This mind Map was created By Jana Shaker and it was revised and edited By Dr Arwa M Amin. The information of the mind-map are from: Chapter 96: Menstruation-Related Disorders, Pharmacotherapy: A Pathophysiologic Approach, 11e

1. HMB
Epidemiology
Menstrual blood loss greater than 80 ml per cycle
Or Bleeding greater than 7 day per cycle this
definition has been questioned ?
 difficult in quantifying menstrual loss in clinical
practise
 there are many women with (heavy menses )
but less than 80ml
 Recently, diagnosis is based on the effect of
HMB on quality of life, work productivity &
social activity.
Etiology
PALM -COIN : intermenstrual bleeding as bleeding between predictable and clearly cycle menses
Structural causes (PALM) : Polyp, Adenomyosis .Leiomyoma , Malignancy
Non-structural causes COIN : Coagulopathy . Ovulatory Disorder , Idonendometrial Disorder
AUB: bleeding that is abnormal in regularity , time, volume
Other causes :
1- Pregnancy ( intrauterine pregnancy , ectopic pregnant, ectopic pregnancy , miscarriage )
2- Bleeding disorder ven Willebrand disease , systematic haemophilia , platelet dysfunction ,v111 , IX
factors deficiency
3- Hypothyroidism 4- Uterine structural abnormality (polyp , adenomyosis , leiomyoma, fibrosis )
Clinical presentation
Symptoms :
1. Heavy prolong menstrual flow
2. Fatigue
3. Light headiness
Sign :
1. Orthostatic
2. Tachycardia
3. Pallor if patient have anemia
or acute bloods loss
Laboratory test :
1. CBC , ferritin , hematocrit
,hemoglobin
2. Other tests (prothrombin time
test, activated partial prothrombin
time , INR , von Willebrand factor
antigen , factor VII,IX)
Treatment
Goal :
 Menstrual blood flow
 Improve patient quality of life
 Defer the need for surgical
intervention
General approach treatment :
 Patient history
 Concomitant concern
 ADR effect from some agent
Non pharmacology
therapy :
Surgical treatment
(endometrial ablation
,hysterectomy )
Non-Pharmacological
treatment is reserved
for patients not
responding to
pharmacological
treatment.
Other diagnostic test :
1. pelvic ultrasound
2. Pelvic MRI
3. Endometrial biopsy
4. Hysteroscopy
5. Sonohystogram
6. Papaniacolaou (pap)
smear
Evaluation of therapeutic outcome :
Table number (94-4 )
 Identifies significant pharmacological properties of agent
 Expected outcome for each agent
 Specific monitoring parameters for treatment modalities
in HMB management see table number (94-4 ) ‫ﻣﻬﻢ‬
‫ﺟﺪا‬ ‫ﺟﺪا‬
Pharmacology treatment : First
option treatment before surgery
Estrogen :manage acute
sever bleeding episodes
Women not have any
bleeding disorder
Initial treatment should
continue to prevent
future episodes
Estrogen contain CHCs
+ progesterone
Only as maintenance
therapy
FDA approved drug
estradiol valerate and
dienogest
if CHCs is contraindicated,
use progestin only method.
4-phasic formulation
containing estradiol
1
Four-phasic oral
contraceptive pills
provide 4 different doses
of progestin/estrogen
during a 28-day cycle.
Ethinylestradiol and
levonorgestrel extended
cycle
Dienogest and
estradiol
This mind-map is created by Jana Shaker, Edited and revised By Dr. Arwa M. Amin. The information of the mind-map is
based on Chapter 96: Menstruation-Related Disorders, Pharmacotherapy: A Pathophysiologic Approach, 11e

2. SERUM CREATININE DOSE
(1.4-2.8mg/dl) 1300 mg by mouth twice
daily
(2.9-5.7mg/dl) 1300 mg by mouth once
daily
more than (5.7mg/dl) 650 mg by mouth once daily
NSAID: only during menses
Menorrhagia present
Contraception desired
NO yes
Consider LNG - IUS
Continue
NSAID
Consider tranexamic acid
Or luteal phase
progesterone or x 21 day
starting on day 5
Repeating next cycle Use of LNG-IUS OR
conservative endometrial
ablation surgery
NOyes
Continue
LNG-IUS
Consider
OC
Continue OC Consider conservative
endometrial ablation
surgery
NOyes
yes NO
yes NO
Special population
IUS avoid in
nulliparous
women
Tranexamic acid
Dose adjustment
Caution with history of thrombosis
may cause thromboembolism
Should not be combined with
estrogen containing contraceptive
OC= oral contraceptive
LNG- IUS= levonorgestrel releasing
intrauterine system
Is preferred when pregnancy is desired or
when hormonal therapy is contraindicated
LNG-IUS is
considered the
most effective
treatment to
reduce menstrual
flow
2
This mind-map is created by Jana Shaker, Edited and revised By Dr. Arwa M. Amin. The
information of the mind-map is based on Chapter 96: Menstruation-Related Disorders,
Pharmacotherapy: A Pathophysiologic Approach, 11e
This mind-map is created by Jana Shaker, Edited
and revised By Dr. Arwa M. Amin. The information
of the mind-map is based on Chapter 96:
Menstruation-Related Disorders, Pharmacotherapy:
A Pathophysiologic Approach, 11e

3. 94-4 VERY IMPORTANT from Chapter 96: Menstruation-Related Disorders,
Pharmacotherapy: A Pathophysiologic Approach, 11e