Aub A P Class
Aub A P Class
Aub A P Class
AUB-POLYP
DR. GARIMA (FACULTY)
DR. SOUMYA (PG)
DR.BHUVNANA(PG)
DR.ARPITA(PG)
CASE PRESENTATION 1
Mrs A, resident of Badarpur is a 42-year-old, housewife by occupation, belongs to
lower middle class family according to modified kuppuswamy scale presented with
CHIEF COMPLAINTS : heavy menstrual bleeding and painful menses since 8
months.
HOPI: Patient was apparently well 8 months back when she prolonged and heavy
menstrual bleeding, during regular menses, which was insidious in onset lasting for 8-
10 days with soakage of 4-5 pads per day, associated with passage of clots. Patient
also has complaint of pain during menses since 8 months, pain starts 1-2 days before
the onset of menses, intermittent dull aching pain in lower abdomen no aggravating
factors relieved with the onset of menses.
◦ No h/o intermenstrual bleeding, post coital bleeding, discharge per vagina.
◦ No h/o abdominal distention, increased urinary frequency, difficulty in micturition,
constipation
◦ No h/o fever, fatigue, loss pf appetite, weight gain or weight loss.
◦ No h/o hot and cold intolerance.
◦ No h/o acne, hirsutism, lactorrhea
◦ No h/o gum bleeding, joint swelling, blood transfusion, bleeding from other sites
◦ No h/o HTN or DM
◦ No h/o any hormonal contraceptives of Iud insertion
◦ No h/o other drugs: (NSAIDS, anticoagulants)
MENSTRUAL HISTORY
Menarche- 14 years
LMP 17/10/2023
Frequency (days) 25 25
Family History: No history of any chronic illness in family. No h/o any malignancy.
Personal history: mixed diet, appetite normal, sleep adequate, no h/o any tobacco/alcohol or any
other substance intake.
Contraceptive history: used barrier contraception. No h/o any hormonal contraception or iud
insertion.
GENERAL PHYSICAL EXAMINATION:
◦ Patient is moderately built and average nourished
◦ Oriented to time, place, person
◦ Height 158cm
◦ BMI: 24.84 Kg/m2
◦ Cyanosis absent
◦ Clubbing absent
◦ Oedema absent
◦ Lymphadenopathy absent
◦ Thyroid normal
◦ No acne/ hirsutism
◦ Breast examination WNL
◦ Vitals bp 124/76 PR 78
SYSTEMIC EXAMINATION:
Palpation:
Percussion:
Resonant, no dullness, shifting dullness, fluid thrill
Differential diagnosis:
◦ Adenomyosis
◦ Fibroid
◦ Endometrial Hyperplasia
◦ Polyp
Investigations
UPT - Negative
Hemogram with P/S – 7.9gm/dL platelet 1.8 lac
TSH -1.75
BT/CT- normal
PT/aPTT – normal
ESR, Mantoux, CXR – Normal
USG(TVS) finding:
Uterus bulky, multiple intramyometrial cysts 2 to 7mm size, endo-
myometrial junction ill defined. ET = 10mm, B/L adnexa normal.
Final Diagnosis
Williams Gyne 4e
More common in multiparous women.
ENDOMETRIOSIS
Persistence of pelvic pain following optimal endometriosis surgical therapy strongly points towards adenomyosis.
Patients with adenomyosis compared with endometriosis had increased parity, earlier menarche, and shorter
menstrual cycles.
INFERTILITY
Focal>diffuse
TYPES OF ADENOMYSOSIS:
HISTOPATHOLOGICALLY
DIFFUSE JUNCTIONAL
ZONE DISEASE
GROSS: Uniformly enlarged and FOCAL Endometrial tissue within the
boggy.
HPE- Myometrium thickened with myometrium at a distance of at
endometrial glands dispersed GROSS: Resembles leiomyoma without least two low-power fields from
throughout myometrium. pseudo capsule. JZ zone.
USG : If <25% of the circumference HPE: Nodular aggregates of endometrial
of lesion is surrounded by normal glands in one part of myometrium.
myometrium USG: >25% of the lesion is surrounded by
normal myometrium.
Williams 4e
EVALUATION
HISTORY TAKING
• Detailed menstrual history.
• To rule out other causes of AUB.
• Other relevant chronic illness.
GENERAL EXAMINATION
◦ Look for signs of anemia.
◦ Look for signs of malignancy.
ABDOMINAL EXAMINATION
• For palpable masses or free fluid.
SENSITIVITY SPECIFICITY
ULTRASOUND 72 81
MRI 77 89
Features of adenomyosis can also change with the menstrual cycle. For example, cysts may become larger
and echogenic masses within the myometrium may change in echogenicity during the menstrual cycle.
(?)NEEDLE BIOPSY
• Not common practice and is reserved for clinical situations in which a malignancy needs to be
excluded.
