WRITE UPS - MISCELLANEOUS: (GYN) - Current Concepts In Screening For Ovarian Cancer


DUB is a very common occurrence in routine gynecological practice. Disturbances of menstrual bleeding are a major medical problem not only for women but also for their medical practitioners and for their families and health services. Dysfunctional Uterine Bleeding (DUB) affects about 5% of menstruating women yet the majority of medical practitioners who manage the problems do not adequately understand the underlying pathophysiology nor the principles involved in appropriate management. (Wren- 1998)


Dysfunctional Uterine Bleeding (DUB) is best defined as abnormal bleeding from uterus in the absence of organic disease of the genital tract.


 DUB is classified as under:


Characterized by dysfunction of uterus ovary, pituitary, hypothalamus or other part of reproductive system.


· Subdivided into :-

a) DUB secondary to use of IUCD or administration of sex hormones for contraception purpose.
b) DUB secondary to organic disease outside the genital tract.


 Clinical classification of DUB is as under: -

a) Mixed etiology
Short Proliferative & or secretary phase
Midcycle spotting

b) Corpus luteum insufficiency
Luteal phase defect

c) Prolonged corpus luteum activity
Persistent corpus luteum activity
Irregular shedding

d) Anovulatory




To diagnose abnormal bleeding attempts must be made to understand the subtle features of normal bleeding:
CYCLE: Cycle length may normally vary from 23 to 39 days. Any menstruation outside these units, any bleeding at other times in the menstrual cycle & any cyclical premenopausal or postmenopausal bleeding is regarded as abnormal.


DURATION:- Normal duration varies from 2 to 7 days. Menstruation lasting longer than 8 days in longer is regarded as excessive.


BLOOD LOSS upto 80 ml is regarded as normal Menstrual Blood Loss (MBL)




  It is one of the most frequently encountered conditions in gynecology OPD. It is the principal diagnosis is atleast 10% of all new patients in OPD. It is found in 5% of all menstruating women (Wren – 1998). DUB occurs quite frequently in reproductive years and not only at the extremes. O.C.pills tend to decrease and IUCD tend to increase MBL. Multiparous women have higher incidence of DUB.



There is little correlation between the gross histology of the endometrium and the amount & type of uterine bleeding. Wide varieties of endometria are observed in association with DUB including many cases with normal secretory endometrium (60%).




15-25% of case with ovulatory menorrhagia shows irregular ripening of endometrium on histology due to deficient progesterone production. Irregular shedding with a persistent corpus luteum has also been described, but the true incidence is unknown.




It is the most commonly diagnosed (30%) abnormality in DUB and varies from slight exaggeration of proliferative phase to marked overgrowth approaching adenocarcinoma of endometrium. Both stroma and glands increase in number and dilate, producing typical “Swiss Cheese” endometrium. There is also abnormal vascularization with numerous thick-walled spiral arterioles and grossly dilated veins or sinuses just beneath the endometrial surface. Frequent infarction and thrombosis of blood vessels with necrosis and shedding of superficial layers of endometrium results in menorrhagia .The principal significance of endometrial hyperplasia is the possibility of progression from benign to aderomatous hyperplasia and eventually to carcinoma if the condition persists. Increased endometrial glandular papooses may serve as a morphological marker of abnormal endometrial development is otherwise normal biopsy specimen.




This is probability the commonest cause of postmenopausal uterine bleeding. Large dilated venules are situated superficial under a thin endometrium and may rupture to cause excessive uterine bleeding.



