ABNORMAL UTERINE

BLEEDING
Abnormal uterine bleeding

 can take many forms:

 infrequent episodes
 excessive flow
 prolonged duration of menses
 intermenstrual bleeding
Infrequent uterine bleeding

 oligomenorrhea - intervals between bleeding

episodes vary from 35 days to 6 months

 amenorrhea - no menses for at least 6 months

Definition of terms
 DYSFUNCTIONAL UTERINE BLEEDING
 excessive uterine bleeding with no demonstrable
organic cause
 it is most frequently due to abnormality of
endocrine origin, particularly anovulation

 INTERMENSTRUAL BLEEDING
 bleeding of variable amounts occurring between
regular menstrual periods
MENORRHAGIA (hypermenorrhea)
prolonged (more than 7 days) or excessive (greater than
80ml) uterine bleeding occurring at regular intervals

METRORRHAGIA
uterine bleeding occurring at irregular but frequent
intervals, the amount being variable

MENOMETRORRHAGIA
prolonged uterine bleeding occurring at irregular
intervals
POLYMENORRHEA
uterine bleeding occurring at regular intervals of less
than 21 days

AMENORRHEA
no menses for at least 6 months
Definition of terms
Term Interval Duration Amount
Menorrhagia Regular Prolonged Excessive
Metrorrhagia Irregular  Prolonged Normal
Menometrorrhagia Irregular Prolonged Excessive
Hypermenorrhea Regular Normal Excessive
Hypomenorrhea Regular Normal or Less
loss
Oligomenorrhea Infrequent Variable Scanty
&/or
irregular
Polymenorrhea regular normal normal
 NORMAL

MENORRHAGIA

HYPOMENORRHEA

POLYMENORRHEA

OLIGOMENORRHEA

METRORRHAGIA

MENOMETRORRHAGIA
Normal Menstrual Flow
 mean interval between menses is 28 days (±7
days)
 mean duration of menstrual flow is 4 days
 Menstrual blood loss should not exceed 80 ml
 number of sanitary pads - unreliable
indication of MBL

Katz: Comprehensive Gynecology, 5th ed.

Thus queries about the passage of blood clots or the
degree of inconvenience caused by the bleeding are
more helpful than counting the number of pads used
in order to ascertain whether menorrhagia exists…

Katz: Comprehensive Gynecology, 5th ed.

Etiology
 Organic
 Systemic disease
 Reproductive tract disease
 Iatrogenic

 Dysfunctional (or endocrinologic)

 Ovulatory
 Nonovulatory
Organic Causes
Systemic Disease: Reproductive Iatrogenic Causes:
Blood coagulation: Disorders: Drugs/Medications:
 Von Willebrand’s • Pregnancy
• Steroids
disease Complications
• Endometritis • tranquilizers
 prothrombin
deficiency • Anatomic uterine • psychotropic drugs
Platelet deficiency: abnormalities
• Malignancy
 Leukemia
• Cervical Lesions
 severe sepsis • Trauma
 ITP
 Hypothyroidism
 Cirrhosis

Katz: Comprehensive Gynecology, 5th ed.

SYSTEMIC DISEASES
Blood Coagulation Disorders
• initially present as abnormal uterine bleeding
• present in about one fourth of those whose
hemoglobin levels fall below 10 g/100 mL
• Routine screening for coagulation defects is
mainly indicated in the adolescent who has
prolonged heavy menses beginning at menarche
• In the adult, abnormal bleeding may be
encountered frequently in women receiving
anticoagulation for a variety of medical disorders
• If hypoprothrombinemia is present, the incidence of
abnormal bleeding will be increased
Hypothyroidism
 incidence has been estimated to range
between 0.3% and 2.5%
 TSH should be measured in women with
menorrhagia of undetermined origin
 frequently associated with menorrhagia as
well as intermenstrual bleeding
Cirrhosis

 associated with excessive bleeding secondary

to the reduced capacity of the liver to
metabolize estrogens
REPRODUCTIVE TRACT
DISEASE
Pregnancy Complications

 Threatened abortion
 incomplete abortion
 missed abortion
 ectopic pregnancy.
 trophoblastic disease
Infections and Malignancies
 Endometritis
 Endometriosis

 endometrial and cervical cancer

 vaginal, vulvar, and fallopian tube cancer
 estrogen-producing ovarian tumors
 granulosa-theca cell tumors
Uterine Abnormalities
 submucous myomas
 endometrial polyps
 adenomyosis

 Foreign bodies in the uterus, such as the IUD,

frequently produce abnormal uterine bleeding.
Cervical and vaginal lesions
 erosions, polyps, and cervicitis
 postcoital spotting
 These lesions can usually be diagnosed by
visualization of the cervix.

 traumatic vaginal lesions

 severe vaginal infections
 foreign bodies
IATROGENIC CAUSES
 Oral and injectable steroids
 such as those used for contraception and hormonal
replacement or for the management of dysmenorrhea,
hirsutism, acne, or endometriosis.

