3. What is normal vaginal bleeding?
Normal vaginal bleeding is the periodic blood
that flows as a discharge from the woman's
uterus. Normal vaginal bleeding is also called
menorrhea. The process by which menorrhea
occurs is called menstruation.
4. • Unless pregnancy occurs, the cycle ends with the shedding of
part of the inner lining of uterus, which results in
menstruation.
• The time of the cycle during which menstruation occurs is
referred to as menses. The menses occurs at approximately
four week intervals, representing the menstrual cycle.
• Menarche is the time in a girl's life when menstruation first
begins.
• Menopause is the time in a woman's life when the function
of the ovaries ceases. The average age of menopause is 51
years old.
5. MENSTRUATION
Shading of the upper layers of the
endometrium
•Stratum compactum
•Stratum spongiosum
•Stratum basalis
6. Menstruation is normally under Endocrine
Control
• Hypothalamus - GnRH
• Pituitary – LH & FSH
• Ovary – OESTROGEN & PROGESTERON
=Effect of the uterus
8. Thus Normal Menstruation
• Results from fluctuations in the circulating levels of
estrogen and progesterone.
• Estrogen causes increased blood flow to the
endometrium
• A significant correlation exists between plasma
Estradiol and endometrial blood flow, with both
increasing in the days preceding ovulation.
9. •Estradiol and progesterone levels decrease
several days prior to the onset of menses.
•Endometrial blood flow decreases
•Endometrial height decreases and vascular
stasis occurs.
•Tissue ischemia occurs.
•Arterial relaxation
•Sloughing of the endometrium.
•Uterine bleeding occurs
10. NORMALLY
•Frequency of menses
•21 days (0.5%) to 35 days (0.9%)
•Average 28 days
•Duration of menses
•2 days to 8 days
•Usually 4-6 days
13. Any deviation in normal
frequency, duration and
amount of blood flow in
women of reproductive tract
in reproductive age
14. •In order to determine whether bleeding is
abnormal, and its cause, as a doctor you
must consider these three questions:
•Is the woman pregnant?
•What is the pattern of the bleeding?
•Is she ovulating or not?
15. 1. Pregnancy related AVB
Much of the abnormal vaginal bleeding during
pregnancy occurs so early in the pregnancy that
the woman doesn't realize she is pregnant.
Therefore, irregular bleeding that is new may be
a sign of very early pregnancy, even before a
woman is aware of her condition.
16. •Vaginal bleeding during pregnancy can also be
associated with complications of pregnancy,
such as:
• Spontaneous abortion
• Ectopic pregnancy
• Placental previa
• Abruptio placenta
• Trophoblastic disease
• Puerperal complications
17. 2. Abnormal Bleeding Patterns
• Polymenorrhoea: frequent (<21 d) menstruation, at regular
intervals.
• can be caused by certain sexually transmitted diseases (STDs)
(such as chlamydia or gonorrhea) that cause inflammation in the
uterus. This condition is called pelvic inflammatory disease.
Endometriosis is a condition of unknown cause that can lead to
pelvic pain and polymenorrhea. Sometimes, the cause of
polymenorrhea is unclear, in which case the woman is said to have
dysfunctional uterine bleeding.
18. •Menorrhagia: Excessive (>80 ml) & / or
prolonged menstruation, at regular intervals
•Metrorrhagia: Excessive (>80 ml) & / or
prolonged menstruation at irregular intervals.
•Hypomenorrhoea: scanty menstruation.
•Oligomenorrhea: infrequent menstruation (>35
d)
19. • Menometrorrhagia: both menorrhagia and metrorrhagia
• can be due to benign growths in the cervix, such as cervical polyps.
• Metrorrhagia can also be caused by infections of the uterus
(endometritis) and use of birth control pills (oral contraceptives).
• Sometimes does not have an identifiable cause.
• Perimenopause is the time period approaching the menopausal
transition. It is often characterized by irregular menstrual cycles,
including menstrual periods at irregular intervals and variations in the
amount of blood flow. Menstrual irregularities may precede the onset
of true menopause (defined as the absence of periods for one year)
by several years.
20. •Hypomenorrhoea: scanty menstruation.
•An overactive thyroid function
(hyperthyroidism) or certain kidney
diseases can both cause
hypomenorrhea. Oral contraceptive pills
can also cause hypomenorrhea.
