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The rapid evolution in ambulatory hysteroscopy AH has transformed the approach to diagnose and manage abnormal uterine bleeding AUB. The medical management in primary care remains the mainstay for initial treatment of this common presentation; however, many women are referred to secondary care for further evaluation. To confirm the diagnosis of suspected intrauterine pathology, the traditional diagnostic tool of day case hysteroscopy and dilatation and curettage in a hospital setting under general anesthesia is now no longer required.

The combination of ultrasound diagnostics and modern AH now allows thorough evaluation of uterine cavity in an outpatient setting. Advent of miniature hysteroscopic operative systems has revolutionized the ways in which clinicians can not only diagnose but also treat menstrual disorders such as heavy menstrual bleeding, intermenstrual bleeding and postmenopausal bleeding in most women predominantly in a one-stop clinic. This review discussed the approach to manage women presenting with AUB with a focus on the role of AH in the diagnosis and treatment of this common condition in an outpatient setting.

Abnormal uterine bleeding AUB is very common in women of every age group from adolescence to menopause and includes heavy menstrual bleeding HMB , irregular or intermenstrual bleeding IMB and postmenopausal bleeding PMB. In particular, PMB and persistent IMB are known as red flag symptoms of suspected endometrial cancer and cervical cancer.

A large proportion of women are still referred to secondary care facility for diagnosis and management of various menstrual disorders. The easy accessibility of diagnostic tools such as pelvic ultrasound, endometrial sampling and, most importantly, the facilities to perform outpatient hysteroscopy has made it possible to promptly diagnose and treat an increasing number of menstrual disorders in an office setting.

Advances in technology have led to miniaturization of high-definition hysteroscopes without compromising optical performance, thereby making hysteroscopy a simple, safe and well-tolerated office procedure. Ambulatory hysteroscopy AH allows an efficient and accurate diagnosis of intrauterine pathology, including submucous fibroids, endometrial polyps and potentially hyperplasia and cancer. There is good evidence to suggest that hysteroscopy in an ambulatory setting is preferred by most women, avoids complications and allows a quicker recovery time.

AUB affects women of all ages and constitutes a major proportion of outpatient referrals to the department of gynecology. Most women present with HMB that affects their medical, social, economic and psychological well-being.

The other categories causing abnormal bleeding that are unrelated to structural anomalies are classified as COEIN: coagulopathy, ovulatory dysfunction, endometrial, iatrogenic and not yet classified N category Figure 1. Multiple factors can contribute to the genesis of AUB, and this may vary depending on the age of the woman and the symptoms at presentation.

Often there may be pathology eg, subserosal fibroid that is present but not thought to be contributing to AUB. Therefore, the investigation of women with AUB must be undertaken diligently in a comprehensive manner, ensuring appropriate use of the available resources. A thorough history with focus on abnormal bleeding pattern and the possible causes of these symptoms in the specific age group should guide the clinician to determine the course of investigations to take in women with AUB.

Table 1 summarizes the differential diagnoses in various age groups that can present with AUB. Histology is not often warranted in younger women presenting with menstrual disorders. The causes of vaginal bleeding in young premenarchal girls differ substantially from those in postpubertal girls. Most commonly, it is secondary to bleeding from the lower genital tract vulvovaginitis, foreign body, trauma, urethral prolapse rather than uterine origin.

Bright red spotting should alert the clinician about the possibility of malignant lesions in the lower genital tract such as sarcoma botryoides or endodermal sinus tumor of the vagina. Other cause of uterine bleeding in this age group is attributed to precocious puberty, which may have hormone-producing ovarian tumor as an underlying cause. The approach to evaluation of AUB in this age group should therefore reflect relevant investigations directed at abovementioned differential diagnoses.

The most common cause of AUB in adolescents is anovulation. Anovulatory uterine bleeding generally resolves with maturation of the hypothalamic—pituitary—ovarian axis. Girls and older women with positive screening warrant further hematological investigations, including testing for von Willebrand factor and Ristocetin factor and consultation with a hematologist.

Other bleeding disorders include Factor XI deficiency or hemophilia carrier states. Clinical screening for an underlying hemostatic disorder in women presenting with excessive menstrual bleeding.

Majority of women presenting with AUB belong to this age group. History taking should take into account the range and natural variability in menstrual cycles and blood loss when diagnosing HMB. It is acceptable to commence pharmaceutical treatment without other investigations at initial consultation in primary care National Institute of Clinical Excellence [NICE]. Physical examination including speculum examination and a bimanual examination is recommended to evaluate the lower genital tract and pelvis to confirm the source of bleeding and to look for structural causes such as fibroids or cervical polyps.

