelling]


    ❄️Local examination
             🧊Inspection=>
Search for blood , clots ,  discharge , swelling , ulcer , scar , change in color , abnormal hair distribution, etc ...
   
    🧊 Specular inspection
    🧊 Bimanual examination

🌨Investigations u should order for pt with AUB ;
         ❄️CBC
         ❄️ Swab & Smear
         ❄️Hormonal profile ; if pt has signs&/or symptoms of Hyperthyroidism or Hyperprolactinemia 
        ❄️ Coagulation profile; for pt with bleeding tendency
        ❄️ Tumor Factors; if U suspected Malignancy
        ❄️ US ; Vaginal & Abdominal
        ❄️ MRI ; More accurate for Adenomyosis
        ❄️ Saline infusion sonography; to diagnose endometrial polyp
        ❄️ Hysteroscopy
        ❄️ Biopsy

Dr. Arwa Alrabie ✨



🔴 Abnormal uterine bleeding (AUB)

🔷 Menorrhagia is a modern term that mean :
           . Excessive menstruation
           . Intermenstrual bleeding
           . Post coital bleeding
           . Post menopausal bleeding

🔷 Causes of AUB [ Mnemonic Category] :
         [ PALM COEIN ]

   1."Structural causes"
 
P : Polyp
A : Adenomyosis
L : Leiomyoma
M : Malignancy

    2. "Non structural causes"

C : Coagulation disorder
O : Ovarian
  I : Iatrogenic for ex. IUD,Drugs as aspirin or warfarin.
  E : Endometrial
N : Non classified


🔺 Excessive menstrual bleeding:

      🔅> 80ml

      🔅Presence of clots

      🔅Number of pads changed daily.

      🔅It is subjectives diagnosis => depend on pt description of  her menses on her own words .

      🔅80% of pt in reproductive age complaining of excessive menses .



🔺 Bleeding of endometrial origin = Dysfunctional Uterine Bleeding (DUB)
       🔅Abnormal secretion of Prostaglandin.
       🔅Chronic anovulation as in PCOS.




📌Evaluation is acheived by history , examination and investigation .

📌 History
   - Onset , course , duration
   -  Presence of clots , number of pads changed daily and if it soak to the clothes
   - Fatiguability with exertion => anemia
   - Gain weight & Fatiguability => hypothyroidism .

📌 Examination:

  🔅 General look and examination
     . Signs of anemia
     . palpate for pelviabdominal mass.


  🔅Gynaecological examination
         _ Inspection (bleeding , swelling .....)
         _ Bimanual (size, shape, consistency , contour and position of uterus )
         _ Speculum examination

🔻Investigation :

According to NICE (National Institute for health and Clinical Excellence ) guidlines :

🔅CBC
🔅Hormonal profile ( If there are indicators suggest endocrine diorder )
🔅Coagulopathy screen ( If there are indicators suggest bleeding disorder )

🔅UltraSound [ transvaginal u.s  is better than transabdominal u.s as it detect the size and site of the mass ] .

🔅Endometrial biopsy:

      🔷 Indication :
         🔸 Endometrial thickness > 4mm
         🔸 Pt >45 years old (risk factor)
         🔸 If medical ttt is failed
         🔸 Ablation for endometrium
         🔸 Hysteroscopic guided endometrial biopsy if the Ultrasound did not give enough information

        🔸 Therapeutic for small polyps





🔻Treatment:

🥇. Reassurance

🥈. Medical :

   🎯If there is no structural factors or if present but not significant.
   🎯 Is not a final ttt
   🎯 Needs good evaluation and concentratiin on case
   🎯 Needs to ask about past medical and surgical history

   🎯 Is of two types:
1. Hormonal [ progestron , GnRH (treating fibroids and cause estrogen shut down and amenorrhea) ]
2. Non hormonal [ NSAID, Tranexamic acid]


🥉. Surgical :

   
    🔎 Indication:

      🎯 If medical ttt failed [ no response]
      🎯If surgical ttt is needed as if medical ttt is contraindicated or the pt is hemodynamically  unstable

    🔎 Procedure :

🪡Endometrial Ablation :
      🔸Uterus size =>10
      🔸Fibroid < 3cm
      🔸Done by radiologist

       🔸 The results:
50% ---> amenorrhea
40% ---> decrease bleeding
10% ---> failure of ttt ( still has bleeding )



🪡Hysterectomy :
      🔸For case that

           🫧Does not respond to any medical ttt

          🫧 With no desire fertility


     🔸May be done abdominally or vaginally .



♨️So if pt coming complaining of excessive bleeding :
1. Admission [ A B C D ]
2. Stabilization
3. Evaluation
4. Urgent ttt

د. سبأ شجاع الدين ♥️♥

📌 Pelvic Organ Prolapse ( POP )

🌻In case of POP we should ask the patient about :-
🔸Predisposing factor as
( chronic cough , chronic constipation , previous prolapse surgery  , masses in abdomen , ascites , obesity ) .
🔸Urinary symptoms as
( urine incontinence , difficulty in micturition ,urgency and dysuria ).
🔸Sexual dysfunction as dysparonia .

🌻Obs history is very important in case of POP and we should ask the patient about :-
🔸Instrumental delivery .
🔸prolonged delivery .
🔸IF there's tearing during delivery .
🔸size of baby (macrosomia ) .

🌻In family history ask about
   🔸If there's similar condition in her family because may be the cause of POP is Genetic .

🌻In examination we should focus about
🔸Cyanosis , conjunctival hemorrhage , Barrel chest which indicate respiratory disease.
🔸Comment about the  Infections , Ulceration , odema and pigmentation in prolapsed organ.

🌻Investigation :-
🔸CBC .
🔸Urine analysis.
🔸Urine culture and swap if there's urinary infection .
🔸Chest X-ray (if there's chronic cough)
🔸 US ( Abdominal and pelvic )

🌻NOTE ...
🔸Signs of UTI are urgency , hiestency , lower pain and fever .
🔸Types of  incontinence :-
🥇Urinary incontinence which Classified into ( stress and urge )
★In stress incontinence ask about any cause that increase intra-abdominal pressure as chronic cough , constipation , sneezing , lifting heavy object .
★Urge incontinence associated with detrusor overactivity .
🤔How can we differentiate between stress and urge incontinence ?!
By Urodynamic evaluations .

🥈Fecal incontinence:-
★ present in case of rectocele prolapse due to weakness in the  muscle or pelvic Floor , it can be present in form of solid , soft ( in diarrhea ) or in gases ( flatus ) .