22. • Intermenstual bleeding: episodes of uterine bleeding between
regular menstruations
• Women who are ovulating normally can experience light bleeding
(sometimes referred to as "spotting") between menstrual periods.
• Hormonal birth control methods (oral contraceptive pills or patches)
as well as IUD use for contraception may sometimes lead to light
bleeding between periods. Psychological stress, certain medications
such as anticoagulant drugs, and fluctuations in hormone levels may
all be causes of light bleeding between periods. Other conditions that
cause abnormal menstrual bleeding, or bleeding in women who are
not ovulating regularly (see below) can also be the cause of
intermenstrual bleeding.
23. 3. Is the woman ovulating?
• Usually, the ovary releases an egg every month in a process called
ovulation. Normal ovulation is necessary for regular menstrual
periods.
• There are certain clues that a woman is ovulating normally including
regular menstrual intervals, vaginal mucus discharge halfway between
menstrual cycles, and monthly symptoms including breast
tenderness, fluid retention, menstrual cramps, back pain, and mood
changes.
• If necessary, doctors will order hormone blood tests (progesterone
level), daily home body temperature testing, or rarely, a sampling of
the lining of the uterus (endometrial sampling) to determine whether
or not a woman is ovulating normally.
24. On the other hand, signs that a woman is not ovulating
regularly include:
•prolonged bleeding at irregular intervals after not
having a menstrual period for several months,
•excessively low blood progesterone levels in the
second half of the menstrual cycle,
•lack of the normal body temperature fluctuation
during the time of expected ovulation.
• Sometimes, a doctor determines that a woman is not ovulating by
using endometrial sampling with biopsy.
25. Hx, PE, Preg test
Preg test POS Preg test NEG
Pregnant
• Location
• Viability
• GA Dating
Non-uterine bleeding
NON PREGNANT
Uterine bleeding
Cervix Vagina AnusUrethra
Abnormal Vaginal
Bleeding
34. Iatrogenic Causes of AVB
•Intra-uterine device
•Oral and injectable steroids
•Psychotropic drugs
35. Anovulatory Bleeding
•90-95% of reproductive age
•Cause: systemic hormonal
imbalance
• Hypothalamic
• Pituitary
• Ovarian
•Always a relative progestin-deficient state.
36. Anovulatory Bleeding
•With anovulation a corpus luteum is NOT
produced and the ovary thereby fails to
secrete progesterone.
•However, estrogen production continues,
resulting in endometrial proliferation and
subsequent AUB.
37. Postmenopausal bleeding.
• Bleeding from the genital tract 12 months after the cessation of menses.
Causes:
• hypoestrogenism, vaginal and endometrial atrophy,
• vaginal, cervical and uterine cancers,
• urethral caruncle, cervical polyps, uterine fibroids.
• Vulvar tumors, vulvovaginitis.
• estrogen and progesterone hormone therapy
Differential diagnosis:
• causes of bladder and rectal bleeding which can be confused with vaginal
bleeding
38. Vaginal bleeding during or after sexual
intercourse
Vaginal bleeding may occur during or after sexual
intercourse for a number of reasons including:
•Injuries to the vaginal wall or introitus (opening to
the vagina) during intercourse
•Infections (for example, gonorrhea, chlamydia, yeast
infections) can be a cause of vaginal bleeding after
intercourse.
39. • lowered estrogen levels in peri-menopausal or
postmenopausal women may cause the lining of the
vagina to become thinned and easily inflamed or
infected, and these changes can be associated with
vaginal bleeding after intercourse.
• Anatomical lesions, such as tumors or polyps on the
cervix or vaginal wall may lead to vaginal bleeding
during or after intercourse.
