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EVALUATION AND

MANAGEMENT OF ABNORMAL
UTERINE BLEEDING IN
PREMENOPAUSAL WOMEN
By :
Siti Arfiah Meisari
16710127

Pembimbing :
D r Yu s u f N a w i r S p . O G
Abnormal uterine bleeding occurs in
9 to 14 percent of women between
menarche and menopause, significantly impacting quality
of life and imposing
financial burden

(AUB) is a common and debilitating condition with


high direct and indirect costs.

INTRODUCTION
AUB frequently co-exists with fibroids, but the relationship
between the two remains incompletely understood and in
many women the identification of fibroids may be incidental to
a menstrual bleeding complaint.
Based on WHO 2011
18 millions
women from 50% in 20% in
3,5 billlion perimenopa adolescence
women in use period
the world
A NORMAL CYCLE

pituitary follicle- Estrogen A luteinizing the resultant inducing a In the absence of


stimulating stimulates hormone surge corpus secretory pregnancy,
hormone proliferation of the prompts ovulation luteum produces endometrium. estrogen and
induces ovarian endometrium. progesterone, progesterone
follicles to produce levels decline,
estrogen.

and withdrawal
bleeding occurs
13 to 15 days
postovulation.

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Differential Diagnosis and Evaluation of Abnormal Uterine Bleeding

Anovulatory Ovulatory
Irregular, often infrequent Periods Regular intervals (every 24 to 35 days) with
Characteristics progesterone-deficient/ estrogen-dominant state . excessive bleeding or duration greater than
Flow ranges from absent or minimal to seven days . Less than 1 percent of
excessive , 14 percent of women with recurrent women develop cancer or hyperplasia if they
have no more than one risk factor for
anovulatory cycles develop cancer or hyperplasia
endometrial cancer

Adolescence Medication effects


Differential Diabetes mellitus, Antiepileptics Bleeding disorder Hypothyroidism
diagnosis uncontrolled Antipsychotics Factor deficiency Liver disease, advanced
Eating disorder Perimenopause Leukemia Structural lesions
Hyper- or Polycystic ovary syndrome Platelet disorder Fibroids
Hypothyroidism Pregnancy von Willebrand disease Polyps
Hyperprolactinemia

Laboratory tests for pregnancy, complete


Laboratory tests for pregnancy
blood count,
Evaluasi Endometrial biopsy
TSH level
risk factors: chronic anovulation,
Test for bleeding disorder in adolescents
diabetes,
and in women history of bleeding disorder;
infertility,
Imaging*
nulliparity,
Endometrial biopsy
obesity,

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Anovulatory Bleeding
ACOG recommends endometrial tissue assessment to rule
At extremes of the reproductive years, irregular cycles out cancer in adolescents and in women younger than
resulting from anovulation can occur. Following menarche, 35 years with prolonged unopposed estrogen stimulation,
the immature hypothalamic-pituitary-ovarian axis may women 35 years or older with suspected anovulatory
result in anovulatory cycles for two to three years bleeding, and women unresponsive to medical therapy

During the rest of the reproductive years, however, recurrent ACOG recommends treatment
irregular cycles may be caused by anovulation and are with combination oral contraceptives or cyclic
considered abnormal progestin

Evaluation
history, physical examination to look After the initiation of treatment, endometrial biopsy
for obesity and hirsutism (manifestations of polycystic should be repeated in three to six months to assure
ovary syndrome) resolution of the hyperplasia
a pregnancy test, and measurement of thyroid-
stimulating hormone
and prolactin levels

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A N O V U L AT O R Y
BLEEDING
Evaluation
Pregnancy test
Complete blood count,
Measurement of thyroid-stimulating hormone level.

History about illness


a family history of bleeding disorder;
A history of treatment for anemia; or
a history of excessive bleeding with tooth
Ovulatory extraction, delivery or miscarriage, or surgery
Imaging
Bleeding Transvaginal ultrasonography
Saline infusion sonohysterography
Ovulatory abnormal uterine bleeding, or
Endometrial biopsy
menorrhagia, presents as bleeding that occurs
at normal, regular Hysteroscopy
intervals but that is excessive in volume or
Goal
duration.
The goals of treatment for menorrhagia are to reduce
flow volume and to correct anemia

Tr e a t m e n t
Hormonal Therapies. Progestins
Nonhormonal Therapies. (NSAIDs)
Surgery
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OVULATORY
BLEEDING
A N O V U L AT O V U L
AT O R Y
BLEEDINGORY
BLEEDING
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Perdarahan uterus abnormal dengan anovulasi dilakukan evaluasi awal yaitu riwayat penyakit,
pemeriksaan fisik untuk mencari obesitas dan hirsutisme (manifestasi sindrom ovarium
polikistik), tes kehamilan, dan pengukuran tingkat hormon perangsang tiroid dan tingkat
prolaktin. ACOG merekomendasikan penilaian jaringan endometrium untuk menyingkirkan
kanker.
Dan untuk terapi, ACOG merekomendasikan pengobatan dengan kombinasi kontrasepsi oral
atau progestin siklik. Terapi progestin dan kontrasepsi oral menginduksi pendarahan
penarikan rutin, mengurangi risiko hiperplasia atau kanker, dan memperbaiki pendarahan
menstruasi terkait lainnya

Pendarahan uterus abnormal dengan ovulasi atau menorrhagia, timbul sebagai


pendarahan yang terjadi pada interval normal dan teratur namun berlebihan dalam
volume atau durasi. Hipotiroidisme, penyakit hati stadium akhir, 6 atau gangguan
pendarahan dapat menyebabkan menorrhagia, sepertijuga perubahan struktural,
seperti fibrida submukosa atau polip endometrium.

Evaluasi awal menorrhagia harus mencakup tes kehamilan, hitung darah


A N A LY S I S menyeluruh, dan pengukuran kadar hormon tiroid-stimulating. American Academy
of Pediatrics dan ACOG merekomendasikan untuk mengevaluasi remaja dengan
menorrhagia untuk kemungkinan gangguan pendarahan.

Untuk terapi menggunakan terapi hormonal, terapi non hormonal seperti NSAID, dan
operasi.
T h a n k Yo u

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