This is a relatively new finding described by Stewart (1999). Routinely processed, haematoxylin and eosin-stained endometrial biopsies were assessed in 26 patients with symptomatic menstrual abnormality, mainly menorrhagia, and in 24 controls. All biopsies were in the proliferative phase and had been reported as within normal limits and consistent with the menstrual cycle dates provided. Apoptotic and mitotic figures were counted in a minimum of 100 transversely sectioned endometrial glands in all cases. In 16 biopsies (12 DUB and four controls) Apoptotic figures were identified in most control biopsies averaging 5.6/100 glands, and were significantly increased in biopsies from patients with DUB averaging 13.9/100 glands. There was no difference in mitotic figure counts. Apoptoses tended to be clustered within adjacent glands in both groups and individual glands exhibited both mitotic and apoptotic activity. Application of the Tunel method gave broad agreement with morphological assessment although approximately 20-25% of typical apoptotic figures were not labeled. They concluded that Endometrial glandular apoptosis is present in most normal proliferative phase biopsies and appears increased in some cases of DUB. The significance of this finding is not known but increased apoptosis may serve as a morphological marker of abnormal endometrial development in otherwise normal biopsy specimens (Stewart CJ-1998).






Primary DUB results from disturbances in Eicosanoid metabolism and in fibrinolytic and lysosomal enzyme systems of the endometrium. The most common etiology for DUB is estrogen withdrawal or estrogen break through bleeding in an anovulatory patient. In absence of progesterone exposure to cause inhibition of DNA synthesis and mitosis, the estrogenic proliferative response causes stream cell growth to exceed the structural integrity of its stromal matrix, and the endometrium breaks downs with irregular bleeding. Unopposed estrogen results in vascular endometrial tissue with relatively scanty stroma, giving glands a back to back appearance. The endometrium is fragile and undergoes repetitive spontaneous breakdown. In absence of normal control mechanism to limit menstrual blood loss, bleeding can be prolonged and excessive.


Normal menstruation involves the breakdown, remodeling and repair of the functional endometrial layers. Endometrial destruction and regeneration are largely controlled local factors that are dependent on the levels of estradiol and progesterone. Prostaglandins and endothelins appear to be powerful vasoactive substances in the control of menstrual blood loss. The tissue endothelin concentration may interact with relaxing factors, such as nitric oxide, prolonging or increasing menstrual blood loss. (Capdevila C 1997)


 Role Of Eicosanoids: -


The role of eicosanoids including prostaglandin PGE2, PGE2 alpha and the prostanoids prostacycline PGI2 and Thromboxane TxA2, and leukotrienes has been well studied. Arachidonic acid is initially metabolized by cyclooxgyenase into insatiable endoperoxides which are rapidly converted by specific syntheses into PGF2 alpha (Vasoconstriction and weakly platelet aggregatory), PGE2 (vasodilator and weakly platelet anti-aggregatory), PGD2 (a platelet agglutination inhibitor), PGI2 ( a potent vasodilator and inhibitor of platelet aggregation) and TxA2 ( a potent vasoconstrictor and platelet aggregator. In normal menstruation the ratio of PGF2a: PGE2 in menstrual fluid is roughly 2:1 so that it is the vasoconstrictor and platelet aggregator actions that predominate. 


Anovulatory DUB: -


In anovulatory DUB, the lack of progesterone results in a decrease in the PGF2a: PGE2 ratio and a relative increase in the vasodilator and anti-platelet aggregators PGE2. This would account for the increased menstrual blood loss. It also accounts for absence of uterine contractions and painless periods characteristic of anovulatory menstruation.


 Ovulatory DUB: -

In women with normal MBL, the order of production of prostaglandin by secretory endometrium is PGF2a/ PGE2/PGD2 but in women with ovulatory DUB, the order of synthesis is reversed to PGE2/PGD2/ PGF2a. Also increased synthesis of PGI2 in myometrium causes dilatation of radial arteries and an increase in MBL.


 Role Of Leukotrienes: -


Leukotrienes are eicosanoids produced by leukocytes, by action of lipoxygenase on arachidonic acid. MBL is roughly proportional to degree of infiltration by leukocytes producing leukotrienes.


Fibrinolytic and Lysosomal Enzymes: -


Progesterone withdrawal causes a breakdown of hysoymes and release of phospholipase A2 that causes formation of Arachidonic Acid iron phospholipids and initiates the prostanoid cascade. There is a marked increase in both plasminogen activators and in Fibrinohytic activity in the menstrual fluid in case of DUB.


