1. Abnormal uterine bleeding

2. It is an descriptive term applied to any alteration in the normal pattern of menstrual flow and it is the uterine bleeding that is abnormal in amount, duration or timing. The abnormalities of menstruation are only symptoms and do not describe pathological entities.

3. definitions menorrhagia
The average menstrual period lasts for 3-7 days, with a mean blood loss of 35 mL. Menorrhagia ('heavy periods') is defined as a heavy,prolonged regular blood loss of greater than 80 mL per period. This definition is rather arbitrary, but represents the level of blood loss at which a fall in haemoglobin and haematocrit concentration commonly occurs

4. Polymenorrhoea
: is a frequent menstruation as menses occurring at < 21 days interval associated with a shortened follicular phase or inadequate luteal phase Metrorrhagia -irregular intervals with excessive flow and duration

5. Intermenstrual bleeding –
Uterine bleeding of variable amounts occurring between regular menstrual periods.
*Midcycle spotting :
is scanty intermenstrual discharge occurring just before ovulation that is associated with a decrease in estrogen at midcycle.

6. *Postcoital bleeding: is non-menstrual bleeding that occurs immediately after sexual intercourse. *With drawl bleeding: bleeding occurred after stopping oestrogen and progestrone use or progestrone use. *Postmenopausal bleeding - Recurrence of bleeding in a menopausal woman at least 6 months to 1 year after cessation of cycles.

7. Prevalence Menorrhagia is extremely common
Prevalence Menorrhagia is extremely common. Indeed, each year, 5 per cent of women between the ages of 30 and 49 consult their general practitioner with this complaint. Menorrhagia is the single leading cause of referral to hospital gynaecology clinics.

8. Classification Menorrhagia can be classified as: • idiopathic, where no organic pathology can be found: idiopathic menorrhagia is otherwise known as dysfunctional uterine bleeding-(DUB). The majority of women who present with menorrhagia will have DUB, • secondary to an organic cause, such as fibroids.

9. Aetiology A. Organic causes: 1. Local disorders: Uterine fibroids.
Endometrial/ Endocervical polyp.
Adenomyosis.
Pelvic endometriosis.
Intrauterine device (IUD).

10. Cervicitis
pco
Pelvic inflammatory disease (PID).
Oestrogen-secreting ovarian tumour.(granulosa or theca cell tumour).
Cervical carcinoma.
Uterine body carcinoma.
Trauma of lower genital tract
Urethral caruncle.

11. 2. Systemic disorders:
Menorrhagia is a feature of a number of organic conditions, which should be considered in the differential diagnosis. These include

12. 1.Endocrine disorders may interfere with normal feedback mechanisms that regulate secretion of gonadotrophin- releasing hormone (GnRH), gonadotrophin, sex steroid. A. Thyroid disorder (Hypothyroidism or hyperthyroidism). B. Diabetes mellitus. E. Prolactin disorders

13. 3. Haemostasis disorder:
A. Von Willebrand's disease.
B. Idiopathic Thrombocytopenic purpura (ITP).

14. 4. Liver disorder 5. Renal disease 6
4. Liver disorder 5. Renal disease 6. Medications as steroid hormones, anticoagulants and cytotoxic agents, contraceptive method

16. 7.Psychological and emotional cause, Excessive exercise, stress, and weight changes. All these can cause hypothalamic suppression leading to abnormal uterine bleeding due to disruption along the hypothalamus-pituitary-ovarian pathway 8. Pregnancy Should be considered in women of reproductive life in any patient presenting with abnormal uterine bleeding

17. B. Non –organic cause (Dysfunctional uterine bleeding (DUB) no specific organic cause can be found

18. is defined as abnormal uterine bleeding in the absence of organic disease. It is the most common cause of abnormal vaginal bleeding during a woman's reproductive years. bleeding is most common at the extreme ages of a woman's reproductive years, either at the beginning or near the end, but it may occur at any time during her reproductive life. It is a diagnosis of exclusion

19. Aetiology Despite extensive research, the aetiology of DUB remains unclear. Disordered endometrial prostaglandin production has been implicated in the aetiology of this condition, as have abnormalities of endometrial vascular development