40. Genital Trauma
•Commonly due to vigorous
voluntary/involuntary sexual activity
•Associates with Sex toys
•Posterior fornix is most common area
injured
41. adenomyoses
•Caused by endometrial glands growing into
myometrium
•May cause menorrhagia and dysmenorrhea at
the time of menstruation
•Treatments are analgesics for pain – surgery may
be needed for severe bleeding refectory to
medical therapy
42. leiomyoma
• Fibroids – smooth muscle cell tumors - responsive to estrogen, usually multiple
• Size increases in first part of pregnancy and at times with OCP use
• Size decreases with menopause
• Fibroids are usually found during manual exam or by ultrasound
• If acute degeneration or torsion occurs – patients will present with acute
abdomen symptoms on physical exam
• Treatment is NSAIDs, progestins, GNRHs, or surgery if indicated
• Uterine artery embolization is a new promising therapy
43. Blood Dyscrasias
• Menstrual bleeding may be excessive and be the presenting
symptom of a bleeding disorder
• Treatment includes antifibrinolytics and OCPs. OCPs increase
levels of factor VIII and vWF factor
• Desmopressin (DDAVP) – increases release of factor VIII and
vWF
• In these groups NSAIDs are not helpful and may cause
increased bleeding
44. Polycystic Ovary Syndrome
• PCOS – caused by hyperandrogenism and anovulation
without disease of adrenal or pituitary glands
• Triad usually seen – obese, hirsutite, oligomenorrhea
• Menses are heavy and prolonged
• Other characteristics – alopecia, increased androgens,
increased LH and FSH and acne
• Therapy – OCPs – low doses or cyclic progestins
45. DYSFUNCTIONAL UTERINE BLEEDING
• Accounts 60 % of AVB
•Defined as ABNORMAL uterine bleeding with no
demonstrable organic cause, genital or extragenital.
•Patients present with “abnormal uterine bleeding”
•DUB occurs most often shortly after menarche and at the
end of the reproductive years.
–20% of cases are adolescents
–50% of cases in 40-50 year olds
46. causes of dub
• The main cause of DUB is anovulation resulting from altered
neuroendocrine and/or ovarian hormonal events.
• In premenarchal girls, FSH > LH and hormonal patterns are
anovulatory.
• The pathophysiology of DUB may also represent
exaggerated FSH release in response to normal levels
of GnRH
48. A. History
• Personal history
(a) Age: The commonest age incidence for carcinoma of uterus is 55-
70 years while that for carcinoma of the vulva is 60-70 years.
(b) parity: some tumours are more common among nulliparae e.g.
endometrial and ovarian carcinoma.
• Present history
• Ask about the
• Onset, frequency, duration, cyclic vs.acyclic, severity
• Pain, change from menstrual pattern (calendar)
• Age, parity, marital status, sexual hx, contraception
• medications, dates of pregnancies
• symptoms of pregnancy and reproductive tract disease
49. •Past history
(a)Oestrogen therapy.
(b) diseases as diabetes mellitus, hypertension and
blood diseases as leukemia.
Endometrial carcinoma is more common in
hypertensive patients.
• Family history
Carcinoma of the body of the uterus and ovary
a familial tendency
50. B. General Examination
(I) Signs of anaemia.
(2) signs of bleeding disorders.
(3) presence of cachexia.
(4) examination of heart and chest for
secondaries.
(5) estimation of blood pressure
51. C Abdominal Examination
For a pelvi-abdominal mass and ascites which
is common with ovarian malignancy.
D. Pelvic Examination
To detect a local cause for bleeding. The
urethra and anal canal are excluded as being
the source of bleeding.
52. E. Special Investigations
1. sonography. It excludes the presence of an
ovarian tumour or alesion in the uterus as
endometrial carcinoma.
TAS: can exclude pelvic masses, pregnancy
complications
TVS: More informative than TAS. Measurement of the
endometrial thickness is not a replacement for biopsy.
All endometrial carcinoma in postmenopausal with
endometrial thickness>4 mm (Osmers,1990)
53. •TVS is recommended in:
•1. Weight >90 Kg
•2. Age > 40 yrs
•3. Other risk factors for endometrial
hyperplasia or carcinoma e.g. infertility,
nulliparity, family history of colon or
endometrial cancer, exposure to unopposed
estrogen (Grade B)
54. 2. Cervical smear.
Taken in absence of bleeding to
detect the presence of malignant
cells which may come from the
cervix, endometrium, tubes, or
ovaries.
55. 3. Endometrial biopsy.
It must be done in every case of
postmenopausal bleeding, as is
the only sure method to exclude
endometrial carcinoma.
56. Indications:
• Between 20 & 40
• If endometrial thickness on TVS is >12mm, endometrial sample
should be taken to exclude endometrial hyperplasia (Grade A).
• Failure to obtain sufficient sample for H/P does not require further
investigation unless the endometrial thickness is >12 mm (Grade B)
Aim:
• diagnosis of the type of the bleeding
57. 4. Biopsy is taken from any
suspected lesion in the vulva,
vagina, or cervix.