 Endocrine Changes: -


Finding of normal secretory endometrium in upto 84% of women with DUB is strong evidence against endocrine abnormalities as a common cause of DUB. It is now accepted that there is usually no deflectable endocrine dysfunction in DUB. The occurrence of endometrial hyperplasia was in upto 30% of women with DUB. This suggests that endocrine abnormalities are important etiological factors in a significant minority of cases,


 A) Ovulatory DUB:-


This the most common of DUB. Variations in cycle length are most often associated with disturbances in proliferative phase: short cycles resulting in Polymenorrhea, and long cycles in Oligomennohrea. In adolescence menstrual irregularities are usually due to impaired response of the hypothalamus and immaturity of the estrogen feedback system and they nearly always resolve spontaneously.

· Corpus luteum abnormality :-

I) Corpus luteum Insufficiency: Inadequate development of corpus luteum may result in insufficient progesterone production and insufficient secretory changes in the endometrium with a decrease in PGF2a: PGE2 ratio in the endometrium and hence in menorrhagia. Progesterone deficiency can be identified by plasma progesterone estimation or on histological examination by irregular ripening of the endometrium in the second half of the cycle. It may be suspected if there is premenstrual spotting and/or shortening of the menstrual cycle.


II) Persistent corpus luteum: A persistent corpus luteum may result in continued estrogen and progesterone secretion and absence of the normally sharp fall in these hormonal levels, which precedes menstruation. This in turn causes inadequate release of phospholipase A2 and inadequate release of prostaglandins, with irregular shedding of the endometrium. Persistent corpus luteum may be suspected if there is an abnormal prolongation of menstruation and endometrial figments are found in menstrual discharge more than 48 hours after on set of menstruation.


 B) Anovulatory DUB:

It is the most commonly recognized endocrine abnormality as it results in proliferative endometrium in the second half of the cycle or endometrial hyperplasia. There are two types of abnormalities leading to anovulatory DUB.
· Insufficient follicular Development.


Due to insufficient follicular development there is inadequate estrogen production and hence inadequate proliferation of endometrium without any secretory charge, resulting in a deficient or atrophic endometrium with large dilated subendothelial vessels causing excessive bleeding.

· Persistent Ovarian Follicle:-

Anovulation results in persistent ovarian follicle with adequate estrogen secretion, but since corpus luteum fails to develop, progesterone secretion is absent. A continuous unopposed high level of estrogen as in polycystic ovaries or un-ruptured follicle syndrome results in endometrial hyperplasia, adenomatous hyperplasia and eventually carcinoma of endometrium. Bleeding in this condition occurs either when endometrium outgrows its blood supply or when there is decrease in estrogen level.






 Continuous oral administration of low dose progestogens, injectable depot progestins and excessive DUB: Low dose progesterone causes underdevelopment of the spiral arterioles and degenerative and vascular lesions of the dilated verges large depot injections of progestogens produce large superficial dilated venules with atrophy of the endometrium.
 Non-medicated and copper IUDs produce a marked increase in menstrual loss varying from 26 to 116% with an average doubling of MBL. Progestogen releasing devices reduce the volume of MBL by 40-50%. Superficial ulceration of endometrium and increased vascularity and interstitial red cell extravasation with absence of platelet fibrin thrombosis, lead to DUB secondary to IUCD. There is also an increase number of macrophages which produce PGE2, PGF2a, plasminogen activator and fibrinolytic enzymes.




A) Bleeding Disorders: Bleeding disorders like thrombocytopenia, thrombocytopathic afibirogenmia, Von Willebrand’s disease, macroglobinacmia and factor II,V, VII, X & XI deficiency disorders were responsible for 30% of teenage DUB cases.

B) Hypothyroidism: - Incidence of menorrhagia in myxoedema varies from 32 to 80% It promptly responds to Thyroid replacement.

C) Iron Deficiency Anemia: - Iron deficiency anemia causes reduction in MBL out of reproduction to fall in hemoglobin concentration.




Any case of DUB is evaluated on two grounds, age group and pattern of bleeding.