• Sensitivity of needle biopsy depends on several factors, including the extent of disease, number of
biopsy specimens obtained, sampling site, needle gauge, and operator experience.
DEFINITIVE DIAGNOSIS -
HISTOPATHOLOGY
Presence of endometrial tissue more than 2.5 mm below the endomyometrial junction or a JZ
>12 mm thickness.
According to the depth of adenomyotic foci:
DEEP SUPERFICIAL
(>80%) INTERMEDIATE (<40%)
(40%-80%)
MANAGEMENT OF
ADENOMYOSIS
NON HORMONAL HORMONAL
NSAIDS Progesterone-oral
(First line) Injectable: DMPA
LNG IUS: Mirena (Preferred
first line)
Danazol
GnRH Analogue
GnRH Antagonist
Mifepristone
NON-HORMONAL
NSAIDS
TRANEXAMIC ACID
PG synthesis inhibitor- COX 1 (present on platelets) and COX 2. MOA- Antifibrinolytic action.
Decreases inflammatory mediators thus giving pain relief. Decrease blood loss by 40-50%.
Minimal side effects.
Cost effective and well tolerated.
Decreases blood loss by 25 percent.
EG. MEFENEMIC ACID,IBUPROFEN , NAPROXEN.
Side effect-GI side effect, gastritis
NSAID DOSAGE
1)MEFENEMIC 500 mg TDS X 5 days.
ACID
2)NAPROXEN 550 mg on first day then 275 mg daily.
3)IBUPROFEN 600 mg daily throughout menses.
TXA 1.3 g 3 times daily x 5 days.
Williams gyne 4e
LOCA PROGESTERON
L
E IUS- “MIRENA”
LNG
1st line of treatment
Contains 52 mg LNG
Releases- 20 mcg/day
Life - 5 years
Efficacy- 94-96% decreases blood loss
MOA- 1)decidualization of endometrial stroma
2)atrophy of endometrial glands
Advantages
• effective for long term
• decrease need for hysterectomy
• decrease dysmenorrhea
EXPULSION RATE – 16%
PREMATURE REMOVAL-
18%
ORAL PROGESTERON
EACETATE (Dose- 5 mg TDS to a maximum of 10 mg TDS)
NORETHISTERONE
MEDROXYPROGESTERONE ACETATE (Dose 10-20 mg/day)
• Efficacy :20-30% decrease in bleeding
DECREASED
• Mechanism –Conversion of E2 to E1 (rapidly cleared from body) ESTROGEN
Inhibits estrogen receptor replenishment LEVELS
NICE 2007
INJECTABL PROGESTERON
E
E
DMPA:
150 mg i.m 3 monthly.
Long acting.
Initially –irregular bleeding.
Can induce amenorrhea in 50% users after 1 year and 80% after 5 years.
OCP’s
◦ Has majorly Progesterone as its component.
◦ Regulates AUB.
◦ Dose-1 pill daily. X 3 weeks and 1 week off.
◦ MOA-Decidualization & atrophy of endometrial tissue &
decrease of retrograde menstruation. Regimen
• Cyclic
◦ Side effects -Nausea/vomiting, headache, irregular • Extended
bleeding, hypercoagulation status • Continuous
DYSMENORRHEA
NOT RESPONDING TO MEDICATION
RECURRENT ABORTION
IVF FAILURES
DUE TO IMPLANTATION FAILURE
Osada et al 2018
Techniques:
ADENOMYOMECTOMY
(Open/Laparoscopic/Hysteroscopic)
(H-incision technique/Wedge resection)
ENDOMETRIAL ABLATION
(Hysteroscopically-In TYPE 1 AD)
RADIOFREQUENCY ABLATION
(Transcervically / laparoscopic / USG guided)
Excisional Surgical Technique Method
TRANSVERSE H- INCISON H- shaped incision on anterior uterine wall & serosa is widely separated from the
TECHNIQUE underlying myometrium. The
adenomyoma tissue is removed using an electro surgical scalpel or scissors. A
tension-less suturing technique is used to apposition the myometrial edges and
close the wound in one or two layers.
WEDGE RESECTION OF Part of seromuscular layer with adenomyoma removed by wedge resection after a
UTERINE sagittal incision in the
WALL(OPEN/LAPAROSCOPIC) uterine body.
ASYMMETRIC DISSECTION OF Uterus dissected in asymmetrical fashion, removing adenomyotic lesion using
UTERUS loop electrode and a high
frequency cutter. From the incision, the myometrium is dissected diagonally as if
hollowing out the uterine cavity.
While inserting the index finger in tothe uterine cavity, the adenomyosis lesion is
excised to >5 mm of the inner myometrium. The lesion is then excised to >5 mm
of the serosal myometrium. Afterwards, the uterine cavity is sutured and closed,
followed by uterine reconstruction.
