Abnormal uterine bleeding

Ob/Gyn .
 Lecture Plan

1. Part 1 (10 min)

2. Part 2 (20 min)

3. Part 3 (10 min)

4. Lecture Quiz (5 min)

Ob/Gyn .
 Definitions :

A. Cyclic bleeding B. Acyclic bleeding

• Menorrhagia: excessive amount / duration at time of • Metrorrhagia (irregular bleeding unrelated to

menses (Now known as heavy menstrual bleeding menstrual cycles)
HMB) • Menometrorrhagia
• Polymenorrhea: too frequent menstruation d.t. too • Intermenstrual bleeding e.g. contact bleeding, mid
short cycles -cyclic spotting
• Polymenorrhagia combination of the above
 Classification
A. Organic causes
I. General causes

1. Von Willebrand disease (VWD) 1. Hypertension,

2. ITP 2. Congestive
3. Platelet dysfunction heart failure
4. Acute leukemia 3. Advanced
5. Liver disorder (also affect nephropathy
steroid metabolism & SHBG)

1. Thyroid disorders, 1. Antiplatelet, anticoagulants

2. Adrenal (Cushing) 2. Corticosteroids
3. DM (vasculopathy) 3. Phenytoin
4. Chemotherapy
 Classification
A. Organic causes
II. Local
causes

1. Early: abortion, ectopic, V.M. 1. Hormonal contraception

2. APH: placental, extraplacental 2. IUCD
3. PPH: atonic, traumatic, retained
placenta, DIC
 Classification
A. Organic causes
II. Local
causes

1. Congenital: 2. Inflammator 3. Neoplastic

y

• Cervix : benign (polyp) / malignant

uterus didelphys / (carcinoma or sarcoma)
PID/
bicornis • Uterus : benign (Fibroid) / malignant
endometritis /
menorrhagia (carcinoma or sarcoma)
cervicitis
• Ovary (neoplastic or non-neoplastic)
4. Trumatic: 5. Vascular: 6. Others:
• Sexual abuse • Genital displacements: prolapse,
• Foreign bodies RVF, chronic inversion of uterus
(including IUCD), • Vulva : condylomata, cysts, tumors
• Accidental traumas Endometriosis • Vagina: vaginitis, Gartner cysts,
• Straddle injuries & adenomyosis polyps, tumors
 Classification
A. Organic causes
III. Diseases outside the genital tract

1. Urinary tract infection, stones

2. Hemorrhoids
3. Inflammatory bowel disease
 Classification
B. Dysfunctional uterine bleeding (DUB)
 Definition: Abnormal uterine bleeding in absence of obvious organic cause
 Common at : • Post-menarcheal (immature HPO axis)
• Menopausal transition (reduced number of follicles)
 Due to:

Metrorrhagia (80% of DUB) Menorrhagia (20% of DUB)

• Abnormal axis control (mostly central) Imbalance between
• Predisposed to by genetic factors, •Vasodilators (PG E2 & Prostacyclin)
weight changes, stress •And vasoconstrictors (PG F2 & TXA2)
 Classification
B. Dysfunctional uterine bleeding (DUB)

 Types
 Classification
B. Dysfunctional uterine bleeding (DUB)

 Types

1. Functional Polymenorrhea & Polymenorrhagia: The cycles are very short

(due to short follicular phase)
2. Irregular ripening of endometrium = Corpus Luteum insufficiency (CLI) =
Luteal phase defect (LPD) : Poor formation of CL premature shedding of
endometrium premenstrual spotting
3. Irregular shedding of endometrium: Incomplete & slow degeneration of
endometrium postmenstrual spotting
4. Halban's disease (Persistent CL)
• A rare disorder with unknown etiology (may be due to PG imbalance within
the ovaries as PG is important for luteolysis)
• Of special interest as it leads to short period of amenorrhea followed by
rupture of the CL cyst with acute abdomen (thus resembling ectopic
pregnancy ~ differentiated by β-HCG ~

Treatment for all…………

* If bleeding is the problem Progesterone - COC
* If fertility is desired Induction of ovulation (clomid ± HCG)
 Classification
B. Dysfunctional uterine bleeding (DUB)

 Types

Metropathia Haemorrhagica
(Schroeder's Disease)
 Metropathia hemorrhagica
(Shröeder’s disease)


Pathogenesis:
The exact cause of this an-ovular type of bleeding is unknown.

The Graaf ia n follicle fails to ovulate, so it continues to grow

forming a small functional cyst which continue in secreting
estrogen which acts on the genital tract unopposed by
progesterone.
Hysteroscopy
 Treatment of Abnormal Uterine
Bleeding

• General and local causes: Are treated according to the

cause.

• Dysfunctional uterine bleeding:

• General treatment:
 Rest in bed,
 iron supplement or blood transfusion according to
amount of blood loss.
 Non hormonal treatment
• Antifibrinolytic agent as tranexamic acid (cyklokapron) tab. 1 gm 4
times/day, it decreases blood loss by 50% in most cases.
• Prostaglandin synthetase inhibitor to decrease the vasodilatation
action of PGE2 & to increase thromboxane to promote
vasoconstriction and platelet aggregation.
• Hemostatic agents as diosmin (Daflon) and ethamsylate (Dicynon) to
promote platelet aggregation and decrease capillary fragility.
Hormonal treatment
• Progesterone as norethisterone (Primolut-Nor), medroxyprogesterone
acetate (Provera), are used to combat high level; of estrogen in cases of
metropathia hemorrhagica, they are given either from the 5th day of the
cycle for 20 days or from 15th day of the cycle for 10 days as tab. 10-15
mg 2-3 tabs/day.

• Combined oral contraceptives, 2-4 tabs/day till bleeding stopped than 1

tab/day for 20 days, they act by leading to atrophic endometrium.
• Estrogen:

in cases of threshold bleeding as oral conjugated estrogen (Premarin) for 20 days to

be combined with progesterone in the last day to promote normal period.

Estrogen may be used in high doses by IM or IV injection to save the patient over a
critical period of life when bleeding is so severe specially in virgins then it is
combined with progesterone for normal withdrawal (medical curettage).
• Androgen: As Danazol or Methyl testosterone and Gestrinon may be
used specially in perimenopausal bleeding.

• GRH analogues: The lead to amenorrhea, they are given as nasal spray,
IM or subcutaneous injection every 3-4 weeks.
 Surgical treatment
• Curettage of uterine cavity:
Is a very important line of diagnosis and management.
50% of cases cured, 25% improve and 25% no effect.

• Levonorgesteryl intrauterine system ( Mirena ) can be used for 5

years
( contraceptive and decrease the blood loss )
( Uterine Artery Embolization (Uterine Fibroid
Embolization
Endometrial ablation

Using laser, electrocautery or thermal

destructive techniques. 50% of cases
develop amenorrhoea and 90% of cases
achieve a decrease in bleeding.

• Ablation of the endometrium carried the

risk of uterine perforation, occurrence of
cancer endometrium in an unreachable
area of endometrium
Resectoscope
• Hysterectomy:
Is indicated after failure of the previous all lines of treatment.
 Thank You

Ob/Gyn .