 By Age Group: -


I) Adolescents: Organic disease and malignancy are very rare in this age group and abnormal uterine bleeding is almost dysfunctional. Adolescent DUB is due to immaturity of hypothalamus and inadequate positive feedback and is often associated with some irregularity of menstruation due to delayed or failed ovulation. 40-50% cases resolve within 2 years Prognosis in better in females in whom DUB starts after a period of normal menstruation than in those whom DUB started at menarche. Bleeding disorders must be excluded. These cases are always managed medically conservatively.


II) Adult (20-39 Yr.)

Benign diseases like pelvic inflammatory disease and fibromyoma are common causes of abnormal uterine bleeding in this age group. Most cases are ovulatory and resolve spontaneously. Organic disease must always be excluded in a case not responding to conservative management.


III) Perimenopausal :-

Abnormal uterine bleeding in women 40 yrs. and over is most commonly dysfunctional. It is mandatory to rule out organic causes such as fibromyoma, carcinoma endometrium before making diagnosis of DUB. Hysterectomy is often indicated.


 By Bleeding Pattern: -

A) Regular Cyclical Bleeding :-

Menorrhagia may be frequently associated with some organic disease like fibroid or PID, but also may be dysfunctional ovulatory. It has a favorable prognosis.

 B) Irregular or Acyclical Bleeding :-

It may be due to organic disease of genital tract especially carcinoma cervix or endometrium. It is also dysfunctional frequently and tends to be anovulatory. Metrorrhagia is unfavorable particularly for perimenopausal women.

 C) Intermenstrual Bleeding:

Cervical and endometrial polyps, submucons uterine fibroids and carcinoma cervix can cause such bleeding. It may also be seen in DUB to fall in estrogen secretion following ovulation.




In clinical practice the diagnosis of DUB is usually made by exclusion of organic disease of the genital tract. The main difficulty in the diagnosis of DUB is deciding the extent of the investigations necessary to perform reasonably to exclude organic disease of the uterus. It is now generally accepted that an adequate clinical examination of the abdomen & pelvis, uterine curettage, hysteroscopy or an endometrial biopsy are essential to rule out organic disease of the uterus.



To be taken as follows:-

· Age, parity, & fertility
· Amount, duration and pattern of uterine bleeding
· Dysmenorrhea, infertility of bleeding disorder or myxoedema.
· Patients wish regarding contraception, future pregnancies and possible hysterectomy
· Social and personal background.

 Examination: -


Thorough abdominal and pelvic examination is essential.


 Investigations: -


 A) Ultrasound: - USG may be used to exclude pelvic masses or possible pregnancy complications. TVS is much more informative.


B) Dilatation of cervix and uterine curettage: It is the commonest investigations resorted to in cases of abnormal uterine bleeding It helps to:

I) Provide endometrium sample to differentiate proliferative from secretory, irregular ripening, shedding or atrophy. Thus helps to judge possible etiology and decide treatment.
II) Exclude intrauterine organic pathology like endometrial hyperplasia, carcinoma, tuberculosis, endometriosis, fibromyoma or endometrial polyps.
III) Arrest bleeding – If it is persistent or excessive particularly in cases where endometrial hyperplasia is suspected.
D & C. is essentially a diagnostic & not a therapeutic procedure, but MBL does decrease is the next cycle.
 Commonest pathology defected is fibromyoma, in 20-40% of cases & endometrial pathology in 2-6% of cases.


C) Hysteroscopy:- With sensitivity of detecting intrauterine pathology as high as 98% hysteroscopy is fast replacing curettage. Hysteroscope provides an excellent view of uterine cavity and polyps, fibromyomas or any suspicious union however small can be readily diagnosed by biopsied.


D) Endometrial Biopsy:- It is useful procedure to exclude endometrial hyperplasia and carcinoma Endometrial sampling by vabra aspirator is an outpatient procedure with less incidences of infection, perforation & hemorrhage, but has following disadvantages:

· It requires skill & experience to perform it 7 may fail in postmenopausal women with stenos cervix.
· Small areas of abnormal endometrium, polyps & submucous fibroids may be missed.
· It does not remove all the endometrium & is not a curative procedure.