Ultrasound assessment may be requested if clinical history or examination warrants further information such as persistent IMB, prolonged periods of bleeding and clinical finding of fibroid uterus. Further investigations such as endometrial biopsy EB and hysteroscopic assessment of uterine cavity are not routinely required to investigate AUB, especially in the younger women.

These can be associated with significant discomfort and should be used diligently when necessary in women who have failed to respond to initial medical therapy or in those with risk factors for endometrial malignancy Figure 2.

For women in this age group presenting with new onset AUB, organic pathology, particularly for atypical hyperplasia or endometrial cancer, must be ruled out as anovulatory cycles and organic pathology can coexist, especially in the perimenopausal women. In postmenopausal women, the high incidence of endometrial polyps is well studied. NICE recommended ultrasound as the first-line screening tool for identifying structural abnormalities.

As PMB warrants thorough investigation to rule out endometrial cancer, it is one of the triggers to initiate an urgent referral pathway. One-stop clinics as discussed later in this review are best suited for this group of women.

The role of hysteroscopy is instrumental in evaluating the uterine cavity in women with abnormal bleeding and has been the gold standard for several years. In the UK, there is national best practice recommendation that all gynecology units should provide dedicated outpatient hysteroscopy service to aid management of women with AUB.

The developments in AH have further fueled the use of this diagnostic modality, and it is no longer necessary to subject women requiring hysteroscopy to a general anesthetic. In majority of women, the diagnosis for AUB disorders can be offered in an ambulatory setting using a one-stop approach with a combination of various ambulatory tests, including blood tests, ultrasonography, outpatient hysteroscopy and EB. In the UK, the ambulatory diagnostic hysteroscopy services are well established in most NHS hospitals, but there is still some inconsistency regarding the provision of see-and-treat one-stop clinics for AUB.

Most hospitals do have one-stop clinics setup for women presenting with postmenopausal bleeding, but this efficient one-stop service is not yet widely available for women presenting with HMB due to variations in management pathways.

Since the publication of the green top guideline on best practice in outpatient hysteroscopy by the Royal College of Obstetricians and Gynaecologists in 14 there is an increasing trend nationally toward offering ambulatory hysteroscopic procedures and optimizing patient experience with particular interest in pain control during these procedures.

As with any procedure requiring instrumentation of the uterus, outpatient hysteroscopy can be associated with significant pain. A single episode of AUB in premenopausal woman or a one-off episode of IMB in a young woman does not warrant hysteroscopy in contrast to persistent abnormal bleeding for several months or prolonged continuous heavy bleeding. Detailed history and clinical evaluation of the presenting symptoms should guide further management.

There are pathways that can be used effectively for management of various forms of AUB, and these are generally useful for primary care professionals. An example of one such pathway Figure 3 is the pathway developed by Gynaecology Clinical Improvement Group in South Derbyshire for initial evaluation of HMB before considering secondary care referral.

The diagnostic options are different in postmenopausal and premenopausal women. Since the main issue in postmenopausal women is to exclude hyperplasia and malignancy, these women should have a fast-track diagnostic setup with a one-stop see-and-treat service. In general, invasive investigations should be performed only if they will make a material difference to the management approaches that can be offered.

Initial laboratory evaluation with a simple full blood count is practical in most cases and should rule out anemia as a consequence of abnormal bleeding pattern, especially if longstanding or severe symptoms exist.

Other blood tests such as thyroid function tests, screening for clotting or bleeding disorders and hormonal profile to determine ovulatory status should be instigated if necessary based on the differential diagnoses considered after a thorough clinical history.

Furthermore, one should also consider a pregnancy test to rule out unexpected pregnancy-related bleeding, vaginal swabs to rule out possible pelvic infection and cervical smear if indicated. Specific diagnostic investigations include tests for further evaluation of the uterine or endometrial causes of AUB such as polyps, adenomyosis, fibroids, endometrial hyperplasia or malignancy PALM.

There are several tests that can be used with variable accuracy to detect these structural abnormalities, including pelvic imaging, endometrial sampling and hysteroscopy.

These should be combined and perceived as complementary methods for optimal evaluation of the uterine cavity. Transvaginal ultrasonography TVS is an appropriate first-line screening tool for women with AUB as it is inexpensive, noninvasive and easily accessible.

It should be performed early in the course of investigations of chronic AUB in women of reproductive age group and even sooner in those women with postmenopausal bleeding. The benefits and diagnostic effectiveness of TVS in assessing the uterus, unlike hysteroscopy, extend to the complete pelvis. Emanuel et al 19 demonstrated TVS to have a sensitivity of 0. In addition, where vaginal access is difficult, as with adolescents and virginal women, TVS is not appropriate and transabdominal pelvic ultrasound with a full bladder can be used.