20. There are clearer reasons why many more women complain of menorrhagia now than they did a century ago. With decreasing family size, women now experience many more menstrual cycles. Additionally, the changing role of women in society and more liberated attitudes to the discussion of reproductive health mean that women are now much less likely to tolerate menstrual loss that they consider to be excessive

21. clinical assessment
History:
*Age, parity, marital status (single, married, widow, divorced).
*Description of the pattern of abnormal menstrual bleeding and it's severity and it's duration and amount of blood loss.
*Presence of other cyclical symptoms as dysmenorrhoea, breast tenderness, psychological disturbance, fatigue, dizziness, and syncope.

22. perhaps greater relevance is to determine the impact of the condition on the patient's lifestyle and quality oflife For example, the patient whose menorrhagia is so severe that she does not leave the house during her period clearly has a much greater problem (and may wish to pursue treatment further) than one to whom menorrhagia is a minor inconvenience.

23. Ask about : Recent illness, psychological stress, excessive exercise, or weight change *Past medical history: Diabetes mellitus, Thyroid disease, Endocrine problems, pituitary tumors, Liver disease. *Past surgical history. *Drug history: Medication usage, including exogenous hormones, anticoagulants, aspirin, anticonvulsants, and antibiotics

24. It is also important to determine the duration of the current problem, and any other symptoms or factors of potential importance. The following symptoms should be enquired about specifically, as they may suggest a diagnosis other than DUB: *irregular,intermenstrual or postcoital bleeding, *a sudden change in symptoms, * pelvic pain or premenstrual pain, * and excessive bleeding from other sites or in other situations (e.g. after tooth extraction).

25. Clinical examination height and weight and body mass index (BMI).
Look for:
height and weight and body mass index (BMI).
signs of anemia or hypovolemia, vital signs.
General looking for stigmata of underlying systemic disease is important. hirsutism, striae, thyroid enlargement or nodularity, skin pigment changes.
Assessment for secondary sexual characteristic.
ecchymoses or petechiae (suggest coagulopathy).

26. it is important to perform a physical examination,
including an abdominal and bimanual pelvic examination,
in all women complaining of menorrhagia.
A cervical smear should be performed if one
is due.

27. investigations
Initial investi gations Full blood count A full blood count (FBC) is done to ascertain the need for iron therapy.

28. B-hCG if any possibility of pregnancy exists.
In patients with suspected endocrine disorders, laboratory studies such as thyroid function tests and prolactin levels may be helpful
A mid-luteal progestrone level in regular cycle only (done in day 21 in 28 day cycle). level >30nmol/L is indicative of ovulation.
Serum androgen in some cases as it is elevated in poly cystic ovary syndrome (PCO), androgen producing tumour, adrenal condition.
Prolactin.

29. Coagulation screen and bleeding time is important to request if bleeding disorder is suspected.
Renal function tests and liver function tests should be requested if systemic condition or malignancy is suspected

30. Pelvic ultrasound.
It is useful to determine shape and size of uterus and adnexal structures.
It may determine the etiology of the bleeding such as a fibroid, endometrial thickening, poly cystic ovary, adenomyosis

31. Endometrial sampling
Endometrial biopsy is important step in evaluation abnormal uterine bleeding. It is indicated for the following patients with abnormal uterine bleeding :
1.Women older than 35 years.
2.Those with abnormal endometrial thickness (>12mm in perimenopausal women and >4mm in postmenopausal women).
3.Obese patients.
4.Women who have prolonged periods of unopposed estrogen stimulation
5. Women with chronic anovulation.

32. Endometrial biopsy can be done by
1. Hysteroscopically directed biobsy:
is the gold slandered procedure as it provides direct visualization of uterine cavity and allows to take biopsy from specific lesion. It is ideally done in proliferative phase of menstrual cycle when the endometrium is at it's thinnest.
2. Aspiration technique.
3.Curettage.

33. Treatments There is a host of different treatments for menorrhagia,
all of which have different efficacies and side
effects.

34. Each treatment option is associated with a different array of side effects, which may be acceptable to some women but not others. For these reasons, and since menorrhagia is rarely life threatening but has an adverse impact on the woman's quality of life, it is essential that the treatment plan is determined in collaboration with the patient.