E) Hematological Investigations:-
Hemoglobin estimation should be carried out in all cases of DUB. Bleeding time, clotting fine, platelet count & coagulation profile should be carried out is young patients with recurrent DUB.


F) Laparoscopy Or Hysterosalpingography :- To diagnose pelvic tumors, polyps, fibroids or pelvic inflammatory disease.


G) Day21 Plasma Progesterone to diagnose corpus luteum insufficiency or involution plasma follicel stimulating hormone & lutenizing hormone to diagnose menopause.


H) Plasma Trilodothyronine, Thyroxine And TSH to exclude myxoedema.




  There is a wide range of treatment option fo DUB. Following steps are undertaken while managing a case of DUB.

I) Exclusion of organic disease of genital tract.
II) Diagnosis of Dysfunction
IV) Assessment of nature and severity of DUB and age, parity & wishes of patient regarding contraception, future reproduction & surgery if indicated.


 General Measures: -


Reassurance by counseling plays an important role in the treatment. Pt is advised to keep “ Menstrual Calendar” in which day to day record of amount of Blood loss is mentioned. This is particularly useful if amount & pattern of bleeding is uncertain. Oral iron therapy is often required because menorrhagia makes the patient anemic and also deflects her iron stores. If DUB is secondary to IUCD other method of contraception needs to be reconsidered.


 Medical Therapy: -


I) Hormone Therapy: -

Endometrial histology in second half of cycle helps to choose most appropriate and effective hormonal therapy.


 A) Combined Estrogen – Progestogen:-

Oral contraceptives are most popular & effective form of hormone therapy. Combined estrogen progesterone therapy corrects any abnormalities of menstrual cycle, regularizes the cycle and reduces MBL. Management of dysfunctional uterine bleeding is determined by the needs of the patient: oral contraceptives are used for women of reproductive age with ovulatory uterine bleeding episodes who also require contraception, they have a strong progestrogenic effect that is evident as early as the first week of pill in take. In the perimenopausal patient, dysfunctional uterine bleeding may be treated by cyclic progestins with or without conjugated equine estrogens oral contraceptives can also be used in non-smokers who have no evidence of vascular disease. (Capdevila C 1997)


 B) Progestogen Therapy :-


Can be administered in three ways:
i) Arrest of Hemorrhage: - Norethisterone, 20-30mg daily is given to arrest severe uterine bleeding for 2-3 days and then confined at a lower does for 21 days.
ii) Luteal phase treatment: - When corpus luteum insufficiency with premenstrual spotting is diagnosed Progestogen therapy is indicated from day 15th to 25th for 3 cycles.
iii) Whole cycle treatment: - When endometrial hyperplasia is diagnosed potent Progestogen like Norethisterone activate 5mg daily or medroxy progesterone acetate 10 mg daily should be used from 5th to 25th day for 3 cycles.


 C) Estrogen Therapy :-


Estrogen therapy is of value in breakthrough bleeding and arresting severe hemorrhage particularly in cases of atrophic endometrium. Estradiol valerate 4 mg daily or ethinyl estradiol 0.05-mg daily or conjugated equine estrogen 2.5 mg daily for 5 days is used.

Estrogens are also indicated is cases of DUB secondary to depot progesterone. In cases of very severe hemorrhage, a single intravenous injection of Premarin 25 mg with dilatation & curettage may the best therapy.


D) Testosterone:


There are best reserved as a third line agent when other forms of therapy may be contraindicated.
Methyl testosterone is given 10 mg daily for 7 days preceding menstruation in cyclical menorrhagia. It
should not be given for more than 3 months danazol is peripherally converted into testosterone and acts
as an androgen .it effectively reduces MBL in dosage of 200 mg for 12 weeks


 II) Prostaglandin Synthetase Inhibitors:-


Prostaglandin syntheses inhibitions like diclofenac, ibuprofen mefenamic acid & naproxen act by blocking cyclo-oxygenase which converts arachidonic acid to endoperoxides & thence to prostanoids.