 Tranquilizers and other psychotropic drugs

 may interfere with the neurotransmitters responsible
for releasing and inhibiting hypothalamic hormones,
thus causing anovulation and abnormal bleeding.
Dysfunctional Causes
 The incidence of this disorder has been
reported to occur in as many as 10% of
ovulatory women.
 postmenarcheal and premenopausal years -
anovulation secondary to alterations in
neuroendocrinologic function
 adolescent years and before perimenopausal -
Ovulatory DUB
Halban's syndrome
 prolonged life of the corpus luteum
 associated with a normal-appearing secretory
endometrium
 A sensitive serum HCG assay should be
performed to differentiate this disorder from
early pregnancy loss.
Irregular shedding of the endometrium
 Has also been reported to produce
menorrhagia
 The diagnosis of this disorder is made if an
endometrial biopsy obtained during the
fourth day of the flow reveals both
proliferative and secretory endometrium.
No recent studies have documented the presence of
these two conditions. Thus the prevalence of these
disorders, if they actually exist, is uncertain…

Katz: Comprehensive Gynecology, 5th ed.

NORMAL HAEMOSTATIC
MECHANISM
General Mechanisms of Hemostasis
(1) localized vasoconstriction
(2) platelet adhesion
(3) formation of a platelet plug
(4) reinforcement of the platelet plug with
fibrin
(5) removal of the coagulated material by
fibrinolytic mechanisms
 The process of hemostasis in the endometrial
vessels differs somewhat from the response to vessel
damage elsewhere in the body.
2 Main Mechanisms for Hemostasis
During Menstruation:
1. hemostatic plug formation
 most important mechanism in the functional
endometrium
2. vasoconstriction
 more important in the basalis layer

 Since vascular occlusion by both mechanisms is never

total, blood leakage continues for several days until
endometrial regeneration is completed…
In women with Regular Ovulatory Cycles
with normal MBL…
 increase in the amount of both PGF2α and PGE2 found
in the endometrium in the late secretory phase and
during menses
 with the endometrial PGF2α/PGE2 ratio steadily
increasing from midcycle to menses.

PGF2α/PGE2
 progesterone was necessary to increase levels
of arachidonic acid, the pre-cursor of PGF2α

 estradiol stimulates synthesis of

prostaglandins from arachidonic acid by cyclic
endoperoxides
In women with Anovulatory Cycles…
 continuous estradiol production
 no corpus luteum formation, no progesterone
production
 the levels of PGF2α are reduced and the levels
of PGE2 are normal, resulting in a decreased
PGF2α/PGE2 ratio.
In women with dysmenorrhea…
 PGE2 also stimulates contraction of the
smooth muscle cells in the myometrium, and
elevated levels of PGF2α are found in the
menstrual blood of women with
dysmenorrhea.
 Anovulatory cycles are usually not associated
with dysmenorrhea, probably because of the
reduced levels of PGF2α.
According to studies… Katz: Comprehensive
Gynecology, 5th ed.

 There is no difference in the concentrations of

fibrinogen–fibrin degradation products in menstrual
blood samples obtained from normal women and
those with menorrhagia.
 Menorrhagia in the absence of pathologic findings
does not result from an excessive number of arteries
or abnormal distribution of the endometrial glands.
 increased MBL in women with ovulatory DUB is also
associated with reduced uterine synthesis of PGF2α
and an increase in synthesis of PGE2 and prostacyclin.
According to studies… Katz: Comprehensive
Gynecology, 5th ed.

 there was an inverse correlation between the

endometrial PGF2α/PGE ratio and the amount of MBL
 there was a direct correlation between the
concentration of myometrial PGE receptor
concentration and MBL
 menorrhagia could be due in part to a relative
deficiency of thromboxane in the endometrium
 there is an increased availability of arachidonic acid
in the endometrium of women with ovulatory
menorrhagia, in contrast to the decreased amount of
this substance in the endometrium of women with
anovulatory DUB.
Thus alterations in prostaglandin synthesis and
release appear to occur in women with both
anovulatory and ovulatory DUB. Why these
changes occur and their exact causal relation with
menorrhagia have not yet been determined…

Katz: Comprehensive Gynecology, 5th ed.

Diagnosis
 Thorough history:
 Frequency
 Duration
 Pattern
 Amount of bleeding
 Indirect assestment of MBL:
 Serum hemoglobin, iron and ferritin
Diagnosis
 Coagulation profile
 hCG determination
 TSH assay
 Document ovulation
 Hysteroscopy, hysterosalpingography, vaginal
sonography
 Endocervical curettage or D&C
 Sonohysterography
Hysteroscopy should be utilized in all women who
have ovulatory menorrhagia to determine if
endometrial pathology exists…

Katz: Comprehensive Gynecology, 5th ed.

Management

 Medical
 Surgical
Medical Treatment
 Estrogen
 Progestin
 Clomiphene citrate
 NSAIDs
 Antifibrinolytic agents
 Danazol
 GnRH agonists
 Ergots
Surgical Treatment
 Dilatation and Curettage
 Endometrial ablation
 Hysterectomy
Thank You!!!