35. In treatment of abnormal uterine bleeding, Consider:
1.Age group.
2.Amount and pattern of bleeding.

36. Medical treatment * Non hormonal therapy:
Non steroidal anti-inflammatory drugs
These medications may reduce blood loss by 20-50%. It is used only during menstruation as it is used with the onset of menses or just prior to its onset and continued throughout its duration. It is generally well tolerated

37. Their mode of action is probably in
restoring imbalanced endometrial prostaglandin synthesis.
An added benefit of these drugs is their painrelieving
properties; thus they are useful alone or in
combination for women who complain of both menorrhagia
and dysmenorrhoea

38. Antifibrinolytic therapy
Tranexamic acid This agent is associated with a mean reduction in MBL of about mL. Its mode of action is by inhibiting fibrinolysis (clot breakdown) in the endometrium. In view of this, theoretical concerns have been raised that tranexamic acid may be associated with an increased risk of venous thrombosis. This theoretical risk is not borne out by the studiesثhat have investigated it to date

39. HORMONAL THERAPY
First-line drugs: *Cyclical Combined oral contraceptive pills ((OCPs

40. Are effective in reducing menstrual bleeding, controlling cycle irregularities and relieving menstrual pain giving for women requiring contraception or for women whom hormonal agents are acceptable. It helps to prevent the risks associated with prolonged unopposed estrogen stimulation of the endometrium

41. Progestogen therapy 1-cyclic progestins
# Treatment with cyclic progestins is preferred when COCP use is contraindicated, such as in smokers over age 35 and women at risk for thromboembolism.
cyclical progestogens are effective for menorrhagia when given for 21days out of 28 and first choice for control of anovulatory dysfunctional bleeding.
withdrawal bleeding occured 3-5 days after completion of the course.

42. #Arrest bleeding. Norethisterone acetate (primolut-N ) mg daily until bleeding stops usually in hours and for not more than 3days and may continued in lower dose for up to 21 days . Once she stopped , withdrawal bleeding will occur in a few days later

43. Luteal phase treatment
#Luteal phase treatment in second half of cycle (from 15th to 26th day) indicated when corpus luteum insuffiency has been diagnosed particularly in premenstrual spotting. Treatment continued for 6-9 months.
Norethisterone acetate (primolut-N ) 5mg tid (three times a day) Or
Medroxy progestrone acetate (Provera) 10 mg tid

44. 2-Whole cycle treatment:
A-Whole cycle treatment: Throughout menstrual cycle (5th to 26th day)
Effective treatment for menorrhagia when given at high doses between days 5 and 26 of cycle. As luteal phase treatment is not so effective in treating menorrhagia. Treatment can be continued for 6-9 months.
Norethisterone acetate (primolut-N ) 5mg tid for 21days out of 28
Or Medroxy progestrone acetate (Provera) 10 mg tid
Side effects include weight gain, headache and bloatedness.

45. B-Long acting high dose progestogens (e. g
B-Long acting high dose progestogens (e.g. #Depo-Provera) may be used to induce amenorrhoea but limited by side effects. #Progestogen-releasing intrauterine system: Levonorgestrel-releasing intrauterine system (LNG-IUS) used to relief Menorrhagia as it induce progressive endometrial atrophy

46. Mean reductions in MBL of around 95 per cent by 1 year after LNG-IUS insertion have been demonstrated. These results are similar to those for the surgical procedure endometrial resection, and the patient satisfaction rates for the two treatments were found to be similar in one stud

47. Estrogen therapy
Alone used rarely in DUB treatment. Used in atrophic endometrium and in cases of DUB secondary to depot progestogen.

