MENORRHAGIA

It is the most common gynecological case seen in the clinic.

It is the most common cause of anemia in developed countries.
And the 2nd common cause of iron deficiency anemia after poor diet in the developing countries.
Subjective: Prolonged or heavy Regular menstrual bleeding.
Objective: menstrual blood loss more than 80 ml (more accurate), but not used in practice , just in researches)
* Normal menstrual blood loss range from 20 - 80 ml with average of 35 ml.

SYSTEMIC PATHOLOGY
(5%)

CAUSES OF
MENORRHAGIA
PELVIC PATHOLOGIC
(35%)

DYSFUNCTIONAL
UTERINE BLEEDING
(60%)

Thyroid: hypothyroidism.
Coagulation disorder: ITP,
VWD, leukemia...
Advanced liver diseases.
Drugs: Warfarin, Heparin,
Aspirin, Tamoxifen, and
hormones.
Fibroid (submucosal).
Endometriosis.
Adenomyosis.
Chronic PID.
Copper releasing IUCD.
Endometrial hyperplasia and
malignancy.
Ovarian tumors; Estrogen
producing.

DYSFUNCTIONAL UTERINE BLEEDING

FACTORS OF BLEEDING AMONG MENSES
ETIOLOGY
1- PG E2 and PG F2.
1. Endometrial dysfunction (Ovulatory DUB):
2- Fibrinolytic system.
- PGs imbalance (dec PGF2a : inc PGE2 ratio).
3- Blood Vessels of the endometrium.
- Increased fibrinolytic activity.
The most important is prostaglandin release and
- Ineffective contraction of myometrial vessels.
2. Hypothalamic Pituitary Ovarian hormonal
Fibrinolytic system any disturbance in them
axis: (Anovulatory DUB)
bleeding.
- Most common age at presentation is less than
Disturbance in prostaglandin release such as if
20 and more than 40.
PGE2 increased (it is a vasodilator) will lead to
bleeding and increased PG F2 which will cause
spasmodic or primary dysmenorrhea.
Also, if too much fibrinolytic system activity
menorrhagia.
HISTORY
PHYSICAL EXAM
INVESTIGATION
- Complaint: Assess the amount of blood
- General examination:
- CBC: Hb and platelets.
loss.
General condition (does she
- Pelvic ultrasound: Uterus; size, shape,
- Associated Gynecological problem:
look pale or not?), Vitals,
masses, and endometrial thickness. Adnexia
Congestive dysmenorrhea, deep
Weight, Thyroid, Lymph
- Cervical smear.
dyspareunia, chronic pelvic pain, pressure
nodes (axillary and
- Office biopsy: Pipelle, Novak
symptoms, and vaginal discharge.
inguinal), Breast, Abdomen
- Hysteroscopy and endometrial biopsy:
- Gynecological & Menstrual Hx: Last cx
(Pelviabdominal mass/
Mandatory
smear, previous gynae surgery,
ascites).
for women older than 40 years.
contraception, IMB, and PCB.
- Pelvic examination:
- Others, according to the suspected problem.
- Medical Hx: Thyroid symptoms,
Speculum examination,
Hematological disorders
Bimanual examination.
- Medications: The previous 4 drugs.
- Previous investigations and treatment.
DEFINITION
Menorrhagia in
the absence of
organic (pelvic,
systemic)
pathology.
Is a diagnosis of
exclusion.

