1. REPRODUCTIVE AGE GROUP
AUB
REPRODUCTIVE AGE GROUP

2. Normal Menses
The mean duration of menses is 4.7 days; 89% of cycles last 7 days or longer.
The average blood loss per cycle is 35 ml .
the blood content of menses varies over the days of bleeding, but on average is close to 50% .
Recurrent bleeding in excess of 80 ml /cycle results in anemia

3. Prevalence
%5 of women between the age 30 and 49 years consult a physician for menorrhagia .
21 to %67 develops iron deficiency anemia .

4. Differential diagnosis
dysfunctional uterine bleeding (estrogen breakthrough. Low levels of estrogen stimulation
whereas higher sustained levels result in episodes of amenorrhea followed by acute, heavy bleeding.
Pregnancy-related Bleeding.
In the United States, more than 50% of pregnancies are unintended.
EP.

5. Differential diagnosis
Exogenous Hormones .
Ocpill. contraceptive patch, vaginal ring, and intramuscular regimens,
Use of progestin-only methods—including DMPA, progestin-only pills, the contraceptive implant, and the levonorgestrel IUS. is associated with relatively high rates of initial irregular and unpredictable bleeding .

6. Causes of abnormal genital tract bleeding
Genital tract disorders :
uterus
polyps
endometrial hyperplasia
Adenomyosis
fibroids
adenocarcinoma
sarcoma
endometritis
anovulatory bleeding

7. