1. DR MANAL IDRIS menorrhagia

2. Introduction Menorrhagia is one of the commenest gynaecological complaints seen in practice and accounts for approximately 12% of all referrals to gynaecology clinic. Among women aged 16-35 yr it has an incidence of around 30%.

3. Definetion The average menses lasts for 3-7 days with interval 21-35 days and mean blood loss of 35 ml. Menorrhagia is generally defined as prolonged and increased menstrual flow of greater than 80 ml.

4. Aetiology - Non organic causes : dysfunctional uterine bleeding (DUB). - Organic causes. - Systemic disorders.

5. DUB Non –organic causes anovulatory :occure in women at the extremes of reproductive age,menorrhagia with irregular interval. Ovulatory:(90%) common in women aged 35-45yr and it is regular period. It may be due to inadequate production progesterone in luteal phase or due to imbalance between PGs on the myometrial and endometrial vasculature.

6. Organic causes - fibroids - adenomyosis - endocervical \endometrial polyps - endometrial hyperplasia - IUCD - pelvic inflammatory disease(PID) - malignancy of CX or uterus - hormone producing tumours:eg,granulosa cell of the ovary.

7. Systemic disorders - endocrine disease :DM,hyper or hypothyroidism,adrenal disease. - disorders of haemostasis:eg,von willebrands disease,ITP. - liver disease. - renal disease. - drugs:steroid hormones,anticoagulants.

8. HISTORY. EXAMINATION. INVESTIGATION. TREATMENT. Management:

9. History include the following:- - Age - menses pattern - Quantity and quality of bleeding involves the presence of clots and flooding - exclusion of pregnancy - pelvic pain and pathology. - sexual activity and post coital bleeding. - contraceptive use IUCD or hormonal - hirsutism - galactorrhea

10. - Systemic disease (hepatic \renal failure, DM,) - Symptoms of thyroid dysfunction - Excesive brusing or bleeding disorders - Current medications hormonal or anticoagulant

11. Examination General examination: - Signs of anemia - Obesity - Signs of androgen excess - Ecchymosis and purpura - Visual field - Thyroid evaluation Abdominal examination: - abdomino-pelvic mass - Enlarged liver or spleen Pelvic examination: speculum ex,bimanual palpation

12. Investigation - CBC - Serum BhcG - Thyroid function test - Prolactin - Serum androgen - Coagulation screen -Renal \liver function test- - US(abdominal-transvaginal)

13. Endometrial sampling It is an integral component of evaluating abnormal uterine bleeding,particularly in women more than 35yr old : - hystroscopical directed biopsy. - D\C. - endometrial aspiration.

14. Treatment Medical treatment : -PG synthesis inhibitors (eg:mefanamic acide) reduces mean blood loss 20-40% -antifibrinolytics eg,tranxenamic acide reduces blood loss 50%. -progestogens :eg,medroxyprogesterone acetate (provera)reduces blood loss 15-30% -COCs :reducing blood loss 50% -danazol:reduces blood loss 60% -GnRH analogues:eg,goserelin -levenorgestral –releasing IUCD

15. Surgical treatment Endometrial resection and ablation:eg -TCRE(transcervical endometrial resection) -laser -diathermy -thermal balloon ablation -radiofrequency endometrial ablation -microwave endometrial ablation Criteria: -age more than 35 yr old -ut less than 10 week in size -performed during proliferative phase -DUB,no endometriosis or adenomyosis

16. Hysterectomy: -total abdominal hysterectomy -subtotal hysterectomy -vaginal hysterectomy -laparoscopic –assisted vaginal hysterectomy -laparoscopic hysterectomy

17. THANKS