58. 5. Laboratory tests. These are done according
to the clinical findings and include:
a. Complete blood count.
b. Platelet count, bleeding time,
coagulation time, estimation of
clotting factors if a bleeding disorder is
suspected.
59. •Choices of investigations are
extensive
•Selection should be tailored to
suspected causes from the history
and physical examination
60. Egs. diagnostic tests are used to evaluate
abnormal vaginal bleeding
• The diagnostic test will depend upon the diagnosis reached.
• A pregnancy test is routine if the woman is premenopausal.
• A blood count may be done to rule out anaemia resulting from excessive
blood loss.
• A Pap smear is also done to rule out cervical cancer. While the Pap smear is
being obtained, samples might be taken from the cervix to test for the
presence of infections such as chlamydia or gonorrhea.
• A pelvic ultrasound is often performed based on the woman's medical
history and pelvic examination.
61. • If something in the patient's (or her family's) medical background or
physical examination raises suspicion, tests to rule out blood clotting
disorders may be done.
• Sometimes, a blood sample can be tested to evaluate thyroid
function, liver function, or kidney function abnormalities.
• A blood test for progesterone levels or daily body temperature
charting may be recommended to verify that the woman ovulates.
• If the doctor suspects that the ovaries are failing, such as with
menopause, blood levels of follicle-stimulating hormone (FSH) may be
tested.
• Additional blood hormone tests are done if the doctor suspects
polycystic ovary, or if excessive hair growth is present.
62. TREATMENT
• Treatment for irregular vaginal bleeding depends on
the underlying cause.
• Treatment Goals includes:
• control bleeding
• prevent recurrence
• preserve fertility
• correct associated conditions
• induce ovulation in patients who want to conceive
63. If the cause of bleeding is DUB
• Medical management is the preferred initial
treatment, especially if the woman desires future
fertility and there is no associated pelvic pathology
• Selection of treatment depends primarily on whether
it is used to stop acute or heavy bleeding, or to control
recurrent episodes
64. Medical management recommended
before Surgical
•effective methods include:
•estrogens, progestins, or both
•NSAID’s
•antifibrinolytic agents (trenexemic acid)
•danazol
•GnRH agonists
65. • Acute bleeding
• Estrogen therapy
• Oral conjugated equine estrogens
• 10mg a day in four divided doses
• treat for 21 to 25 days
• medroxyprogesterone acetate, 10 mg per day for the last 7 days of the
treatment
• if bleeding not controlled, consider organic cause
OR
• 25 mg IV every 4 to 12 hours for 24 hours, then switch to oral
treatment as above.
• Bleeding usually diminishes within 24 hours
66. Commonly used oestrogen agents are
•Conjugated estrogens given IV in 25mg doses
every 6 hours should be effective in controlling
heavy bleeding. This is followed by PO
estrogen.
•For less severe bleeding, PO Premarin® 1.25mg,
2 tabs QID until bleeding ceases.
67. • Acute bleeding can be managed by estrogen which promotes
rapid regrowth of the endometrium over denuded epithelial
surfaces. It also causes proliferation of the endometrial
ground substance and stabilizes lysosomal membranes.
• There are no studies that indicate IV estrogen acts quicker or
is more effective than high dose oral estrogen.
• After treatment is finished, all medications are stopped and
the patient is allowed to have withdrawal bleeding. This can
be heavy so warn patients, but it is rarely prolonged
68. •Acute bleeding (continued)
•High dose estrogen-progestin therapy
•use combination OCP’s containing 35
micrograms or less of ethinylestradiol
•four tablets per day
•treat for one week after bleeding stops
•may not be as successful as high dose
estrogen treatment
69. •Recurrent bleeding episodes
•combined OCP’s
• one tablet per day for 21 days
•Mechanism of action:
endometrial suppression
•Side effects;
headache, migraine, weight gain, breast
tenderness, nausea, cholestatic jaundice,
hypertension, thrombotic episodes
70. •intermittent progestin therapy
•medroxyprogesterone acetate, 10mg per
day, for the first 10 days of each month
•higher doses and longer therapy my be tried
if no initial response
•prolonged use of high doses is associated
with fatigue, mood swings, weight gain, lipid
changes
71. Progestational Agents commonly used
include
• Cyclic medroxyprogesterone 2.5-10mg daily for 10-14
days
• Continuous medroxyprogesterone 2.5-5mg daily
• Progesterone in oil, 100mg every 4 weeks
• DepoProvera® 150mg IM every 3 months
• Levonorgestrel IUD (5 years)
72. •Recurrent bleeding episodes (continued)
•Progesterone releasing IUD - mirena
•avoids side effects
•must be reinserted annually
•Levonorgestrel IUD
• 80% reduction of blood loss at 3 months
• 100% reduction at 1 year
• found to be superior to antifibrinolytic agents and
prostaglandin synthetase inhibitors
73. •Immature hypothalamic-pituitary axis
•progestin therapy by itself for 10 days every month
or every other month until full maturity of the axis
provides effective therapy.
