Menorrhagia: Prolonged (>7 days) and/or heavy (>80 ml) uterine bleeding occurring at regular intervals. Polymenorrhea: An abnormally short interval (<21>35 days) between menses. Metrorrhagia: variable amounts of inter-menstrual bleeding occurring at irregular but frequent intervals.

1. Abnormal Vaginal Bleeding

2. NORMAL MENSTRUATION
 Rhythm: regular from 21-35 days
 Duration: 3-7 days
 Amount: between 30-50 ml
 Flow: non clotted fluid blood

3. DEFINITIONS
 Menorrhagia: Prolonged (>7 days) and/or heavy
(>80 ml) uterine bleeding occurring at regular
intervals.
 Polymenorrhea: An abnormally short interval (<21
days) between menses.
 Oligomenorrhea: An abnormally long interval (>35
days) between menses.
 Metrorrhagia: variable amounts of inter-menstrual
bleeding occurring at irregular but frequent intervals.

4. CAUSES
 Dysfunctional Uterine Bleeding
(endocrinologic causes)
 Organic causes
 Medical
 Clotting defect

5. DYSFUNCTIONAL UTERINE BLEEDING
Definition: uterine bleeding in the
absence of an organic disease
Incidence: 10-20% usually at extremes of
reproductive life.

6. CAUSES OF DUB
 The diagnosis of DUB can be made after
organic, systemic, iatrogenic causes have
been ruled out (diagnosis of exclusion).
1. Anovulatory DUB
2. Ovulatory DUB

7. ANOVULATORY DUB
The predominant type in reproductive age due
to alterations in neuroendocrinologic
function.
Characterized by continuous production of
estradiol-17b without corpus luteum
formation and progesterone release.
estrogens leads to continuous proliferation of
the endometrium, which eventually leads to
irregular, unpredictable bleeding.

8. 2. OVULATORY DUB
 INCIDENCE: UP TO 10% OF OVULATORY
WOMEN
 Polymenorhea is due to shortening of follicular
phase. Or luteal phase can be prolonged by a
persistent corpus luteum.

9. DIAGNOSIS (BY EXCLUSION)
 History
 General examination
 Abdominal-pelvic examination
 Investigations (mainly to
exclude organic causes)

10. ORGANIC CAUSES
 REPRODUCTIVE TRACT DESEASE
 Pregnancy related conditions
 Uterine lesions: endometrial hyperplasia, fibroid.
 Cervical lesion: (postcoital bleeding) – erosion, direct trauma.
 Iatrogenic causes
 include the intrauterine device (IUD), oral/injectable steroids for
contraception or hormone replacement and tranquilizers or other
psychotropic drugs.
 Oral contraceptives are often associated with irregular bleeding
during the first 3 months of use, if doses are missed or the patient
is a smoker. Long-acting progesterone - only contraceptives
(Depo-Provera) frequently cause irregular bleeding.

11. SYSTEMIC DISEASE
 Blood disorders such as von Willebrand disease and
prothrombin deficiency may present with profuse
vaginal bleeding during adolescence. Other disorders
that produce platelet deficiency (leukemia, severe
sepsis) may also present as irregular bleeding.
 Hypothyroidism is frequently associated with
menorrhagia and/or metrorrhagia.
 Cirrhosis is associated with excessive bleeding
secondary to the reduced capacity of the liver to
metabolize estrogens.

12. DIAGNOSIS
 Patient age is the most important factor in the evaluation.
 Ruling out pregnancy-related complications in all
women of reproductive age.
 A complete list of medications is essential to rule out
their interference with normal menstruation.
 Non-gynecologic physical findings (thyromegaly,
hepatomegaly) may suggest the presence of systemic
disorder. Genitourinary (urinary infection) or
gastrointestinal (hemorrhoids) bleeding may also be
mistakenly interpreted by the patient as vaginal bleeding.
 Pelvic examination may reveal an obvious structural
abnormality (cervical polyp), but frequently additional
evaluation is necessary.

13. DIAGNOSIS
 Measurement of serum hemoglobin concentration,
iron levels, and ferritin levels is an objective measure
of the quantity and duration of menstrual blood loss.
 Additional laboratory tests (TSH, coagulation profile)
may be indicated.
 To determine whether bleeding is anovulatory or
ovulatory high progesterone levels during the luteal
phase suggests that ovulation has occurred.
 Liver function tests if a liver disorder is suspected
 endometrial biopsy or hysteroscopy.
 A cervical cancer screening test (eg, Papanicolaou
[Pap] test, HPV test) if results are out-of-date
 Testing for Neisseria gonorrhea and Chlamydia sp if
pelvic inflammatory disease or cervicitis is suspected

14. TRANSVAGINAL ULTRASONOGRAPHY
 Can detect structural abnormalities, including
 polyps,
 fibroids,
 endometrial cancer, and
 areas of focal thickening in the endometrium.

15. MEDICAL TREATMENT
Non-steroidal anti-inflammatory drugs: inhibit cyclo-
oxygenase enzyme and the production of
prostaglandins (reduces menstrual blood flow).
 Oral contraceptive pills: One of the most effective
treatments available for both menorrhagia and
dysmenorrhoea.
 Antifibrinolytic agents: Prevent conversion of
plasminogen into plasmin which dissolve the fibrin clots
occluding the blood vessels.
 Progestogens: Norethisterone – medroxy-progesterone
acitate.

16. PROGESTERONE RELEASING DEVICES
Produce marked reduction in menstrual
blood loss up to 80%
 Mechanism of action: mainly locally
leading to atrophic changes in endometrium
with very minimal systemic effect.

17. SURGICAL TREATMENT
 Structural abnormalities frequently require surgery to alleviate
symptoms.
 D&C can be both diagnostic and therapeutic, especially for vaginal
bleeding due to endometrial hyperplasia.
 Hysteroscopy is a surgery procedure that can be used to diagnose and
treat abnormal uterine lesions. The uterine cavity is distended with
fluid, allowed direct visualization of the abnormality and use the
hysteroscopic instruments.
 Endometrial ablation (to remove or destroy the endometrium) reduces
the amount of cyclic blood loss.
 Hysterectomy is performed for women with structural lesions not
amenable to conservative surgery (multiple large leiomiomas). It also
may be indicated in women with persistent DUB, but only if medical
therapy has filed.

18. Thank you,
for your attention!