ABNORMAL UTERINE BEEDING

PENANGANAN DI FKTP

Dr. Joko Pratomo SpOG(K)

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Perdarahan uterus abnormal adalah keluhan yang
paling banyak dirasakan oleh wanita ke dokter

(Livingstone M, Fraser IS, 2002; Zinger M, 2008)

25 % : menoragia
21 % : Siklusnya memendek
17 % : perdarahan diantara haid
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 TERM

• Menorrhagia,
• metrorrhagia,
• Essential menorrhagia,
• idiopathic menorrhagia,
• primary menorrhagia,
• functional menorrhagia,
• ovulatory or anovulatory menorrhagia,
• hypermenorrhoea,
• hypomenorrhoea,
• menometrorrhagia,
• polymenorrhoea,
• polymenorrhagia,
• epimenorrhoea,
• epimenorrhagia,
• metropathica hemorrhagica,
• uterine hemorrhage and
• dysfunctional and functional uterine bleeding.

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 (Fertil Steril, 2011)

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 MENSTRUAL
CYCLE
• Mature follicle 2-25 cm
size

• Corpus luteum complex

cyst 1-3 cm size

• Endometrial height
range 3-14 mm

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 POLIP ENDOMETRIUM
Sebagian Beberapa sel pada lamina
endometrium gagal basalis endometrium
“lepas” saat haid proliferasi abnormal

Lanjut Mampu
proliferasi tiap bertahan
bulan tidak “lepas”
saat haid

Mempunyai satu arteri suplai darah

Pembuluh darah permukaan dinding tipis prominen

Erratic light bleeding

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 Polyp Endometrium

• Diagnosis: US, SIS, Hysteroscopy

• Further sub classification: Dimension, location,& number

• Pre menopausal polys:

• 64-88% have symptoms
• Present with HMB, IMB or post coital bleeding

• Post menopausal polyps:

• Most are symptoms free
• Cause for 21-28% of PMP bleeding
• Associated with cervical polyps in 24-27%
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• SYMPTOM:
• Prolonged, uncontrolled bleeding, Inter-Menstrual Bleeding,
Infertility

• SIGN:
• Uterus is usually normal in size,
• If big, cervical os may be patulous, Polyp extruding outside.

• IMAGING:
• Endometrium looks thickened,
• Saline infusion sonography echogenic smooth intracavitary
mass outlined by fluid.

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 POLIP

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 Management

• FKTP
hystorial taking
physical examination
gynecological examination ( inspeculo , VT)

• FKTL
extirpation and fractional curetage
hystopathology exam

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 Adenomyosis

• SIMPTOMS:
• Heavy menstrual bleeding, dysmenorrhea

• SIGN:
• Uterus enlarged up to 12 weeks, Uniformly enlarged,
globular or may not be tender

• IMAGING:
• Globular uterine enlargement up to 18 weeks (not due to
leiomyoma), Thickening of uterine wall, which may be
asymmetrical in focal disease, Obscuring of endomyometrial
junction; Multiple hypo-echoic halo zones of ≥ 12 mm
thickness; heterogeneous texture of endometrium Echogenic
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ADENOMIOSIS

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 Management
• FKTP
hystorial taking
physical examination
gynecological examiation
NSAIDs

• FKTL
phamacological therapy
GnRH agonis
Progestin

Operative

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 Leiomyoma

• SYMPTOMS
• prolonged uncontrolled bleeding, Intramural variable
amount of HMB, subserous may be asymptomatic

• SIGN:
• Uterus irregularly enlarged Firm

• IMAGING
• Well-defined, solid masses with a whorled appearance; similar
echogenicity to myometrium, occasionally hypoechoic alteration
of the normal uterine contour of uterus 3D-USG –for exact
location in selected patients MRI- fibroid mapping when indicated

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SUBMUCOUS LEIOMYOMA

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 Management
• FKTP
hystorial taking
physical examination
gynecological examiation

• FKTL
phamacological therapy
GnRH agonis
Progestin

Operative

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 Malignancy Hyperplasia
• SYMPTOMS:
• bleeding, Irregular bleeding, pattern at perimenopause

• SIGN:
• Normal to mildly enlarged uterus, mobility may be restricted

• IMAGING
• US- Endometrial hyperplasia-thickened endometrium >12 mm at
premenopausal age Endometrial carcinoma- thickened
endometrium, irregular endometrial lining, loss of
endomyometrial junction.

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 Risk of Endometrial Carcinoma

•- Obesity,
•- unopposed estrogen intake,
•- nulliparity,
•- diabetes mellitus,
•- Stein–Leventhal syndrome,
•- Lynch syndrome
•- tamoxifen therapy

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 Management
• FKTP
hystorial taking
physical examination
gynecological examiation

• FKTL
phamacological therapy
Sitostatika
Radiatheraphy
Operative

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COAGULOPATHY

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GANGGUAN KOAGULASI

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 Coagulopathy Puberty

• SYMPTOMS :
• menorrhagia, Heavy bleeding at menarche, History
suggestive of bleeding diathesis, Family history

• SIGN:
• Uterus normal size, Easy bruis ability Petechiae

• IMAGING :
• Normal scan Might have hemorrhagic cysts in ovary

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 Ovulatory Disorders

• SYMPTOMS:
• Signs of anovulation- Polycystic ovary syndrome,
Oligomenorrhea Signs of insulin resistance
• SIGN:
• Uterus normal size
• IMAGING :
• Polycystic ovaries on ultrasound, Thickened-
endometrium

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 Etiology

- PCOS
- Hypothyroid
- Hyperprolactinemia
- Mental stress
- Obesity
- Anorexia
- Weight loss
- Extreme exercise
- Adolescece
- Menopausal transition

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 Endometrial Inter-menstrual

• SYMPTOMS:
• spotting
• Prolonged spotting

• SIGN:
• Discharge per vaginum, Cervical erosion, Uterus
normal size

• IMAGING:
• Fluid in endometrial cavity

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 Endometrial Inter-menstrual

• It is diagnosed by exclusion
• Etiology:
- Deficiencies productionies of local vasoconstrictors
- Endotelin-1
- Prostaglandin F2α
- Excessive production of plasminogen activators
- Increased local production of vasodilators
- Prostaglandin E2
- Prostacyclin I2
- Dissorders of endometrial repair (Inflamation)
Chlamidia

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 Iatrogenic
• SYMPTOM:
• History of medication intake
• Copper T use

• SIGN:
• No abnormality Uterus normal size

• IMAGING:
• Copper T in situ

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 Not Yet Classified

• SYMPTOM;
• HMB

• SIGN:
• Refer to PALM-COEIN

• IMAGING:
• Ultrasound, Doppler, USG- for
• AVM

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 Not yet Classified

• Dissoders that would be identified or defined

only by biochemical or molecular biology
assay
- Arterio venous malformation
- Myometrial hypertrophy
- Category for news etiologies

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GUIDELINES FOR INVESTIGATORS

Guidelines General assesment

Determine ovulatory status

Screening for hemostasis dissoders

Evaluation endometrium

Evaluation of endometrial cavity structure

Myometrial assesment

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PESAN UNTUK DIBAWA PULANG

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