This document discusses abnormal uterine bleeding and the menstrual cycle. It defines normal menstrual patterns and abnormalities. It covers causes and management of amenorrhea and dysmenorrhea. It also discusses endometriosis and abnormal uterine bleeding, covering heavy menstrual bleeding, intermenstrual bleeding, and post-coital bleeding as well as their management.

1. Abnormal Uterine
Bleeding and the
Menstrual Cycle
Susana Martinez

2. What is ‘normal’?
O A ‘normal’ menstrual pattern is associated
with a monthly bleed (every 21-35 days)
with duration of seven days or less.
O A blood loss of 80mls or less, is regarded
as being in the normal range

3. Menstrual cycle ~ overview
O A regular menstrual patterns depends on
the presence of a functioning reproductive
hormone feedback system which includes
the hypothalamus, anterior pituitary gland
and ovaries, as well as normal uterine and
vaginal anatomy.

4. Menstrual abnormalities
O Menstrual abnormalities include irregular
or absent periods, heavy or prolonged
menstrual loss (for 3 cycles or more),
inter-menstrual and post-coital bleeding,
dysmenorrhoea and pre-menstrual
disorders.

5. Amenorrhoea
O Primary amenorrhoea
O The absence of onset of menstruation – is
regarded as abnormal by the age of 14
years in girls with no other secondary
sexual development, and 16 in girls with
normal secondary sexual development.

6. Causes of primary
amenorrhoea
O Anatomical abnormalities (imperforate hymen,
congenital absence of uterus or vagina)
O Chromosonal anomalies causing failure to
initiate puberty
O Hypogonadotrophic hypogonadism (failure to
switch on puberty)
O PCOS
O Chronic illness or low body mass (or
excessive exercise)

7. Secondary amenorrhoea
O The cessation of menstruation for a period
of six months, after regular cycles have
been established.

8. Causes of secondary
amenorrhoea
O Hyphothalamic-pituitary reasons includes:
O Weight loss (BMI <19 unlikely to have
regular menstrual cycle)
O Excessive exercise
O Obesity
O Secondary to medication: hormonal
contraception, antipsychotics, opiates,
chemotherapy

9. Causes of secondary
amenorrhoea
O Ovarian, uterine or vaginal
O Polycystic Ovarian Syndrome (PCOS)
O Premature ovarian failure
O Other causes
O Thyroid hormone deficiency or excess
O Severe generalised disease

10. Investigations
O Investigate after 6 months of secondary
amenorrhoea which is not secondary to
contraceptive use such as an implant,
Depo injection or Mirena.
O Pregnancy test
O FSH, LH, Prolactin and TSH, oestrodial
O Testosterone levels
O Consider pelvic/transvaginal ultrasound
O Consider bone density scan

11. Management of amenorrhoea
O Primary amenorrhoea
O Refer to a specialist for further
investigation
O Secondary amenorrhoea
O Referral to specialist (gynaecologist or
endocrinologist) where diagnosis or
management is not clear after initial
investigation, and if patient is concerned
about fertility.

12. Dysmenorrhoea
O Dysmenorrhoea is a cyclical lower
abdominal or pelvic pain occuring either
before or during menstruation, or both.
O Prevalence is difficult to estimate, but it is
thought that dysmenorrhoea affects up to
70% of women at some time during
reproductive age.

13. Endometriosis
O Endometriosis is defined as the presence
of endometrial-like tissue outside the
uterus, which induces a chronic,
inflammatory reaction.
O Condition found in women of reproductive
age, from all ethnic and social groups
O Estimated prevalence is up to 10%.
O Endometriosis often begins in
adolescence

14. Adbormal Uterine Bleeding
(AUB)
O Abnormal uterine bleeding includes:
O Heavy menstrual bleeding (HMB –
previously called menorrhagia)
O Intermenstrual bleeding (IMB) and post-
coital bleeding (PCB)

15. Management of HMB
O IUS (Mirena)
O Combined COC (Qlaira)
O Tranexamic acid
O Nonsteroidal anti-inflammatory drugs
(NSAIDs)
O Progestogens (norethisterone (15mg)
daily from days 5-26 of menstrual cycle or
long acting injectable progestogens
(DMPA -Depo)