48. Second line hormonal therapy

49. Gonadotropin-releasing hormone agonists(GnRH analogue)
They produce a profound hypoestrogenic state similar to menopause (They induce medical menopause by suppressing gonadotrophions). Side effects include menopausal symptoms and bone loss with long-term use so it should not prescribed for longer than 6 months because the risk of osteoporosis

50. danazole
l Treatment with danazol for 2-3 months is associated with a mean reduction in MBL in the order of 100 mL. However, danazol is associated with androgenic side effects such as weight gain, acne, hirsutism and voice changes

51. Although the majority of these (with the exception of voice changes) are reversible on cessation of treatment, the fact that they can occur is enough to prevent most women with menorrhagia from opting for danazol treatment

52. gestrinone
Gestrinone is a 19-testosterone derivative which has anti-progestogenic, anti-oestrogenic and androgenic activity.it reduce menstrual blood loss in menorrhagia. However, it also has androgenic side effects

53. Surgical treatment
Surgical treatment is normally restricted to women for whom medical treatments have failed. Women contemplating surgical treatment for menorrhagia should be certain that their family is complete. Whilst this caveat is obvious for women contemplating hysterectomy, in which the uterus will be removed, it also applies to women contemplating endometrial ablation. Women wishing to preserve their fertility for future attempts at childbearing should therefore be advised to have the LNG-IUS rather than endometrial ablation or hysterectomy

54. Surgical method:
Dilatation and curettage (D&C)
Endometrial resection and ablation.
Hysterectomy

55. Dilatation and curettage (D&C):
A D&C may be done for a woman with heavy bleeding used in acute situation (for diagnostic and therapeutic purpose).

56. Endometrial ablation
All endometrial destructive procedures employ the principle that ablation of the endometrial lining of the uterus to sufficient depth prevents regeneration of the endometrium. During normal menstruation, the upper functional layer of the endometrium is shed, whilst the basal 3 mm of the endometrium is retained

57. At the end of menstruation and the beginning of the next cycle, the upper functional layer of the endometrium regenerates from the basal endometrium. In endometrial ablation, the basal endometrium is destroyed, and thus there is little or no remaining endometrium from which functional endometrium can regenerate.

58. There is a variety of methods by which endometrial ablation can be achieved, including the following. Methods performed under direct visualization at hysteroscopy: • Laser • Diathermy • Transcervical endometrial resection

59. Methods performed non-hysteroscopically (i. e
Methods performed non-hysteroscopically (i.e. without direct visualization of the endometrial cavity at the time of the procedure) • Thermal uterine balloon therapy • Microwave ablation • Heated saline

60. All the above operations are performed through the uterine cervix
All the above operations are performed through the uterine cervix. Most take around minutes to perform, and in the majority of cases the patient can return home that evening. The mean reduction in MBL associated with endometrial ablation is around 90 per cent

61. In many units, endometrial ablation is performed using a single method and, in practice, patients may not be able to choose a particular technique for this procedure. This may not be important, as comparative studies have shown that the complication rates

62. The complications associated with endometrial ablation include uterine perfo ration, haemorrhage and fluid overload. Around 4 per cent of women have some sort of immediate complication. In 1 per cent of women, the complications arising during the procedure are sufficiently serious to prompt either laparotomy or another unplanned surgical p rocedure

63. Hysterectomy
Hysterectomy involves the removal of the uterus. It is an extremely common surgical procedure, 20 per cent of women will have a hysterectomy at some point in their lives. Hysterectomy can be 'total', in which the uterine cervix is also removed, or 'subtotal', in which the cervix is retained. Hysterectomy is often accompanied by bilateral oophorectomy (removal of both ovaries).

64. The precise choice of operation should be determined after detailed discussion between the doctor and patient. In terms of the treatment of menorrhagia, it is removal of the uterus that effects a cure, and '-thus removal of the cervix and/ or ovaries is an 'optional extra'.

65. The main perceived advantage of oophorectomy is a reduced risk of ovarian cancer. Additionally, women with pelvic pain and/or severe premenstrual syndrome in addition to their menorrhagia may find that hysterectomy and bilateral salpingo-oophorectomy is more effective at treating their symptoms than hysterectomy alone.

66. These advantages have to be set against the adverse effects of oestrogen loss on bonedensity for women who do not take hormone replacement therapy (HRT) after oophorectomy

67. Mode of hysterectomy Total hysterectomy may be achieved using three main techniques: • abdominal hysterectomy • vaginal hysterectomy • laparoscopically assisted hysterectomy