TREATMENT
LESS THAN 20 YEARS OLD
Menorrhagia is a common cause of Gyn clinic visit in teenager, mainly due to DUB. (delayed maturation of HPO axis)
Treatment is simple and for short duration (few months) till the hormonal axis becomes mature.
Lines of management:
a) Reassurance and explanation.
b) Correction of anemia if present.
c) Medical treatment.
NON-HORMONAL
HORMONAL
ANTIANTIPROGESTOGENS
COMBINED OCP
DANAZOL
GnRH ANALOG
PROSTAGLANDIN
FIBRINOLYTICS
Most commonly
Tranexamic acid: Norethisterone
- 1tab daily for
- It is an androgen
- 3.75mg IM
used.
- 3 capsule daily,
and
21 days, from
analogue (17-
monthly, for 4
from day 1 to day
Medoxyprogest
day 5.
ethinyl
months.
Mefenamic acid 5 of the cycle.
erone acetate.
- menstrual
testosterone).
- Menstrual
(Ponstan):
- menstrual
- Most common
blood loss by
- Also
blood loss by 80- Is the most
blood loss by 50%. drug used for
50%.
antiestrogentic &
100%.
common drug
- Main S/E: nausea DUB.
- Less
antiprogestrogenic.
- Depression of the
used by
and vomiting, ~
- 5 mg twice daily, commonly used - Depression of the
HPO- axis;
adolescent
25% of patients
from day 5 to day due to its side
HPO- axis and has a
Menopausalsx.
female; for
stop it because of
25 of the cycle.
effects.
direct suppressive
- Major risk:
dysmenorrhea as
these side effects. - menstrual
- Minor S/E:
effect on
Osteoporosis if
well.
- Rarely, it may
blood loss by
Nausea,
endometrium.
used more than 6
- 3 capsules daily, cause cerebral
25%.
vomiting,
- menstrual blood
months.
from day 1 to day thrombosis, so it is - No serious S/E.
headache,
loss by 80 100%.
5 of the cycle.
contraindicated in - Safe to use.
- S/E:
*Although, these
irritability, in
- menstrual
patient with risk
Hoarseness of
drugs are
weight...
blood loss by
factors for
voice.
extremely
- Major side
25%.
thromboembolism.
Hirsutism
and
effective, but they
effects: HT,
-S/E: gastritis,
acne.
are no more used
thromboembolis
gastric ulcer.
nowadays due to
muscle mass.
m,
their serious side
cardiovascular
Cliteromegaly.
effects.
Breast atrophy.
Hypooestrogenic

Menopausal sx.

BETWEEN 20 & 40 YEARS OF AGE

Two lines of management:
A] Medical: same as for the teenagers.
B] Levonorgestrol releasing IUCD (Mirena) they
desire contraception; very effective.
- 20 mcg of levonorgestrol daily.
- It decreases menstrual blood loss by 8090 %.
- ~30% of women are amenorrhoeic after one year of
insertion.
- It decreases the incidence of PID.
- Doesnt increase risk of ectopic pregnancy.
- Side effects: breakthrough bleeding & spotting for the
first 3-6 months after insertion.

ABOVE THE AGE OF 40

Three lines of management:
A] Medical: Same, not OCP.
B] Mirena: Safely used.
C] Surgery:
1) Endometrial resection and ablation:
- Day case surgery under GA.
- Short stay in hospital, rapid recovery.
- Cure rate of 7080%.
- Risk of recurrence 2030%; Risk of endometrial
cancer exists.
2) Hysterectomy: Is the best, 100% cure rate.
No recurrence of the problem.

POSTCOITAL BLEEDING
Def: Bleeding during or after coitus.
Cervical Ectropion
The cause is almost always cervical:It is normal, physiological, it is not an ulcer.
- Cervical ectropion, the commonest cause.
- Occurs in high estrogenic state: Pregnancy or COCP users.
- Cervical ulcer, cervicitis.
- The estrogen will cause overgrowth of the columnar
- Cervical polyps.
epithelium of the endocervix into ectocervix postcoital
- Cervical cancer.
bleeding.
How to diagnose?
- C/C: PCB and excessive mucoid secretions.
- History
- In menopause, there will be inversion (the stratified layer
- Examination: General and pelvic, speculum.
of the ectocervix will move inwards).
Treatment: Should be directed toward the cause; Pap
- During pregnancy; Conservative treatment, after delivery
smear is mandatory before treatment.
it usually improves spontaneously.
- If on COCP, stop it, reassess again.