These agents may be particularly beneficial in ovulatory DUB associated with dysmenorrhea. They can be used as first line agent. Their effectively is demonstrated on Colour Doppler studies. It is shown that
tranexamic acid significantly reduces uterine artery vascular resistance in women with dysfunctional uterine bleeding. This effect is unlikely to be a mechanism for the action of tranexamic acid in reducing menstrual blood loss but may have important implications for women taking this treatment in the long term(Lakhani KP 1998).


 IV) Antiflbrinolytic Agents :-

Aminocaproic acid, paraaminomethyl benzoic acid and tranexamic acid are potent inhibitors of fibrinolysis and their use reduce MBL below 80 ml in 50% of cases in essential & IUCD related menorrhagia recommended dose is upto 6gms for first four days & than smaller dose for next four doses.




 Endometrial Ablative Procedures;-


Such techniques are regarded as alternatives to hysterectomy when it is derived to preserve the uterus. Good results wear obtained by TCRE -Transcervical Resection of Endometrium using 26 F gauge resectoscope and by hysteroscopic laser photo vaporization by many workers.


 The surgical treatment outcome prospects for dysfunctional uterine bleeding were studied in a randomized trail designed to compare endometrial ablation against hysterectomy (Strabinsky 1999). Available data from studies with admittedly incomplete. Follow-up suggest that upto one quarter of patients treated with endometrial ablation require repeat ablation or infrequently hysterectomy to stop DUB. Best results in ablative procedures can be obtained by suppressing endometrium for 4-6 weeks with high dose of progestins or GnRH against or danazol.


 In the past the treatment of benign uterine lesions and DUB required, in many instances, a hysterectomy. These days most cases can be successfully treated by hysteroscopy. To be reliable, this technique must lead to a significant reduction in the number of hysterectomies performed for these conditions. The electro-resection technique is preferred to that using the Nd-YAG laser because of its lower cost and its equivalent efficacy. By using the uterine perfusion pump device, the risk of resumption syndrome can be reduced to its minimum. Submucosal myomas<1cm, benign endometrial hyperplasia and adenomyosis are the commonest benign lesions treated. Dysfunctional uterine bleeding can also be treated by an endometrectomy. A preoperative work-up includes a transvaginal ultrasound and a biopsy. This ensures that only benign lesions that are accessible to a hysteroscopy will be submitted to this technique and that no cases of endometrial cancer or atypical hyperplasia would be ignored. One good study presents 270 cases of operative hysteroscopy with a follow-up to 4 years. 82.8% of myomatous lesions were treated with success. The results for patients with benign endometrial polyps or benign endometrial hyperplasia are also excellent with only 4.6% and 5.6% rate of secondary surgery respectively. Adenomyosis does not appear to be a good indication for hysteroscopy as only 37% of patients did not definitive hysterectomy. Rates of operative complications ( post-operative bleeding , uterine perforation resumption syndrome and difficulty of access) are acceptable and get less frequent as the surgeon experience increase(Herman P-1998).
Postoperative granulomas have been described in the uterine cervix, fallopian tube, and other sites after various procedures, as well as in the endometrium after endometrial ablation procedures. Endometrial ablation is a procedure increasingly used by gynecologists to relieve symptoms associated with dysfunctional uterine bleeding. Occasionally, patients will not have a satisfactory result, and some will require subsequent hysterectomy. One study describes the pathological findings in the hysterectomy specimens from 15 patients who had previously undergone endometrial ablation. Indications for subsequent hysterectomy included Dysmenorrhea (7 patients), Menorrhagia ( 7 patients), dysfunctional uterine bleeding ( 5 patients), and pelvic pain ( 4 patients). All patients had varying degrees of fibrous tissue. Histological examination revealed fibrosis with varying degrees of granulomatous inflammation. The majority of the granulomas were associated with refractile brown hematoidin-like pigment, and most were also associated with uniform black pigment. In 8 cases, areas of faintly eosinophilic, homogenous, hyalinized material was present within the endometrium. Comparison is made to granulomas due to other causes, because the postoperative granulomas of the endometrium differ morphologically from granulomatous inflammation caused by other etiologies. As endometrial ablation gains popularity among gynecologists and their patients, it is likely that the practicing pathologist may encounter these sequelae with increasing frequency. (Silvernagel SW 1997)


