Contents

• Review of menstrual cycle

• Definition
• Magnitude of the problem
• Patterns of Abnormal Uterine Bleeding
• Causes
• Evaluation of Abnormal Uterine Bleeding
• General Principles of Management
MENSTRUAL
CYCLE
 AUB
 Definition
 Any deviation in normal frequency, duration,
amount or timing of menstruation in women of
reproductive age
◦ Duration greater than 7 days
◦ Flow greater than 80 ml / cycle
◦ Occur more frequently than every 21 days or
less frequently than every 35 days.
◦ Intermenstrual bleeding or postcoital spotting
 AUB
 Epidemiology
 AUB is one of the commonest problems
that challenges the gynecologist/midwife
◦ Responsible for as many as one-third of all
outpatient gynecologic visits
◦ 30 per 1000 female patients / year consult with
their GP (UK)
◦ 20% of referrals from GP to gynecologists, about
half undergo hysterectomy
◦ 11% of hysterectomies due to AUB (USA)
◦ Major impact on quality of life, productivity, and
healthcare utilization and costs (economic
 TERMS R/T TO AUB
 Menorrhagia ( cycle regular, excessive)
 Metrorrhagia ( intermensrual bleeding)
 Menomterorahgia( excessive irregular bleeding)
 Mterostaxis ( more than 8 days)
 Oligomenorrhea ( menses greater than every 35
days).
 Polymenorrhea ( menses more frequent, than 21
days)
 Cryptomenorrha ( normal cycle , decrease flow
for mechanical reasons.)-Hypomenorrhea
 Amenorrhea cessation of menses.
 Dysmenorrhea( pain during menses)
Patterns of Abnormal Uterine Bleeding
 Menorrhagia
◦ is heavy and/or prolonged menstrual flow
with regular patterns
 Soaking through a pad every hour
 Soaking through bed clothes
 Below normal ferritin, Anemia
Menorrhagia
◦ Most commonly caused by;
 Submucous myomas
 complications of pregnancy
 Adenomyosis
 IUDs
 endometrial hyperplasias
 malignant tumors
 dysfunctional bleeding
 Patterns of AUB
 Polymenorrhea
◦ Menses at intervals less than 21 days
◦ Commonly caused by
 anovulation
 rarely with a shortened luteal phase
 Metrorrhagia
◦ Menses at irregular intervals and frequent
◦ Commonly caused by
 Endometrial polyps
 endometrial and/or cervical carcinomas
 exogenous estrogen administration
 Patterns of AUB
 Hypomenorrhea
◦ Periods with unusually light flow
◦ Commonly caused by
 An obstruction such as hymenal or cervical stenosis
 Uterine synechiae
 OCP use
 Menometrorrhagia
◦ Menses with heavy, irregular bleeding
 Cnt’d
 Oligomenorrhea
◦ Menses at intervals greater than 35 days
◦ associated with
 anovulation,
 either from endocrine causes
 systemic causes
For all women presenting with AUB,
encompasses the mnemonic
(PHIMIC).
 Pregnancy
 Hormones
 Iatrogenic
 Mechanical
 Infection, and
 Cancer
 Causes
 Ovulatory-cyclic bleeding
◦ sex hormones and gonadotropins are normal
◦ menses is cyclic
 Non ovulatory-bleeding
◦ menses is irregular
◦ sex steroids are produced, but not cyclically so
bleeding is irregular.
◦ chronic estrogen production unopposed by
adequate progesterone production allows
continued proliferation of the endometrium

9/20/2011
 Estrogenized
anovulation is the
most common
cause of abnormal
uterine bleeding.
Causes anovulatory bleeding

9/20/2011
…cnt’d

9/20/2011
…cnt’d

9/20/2011
Causes of ovulatory bleeding
 Pregnancy related
 Anatomic uterine lesions
 Anatomic non uterine lesions