TRIPLE FLAP METHOD
a) Adenomyomectomy.
b) Reconstruction of a uterine cavity which can sustain subsequent
pregnancy in which an endometrial uterine muscle flap is prepared by
metroplasty.
c) Reconstruction of a uterine wall resistant to rupture. The uterine
muscle on the serosal side is used to fill the large uterine wall muscle
defect.
Myometrial defect has to be closed with the triple-flap overlap method, with care being taken
to avoid overlapping suture lines.
On one side of the bisected uterus the myometrium and serosa are approximated in the antero-
posterior plane with many interrupted sutures of 2–0 Vicryl (Figure 3E).
Then the contralateral side of the uterine wall (composed also of serosa and myometrium) is
brought over the reconstructed first side in such a way as to cover the seromuscular suture
line (Figure 3F).
Suture lines must not overlap; only myometrial tissue flaps overlap.
Family complete:
• Routine infertility workup is done for women presenting with adenomyosis associated infertility.
• A long protocol GnRH agonist suppression is given for women with normal ovarian function for
spontaneous conception.
• Immediate IVF is advised to women with low ovarian reserve.
• Surgery is not taken in to consideration before ART.
• Repeat long protocol GnRH agonist based IVF/ICSI treatment if natural conception is not possible.
• Indication of conservative surgery if there are severe symptoms & repeat failure of long protocol
GnRH agonist based IVF/ICSI therapy.
• Long protocol.
AUB-POLYP
Types of polyps
Endometrial polyps
Endo cervical polyps
What is endometrial polyp?
Endometrial polyp is hyperplastic growth of endometrial glands and stroma
around a vascular core which forms a sessile or pedunculated projection from
surface of endometrium.
Epidemiology
Prevalence of endometrial polyp in
General population is 9%
Pre menopausal female 7.6%
Post menopausal female 13%
Prevalence is higher in patients undergoing endometrial biopsy
Those with infertility undergoing in vitro fertilization 6 to 30%
Endometrial polyps are rare among adolescent patients
Ref-UpToDate
Williams gyne 4th ed
Risk factors
Obesity
Compared BMI of >/= 30kg/m2 versus <30kg/m2,rate of polyps 52% and 15% respectively
Advanced age
Tamoxifen use
Endometrial Polyps are diagnosed in 30-60% of patients on tamoxifen therapy
Polyps are most common type of endometrial pathology associated with Tamoxifen use
Hormone replacement therapy
Syndromes-lynch syndrome, cowden syndrome
The presence of more than one polyp and endometriosis may be independent risk factors of
recurrent polyps
Ref-UpToDate
Williams gyne 4th ed
Protective factors
Oral contraception use
Levonorgestrel IUD
Pathogenesis
Molecular mechanisms
Monoclonal endometrial hyperplasia
Overexpression of endometrial aromatase
Somatic gene mutation
Age-related accumulation of low-frequency single nucleotide variants in
oncogenes, including mutations in KRAS, PTEN, and TP53
Endometrial polyps express both estrogen and progesterone receptors and
these hormones may play a role in pathogenesis
Ref-UpToDate
Williams gyne 4th ed
Clinical presentation 72% asymptomatic
GENERAL EXAMINATION
• Look for signs of anemia.
• Look for signs of malignancy.
Patient preperation-
1.usually performed during follicular phase of menstrual cycle
2.preoperative endometrial biopsy completed as part of AUB evaluation
3.Pre operative antibiotics,analgesia and VTE prophylaxis not required
Intra operative
Instruments-Resectoscope with 90 degree loop electrode ideal
other-Intra uterine morcellator can also be used
Morcellation
1.After distention medium flow started-hysteroscope and morcellacion device housed
within its operating channel are inserted.
2.Excision proceeds from polyp tip toward the base
The morcellacor also provides suction, which can clear blood, tissue debris, and clots during
resection oflarge growths.
Control of bleeding
1.Coagulation with same resectoscope loop
2.Foley catheter with 30ml balloon as tamponade to stop bleeding
Instrument removal
1.Flow of distension media stopped
2.Hysteroscope and tenaculum removed
3.Fluid deficit must be calculated
Reference
Williams gyne 4th ed
Post operative care
Recovery is rapid within 24 hours(resumes normal activity within 24 hours)
Usually patients experience post operative cramping and light bleeding
Acetaminophen or NSAIDS for pain
Complications
Most common complication-Perforation of the uterus (0.12 percent)
Other complications
1.Fluid overload (0.06 percent)
2.Intraoperative hemorrhage (0.03 percent)
3.Bladder or bowel injury (0.02 percent)
4. Endomyometritis (0.01 percent). Reference
UpToDate
Hysteroscopic polypectomy(resectoscope)
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