•Older perimenopausal women
•cyclic progestin therapy
• prevents development of endometrial hyperplasia
•low dose OCP’s
• healthy non-smokers, free of vascular disease
74. •Other options
•NSAID’s
•cyclooxygenase inhibitors
•inhibits prostacyclin formation
•administered throughout the duration of
bleeding or for the first 3 days of menses.
•treatment results in a sustained reduction in
blood loss so side effects tend to be mild
•most effective in ovulatory DUB
75.
76. •Other options
•inhibitors of fibrinolysis
•EACA (epsilon-aminocaproic acid)
•AMCA (tranexamic acid)
•PABA (para-aminomethybenzoic acid)
•use limited by side effects
•nausea, dizziness
•diarrhea, headaches
•abdominal pain
•allergic manifestations
77. •Danazol
•androgenic steroid
•200mg and 400 mg daily doses for 12 weeks
studied
•200mg dose as effective as 400 mg
•androgenic side effects: weight gain, acne
• side effects minimized with 200mg dose
•100 mg not effective, expensive
78. Mechanism;
• inhibits the release of pituitary Gnt & has direct
suppressive effect on the endometrium
Side effects:
• headache, weight gain, acne, rashes, hirsuitism, mood
& voice changes, flushes, muscle spasm, reduced HDL,
diminished breast size. Rarely: cholestatic jaundice.
• It is effective in reducing blood loss but side effects
limit it to a second choice therapy or short term use
only (Grade A)
79. • GnRH agonists
• treatment results in medical menopause
• blood loss returns to pretreatment levels when discontinued
• treatment usually reserved for women with ovulatory DUB that fail
other medical therapy and desire future fertility
• use add back therapy to prevent bone loss secondary to marked
hypoestrogenism
Side effects;
• hot flushes, sweats, headache, irritability, loss of libido,
vaginal dryness, lethargy, reduced bone density.
80. If the cause of the bleeding is lack of
ovulation (anovulation),
•you may prescribe either progesterone to be
taken at regular intervals, or an oral
contraceptive, which contains progesterone, to
achieve a proper hormonal balance. Such
treatment dramatically decreases the risk of
uterine cancer in women who do not ovulate.
81. If the cause of irregular vaginal bleeding is a
precancerous change in the lining of the uterus
progesterone medications may be
prescribed to reduce the buildup of
precancerous uterine lining tissues in
an attempt to avoid surgery.
82. When a woman has been without menses for less than
six months and is bleeding irregularly, the cause may be
menopausal transition.
• During this transition, a woman is sometimes offered an oral
contraceptive to establish a more regular bleeding pattern,
to provide contraception until she completes menopause,
and to relieve hot flashes.
• A woman who is found to be menopausal as the cause of her
irregular bleeding may also receive menopause counseling if
she has troubling symptoms.
83. If the cause of irregular vaginal bleeding is polyps
or other benign growths
these are sometimes removed surgically to
control bleeding because they cannot be
treated with medication.
84. If the cause of bleeding is infection
•antibiotics are necessary depending on the
infection accuired
•Eg.
doxycycline 200mg on first day then 100mg daily
for 5/7
Metronidazole 400mg tds 5/7
Amoxillin 500mg tds 5/7
86. Indications for surgical treatment
•1. Failure of medical treatment
•2. Family is completed
•3. Uterine cavity <10 cm
•4. Submucos fibroid <5 cm
•5. Endometrium is normal or low risk
hyperplasia.
87. Complications of hysteroscopic methods
1. Uterine perforation
2. Bleeding
3. Infection.
4. Fluid overload
5. Gas embolism
89. Advantages:
1. Complete cure
2. Avoidance of long term medical treatment
3. Removal of any missed pathology
Disadvantages:
1.Major operation
2.Hospital admission
3.Mortality & morbidity