 Hysterectomy: -


Hysterectomy offers advantages like complete cure of the condition and removal of any missed pathology e.g. unsuspected undiagnosed malignancy besides avoidance of continued long-term medical therapy. It is a major operative procedure, necessitating hospital admission patient pain & inconvenience, morbidity and sometimes mortality are also associated. Principle deciding factors are severity & persistence of abnormal bleeding, age and parity & wishes of patient regarding future reproduction. In younger women of reproductive age group it should be the last resort & virtually should never be profound. In women over 30 years it should be performed with reluctance, when medial therapy has failed & family is complete. In women of 40 years or more, hysterectomy should be considered in all cases of persistent or recurrent bleeding and of incomplete response to medical therapy. In this age group missed organic disease are more likely & spontaneous remission is unlikely. Removal of uterus is also psychologically more acceptable to patient of this age.
Many gynecologists are reluctant to do this surgery in luteal phase. But this may not be with any evidence. To determine the relationship between the timing of a hysterectomy performed during the menstrual cycle phase and the postoperative complication rate in women who had undergone surgery for dysfunctional uterine bleeding, the authors examined the charts of 24 patients for the 3 –month period immediately after the hysterectomy. Twelve of the women were in the follicular phase, and 12 were in the Luteal phase at the time they had undergone the hysterectomy. Operative pathology, preoperative and postoperative hemoglobin levels, operation time, blood loss classified patients, days before return to full functioning days in hospital, and uterine morphology. Further prospective studies with longer follow-up time are needed to obtain more conclusive indications regarding the optimal timing of hysterectomy during the menstrual cycle (Baron DA, 1999).


  Radiotherapy: -


External irradiation of the ovaries is performed & amenorrhea results. It has no immediate risks but leaves behind a potentially damaged organ that may develop pyometra, haematometra or carcinoma. It is only resorted to when hysterectomy is indicated but patient is unfit for operation. In the 1940s, 1950s and 1960, low doses of radiotherapy were used to treat benign uterine bleeding. The cases of two women who received this from of therapy and later developed gynecological malignancies and had high dose pelvic radiotherapy were recently published. A 76-years-old women with an International Federation of Gynecology and Obstetrics (FIGO) stage-IIB squamous cell carcinoma of the cervix received external beam radiotherapy and intra-uterine brachytherapy and a 77-year –old women with a FIGO stage-IB endometrial adenocarcinoma received adjuvant postoperative pelvic radiotherapy. Both women had a significant past history of low-dose rate intra uterine irradiation for dysfunctional uterine bleeding. Therefore the theoretical question of carcinogenesis was raised, and also the practical question of what dose had previously been given and what further dose could be safely given with regard to normal tissue tolerance(MacLeod C 1999)




1. Wren BG: Aust Fam Physician 1998-May,27(5):371-7,


2. Stewart CJ: Sydney Menopause Centre, RHW, Histopathology 1999 Feb, 34(2):99-105


3. Capdevila C: Eur J Contracept. Reprod Health Care 1997 Dec:2(4) 229-37


4. Lakhani KP: Marsh MS, Purrcel W: Ultrasound Obstet Gynecol 1998, April,11(4)283-5


5. Stabinsky S S: Modern treatment of menorrhagia attributable to DUB 1999, Jan,54(1): 61-72


6. Herman P Rev Med. liege 1998 Dec, 53(12) : 756-61,


7. Silvernagel SW: Ann. Diag. Pathol 1997-Dec,(2):82-90


8. Baron DA, Hardie T: J Am Osteopath Assoc. 1999 Jan, 99(1):25-7


9. MacLeod C: Australas. Radiol 1998-Aug,:42(3) :229-31



Click here to view other articles in this section