Alternatively, role of MRI or hysteroscopy under anesthesia may be considered occasionally to investigate chronic AUB in this group of patients if medical management has failed to improve symptoms. Contrast hysterosonography COH with saline infusion sonography SIS : the accuracy of TVS in diagnosing intracavity pathology such as submucous fibroids and polyps is improved with SIS to levels of accuracy comparable to that of outpatient hysteroscopy.

Magnetic resonance imaging: MRI is more accurate than TVS in the presence of multiple fibroids to allow mapping and instigate appropriate treatment in selective cases. EB is not required for all patients with AUB. Doctors should use their clinical acumen and assessment of risk factors in order to determine which group of patients would benefit from histological evaluation of endometrium.

The s ushered in the pipelle EB device for outpatient sampling of the endometrium in women with AUB. It is a small-diameter, disposable, flexible cannula that can be used to perform a biopsy quickly in a clinic during speculum examination and is reasonably tolerated. Two meta-analyses have clearly emphasized the satisfactory sensitivity and specificity of an EB in the diagnosis of endometrial cancer in women with AUB.

A positive test result of EB is more accurate for ruling in disease than a negative test result is for ruling it out. Therefore, in cases of AUB where symptoms persist despite negative biopsy, further evaluation is warranted. Particularly in premenopausal women, endometrial sampling is not efficient for the diagnosis of endometrial polyps, adenomyosis or fibroids.

Focal endometrial abnormalities are frequent causes of AUB in postmenopausal women, and although most of these lesions are benign, it is important to diagnose and treat them to resolve the presenting symptoms and rule out malignancy.

This is best achieved by hysteroscopy and removal of the focal lesion under direct vision. Hysteroscopy is confirmed as the gold standard in the assessment of AUB in menopause, permitting the elimination of the false-negative results of blind biopsy through direct visualization of the uterine cavity and the performance of targeted biopsy in case of doubt.

The high accuracy, sensitivity and specificity of hysteroscopy are well studied Table 3. Note: Data from Angioni et al. AH has been widely recommended with substantial evidence to prove its safety, efficacy and acceptability, but it is a mini-invasive procedure and can be associated with complications including severe pain. Like other methods, hysteroscopy is also beset by limitations, especially in premenopausal women.

Some of these include phase of the menstrual cycle, presence of copious bleeding and mistaking uneven surfaces as pathologic. Excessive uterine distension can affect the detection of disease. Cooper et al 43 published an analysis of cost-effectiveness of different strategies for investigating AUB and concluded that outpatient hysteroscopy appeared to be the most cost-effective first-line investigation for women with HMB referred to secondary care after failed medical interventions, including levonorgestrel intrauterine system LNG-IUS.

In conclusion, the above investigations should be used to complement each other depending on available resources to achieve an accurate diagnosis that would then help the clinician to optimize the management of women presenting with AUB. After excluding malignancy, the treatment goals for management of women with AUB include reduction of blood loss, improvement in quality of life and the treatment of any structural abnormality that appears to be contributing to the AUB.

Pharmacological treatment for regulation of the menstrual cycles and reduction of monthly bleeding should ideally be the first-line treatment offered in primary care prior to considering referral of these women with AUB to secondary care. It is now a standard practice in most NHS hospitals to offer outpatient treatment of endometrial polyps.

With advances in endoscopic technology, it is now possible to offer therapeutic ambulatory hysteroscopic procedures without the need for hospital admission and anesthesia. Outpatient polypectomy has been shown to be more cost-effective than inpatient polypectomy.

The convenience and immediacy of the see-and-treat approach seem to be advantageous, especially in the one-stop setup ideal for urgent referrals for women with PMB. To increase acceptability of this new approach, it is extremely crucial that women attending one-stop clinics are well informed.


Asuhan Keperawatan Pada Gangguan Haid Dan Endometriosis

The rapid evolution in ambulatory hysteroscopy AH has transformed the approach to diagnose and manage abnormal uterine bleeding AUB. The medical management in primary care remains the mainstay for initial treatment of this common presentation; however, many women are referred to secondary care for further evaluation. To confirm the diagnosis of suspected intrauterine pathology, the traditional diagnostic tool of day case hysteroscopy and dilatation and curettage in a hospital setting under general anesthesia is now no longer required. The combination of ultrasound diagnostics and modern AH now allows thorough evaluation of uterine cavity in an outpatient setting.


266377204 Askep Endometriosis

Gangguan haid adalah kelainan-kelainan pada keadaan menstruasi yang dapat berupa kelainan atau kelainan dari jumlah darah yang dikeluarkan dan lamanya perdarahan. Premenstrual Tension Ketegangan pra haid 2. Disminorea: primer dan sekunder 3. Esterogen dan progesteron terganggu atau tidak dihasilkan.

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