This document discusses common gynecological presentations and provides information about abnormal uterine bleeding. It defines normal and abnormal menstrual bleeding parameters. Abnormal uterine bleeding can be chronic or acute and has potential structural or non-structural causes categorized by the acronym PALM-COIN. Pelvic pain may be acute, chronic, or cyclic such as dysmenorrhea which can be primary or secondary. Primary dysmenorrhea is caused by increased prostaglandins during menstruation while secondary dysmenorrhea has an underlying pelvic pathology.

2. Gynecological presentations
• Vaginal Bleeding (AUB)
• Pelvic Pain
• Vaginal Discharge (infection)
• Inability to conceive (Infertility)
• Want Contraception

3. Abnormal uterine bleeding

5. Normal limits
Frequency of menses
(days)
Frequent <24
Normal 24–38
Infrequent >38
Duration of flow (days)
Prolonged >8.0
Normal 4.5–8.0
Shortened <4.5
Volume of monthly
blood loss (ml)
Heavy >80
Normal 5–80
Median 40
Light <5
Regularity of menses
(cycle to cycle variation
over 12 months)(days)
Regular variation: ± 2 to 20 days
Irregular variation: >20 days or absent

6. Abnormal uterine bleeding
(AUB)
Any menstrual bleeding from the uterus that is either
abnormal in volume (excessive duration or heavy), regularity,
timing (delayed or frequent) or is non-menstrual (IMB, PCB or
PMB)
Heavy menstrual bleeding
(HMB)
excessive menstrual blood loss leading to interference with
quality of life of a woman (exceeds 80 ml or menses duration
>7 days)
Intermenstrual bleeding
(IMB)
Uterine bleeding that occurs between clearly defined cyclic
and predictable menses.
Postmenopausal bleeding
(PMB)
Genital tract bleeding that recurs in a menopausal woman at
least one year after cessation of cycles
Postcoital bleeding (PCB)
Non-menstrual genital tract bleeding immediately (or shortly
after) intercourse
Chronic AUB AUB has been present for the majority of the past 6 months.
Acute AUB
Excessive AUB bleeding that requires immediate intervention
to prevent further blood loss. Acute AUB may present in the
context of existing chronic AUB or might occur without such a
history

7. STRUCTURAL
P polyp
A adenomyosis
L Leiomyoma (fibroid)
M Malignancy of genital tract
NON-STRUCTURAL
C Coagulopathy (leukemia- warfarin,thrombocytopenia)
O Ovulatory disorder (eg.PCO-hyperprolactinemia)
E Endometrial disorder (eg. endometritis)
I Iatrogenic (COC,IUD,uterine perforation)
N Non-specfic (hypertention-chronic liver disease)

8. Pelvic pain
• Acute pelvic pain
• Chronic pelvic pain (>6mth)
• Cyclic pain (intermittent)
üDysmenorrhea
üOvulatory pain
üdysparunia

9. Dysmenorrhea
• Definition: Pain related to menstruation
• Types:
üPrimary (spasmodic)
üSecondary (congestive)

10. Primary (spasmodic) : Secondary (congestive):
no pelvic disease due to pelvic pathology
Increase in PG production from
the endometrium which increase
uterine contraction
Congenital malformed uterus –
IUD- endometritis-fibroid-polyp-
endometriosis-
From menarche Patient had years without pain
Colicky pain Dull aching
Start few hours before menses,
peak in first day, disappear
within 48h
1-2 wk before menses and relived
by menses onset , persist after
menses
Associated with symptoms of PG
increase: headache-nausia-
vomiting -diarrhia
Associated with symptoms of
pelvic congestion: dyspareunia-
discharge-HMB-dysuria-dyschazia
Normal menstrual blood loss Heavy menstrual blood loss

11. Primary (spasmodic) Secondary (congestive)
Investigations (US) : no plevic
pathology
Investigations (US) : Pelvic
pathology
Treatment:
NSAID( anti-PG )
Hormonal (COC)
Treatment:
NSAID( anti-PG )
Treatment of the cause