9/20/2011
Evaluation of Abnormal Uterine Bleeding
 Detailed history pertaining
◦ The amount of menstrual flow
◦ the length of the menstrual cycle
◦ the length and amount of episodes of
intermenstrual bleeding, and any episodes of
contact bleeding.
◦
 Cont`d
◦ the last menstrual period, the last normal
menstrual period
◦ age at menarche
◦ History of drugs
◦ Bleeding from other sites
 Cont`d
 Physical Examination
◦ One can appreciate
 Anemia
 Abdominal masses
 Genital ulcers
 Genitalial Atrophic changes
 …Cont`d
 Investigation
◦ Base line
 CBC
 U/A
 Pregnancy test (reproductive age )
◦ As needed
 Hormonal profiles
 FBS
 Electrolytes
 Tumor markers
 Coagulation studies
 …Cont`d
 Imagings
◦ Pelvic ultrasound
◦ Hysteroscopy
◦ Sonohysterography
◦ CT scaning
◦ MRI
 Diagnostic Procedures
◦ Endometrial biopsy
◦ Cervical cytology: Pap smear
◦ Laparascopy/laparatomy
General Principles of Management
 Address the underline cause
 rule out unsuspected pregnancies
 Treat complication
 Treat concomitant conditions
General Principles of Management
Dysfunctional uterine bleeding (DUB)
 Exclusion of pathologic causes of abnormal
bleeding establishes the diagnosis
 Virtually all variations of DUB can be related
to disruption in normal ovarian function.
 Greater than 80% Of DUB is anovulatory and
the remaining 20% is due to dysfunction of
corpus luteum or endometrial abnormalities.
 DUB most commonly occurs at the extremes
of reproductive age (20% of cases occur in
adolescence and 40% in patients over age 40).
28
Pathophysiology
 In anovulatory conditions there is continued estrogen
stimulation of the endometrium.
 There are two mechanisms of bleeding.
◦ estrogen break though bleeding where the endometrium
outgrows its blood supply and will desquamate in an irregular.
◦ estrogen withdrawal bleeding where the endometrium
sheds when the estrogen levels decline sharply.
 The pattern of bleeding is dependent entirely on the
duration and level of estrogen stimulation and may take
any pattern of AUB.
 Anovulatory DUB is
◦ acyclic, unpredictable onset of bleeding and variable in the
duration and amount of bleeding.

29
…Pathophysiology
 Ovulatory DUB is
◦ usually associated with premenstrual symptoms :
breast tenderness, dysmenorrhea and weight gain
and
◦ regular periodicity.
◦ It is a result of the dysfunction of the corpus
luteum which in most cases has short life span
◦ Abnormalities in endometrial physiology involving
chemicals like prostaglandins may be a cause of
DUB

30
 Uterine bleeding secondary to such pathologic
entities as blood dyscrasias, endocrinopathies,
hepatic dysfunction and other iatrogenic causes
with no organic pathologic factors should not
be considered as true DUB.
Diagnosis
 DUB is a diagnosis by exclusion (organic causes
of AUB should be ruled out before diagnosis of
DUB is entertained).

31
Treatment
 Individualized treatment plan should be
designed according to
◦ the patient age
◦ the desire for contraception or fertility and
◦ severity and chronicity of the bleeding.
 The goals of treatment should be
◦ arresting the acute episode of bleeding,
◦ preventing recurrences and
◦ inducing ovulation if patient desires to conceive.

32
…Treatment

 Modalities of treatment
◦ Combined estrogen and progesterone
◦ Estrogen and progesterone intermittently
◦ Danazole
◦ Prostaglandin synthesis inhibitor
 NSAID
◦ Antifibrinolytic agents
◦ D& C and hysteroscopy resection
◦ Laser ablation
◦ hysterectomy
33
 …Treatment
 In adolescents, pregnancy related complications
should be ruled out first.
 Acute bleeding episode with vital sign
derangement should be treated with
◦ intravenous fluid resuscitation.
◦ Bleeding can be arrested either by dilatation and
curettage or suction curettage or administration of
high dose estrogen followed by medroxy progesterone
acetate.
 Recurrences can be prevented by 3-6 months
coarse of combined oral contraceptive or
intramuscular progesterone in oil.
 Hysterectomy is rarely needed for this group of
women 34
…Treatment
 In women in reproductive age group (20-
40years),
◦ pregnancy related complications and organic
lesions should be ruled out.
◦ Management of acute episode and
prevention of recurrences is as for
adolescents.
◦ In addition ovulation induction can be given
for those anovulation women who desire
pregnancy.
◦ For persistent cases hysterectomy can be
offered if the woman has no desire for
future pregnancy. 35
…Treatment

 In
Perimenoposal women, appropriate
work up must done to rule out neoplastic
conditions
◦ including Pap smear and endometrial sampling.
◦ Management includes
 hormonal treatment using progesterone derivatives
or combined oral contraceptives or
 surgical treatment using
 dilation and curettage or hysterectomy.
 hysteroscopy resection
 Laser ablation
36
WHAT ARE THE OTHER
MENSTRUAL ABNORMALITY????
 Premenstrual syndrome (PMS)
 Dysmenorrhea (Primary &
Secondary)
REFERENCES
Lange Current Diagnosis and Treatment
Obstetrics and Gynecology Tenth Edition
Pages 57--578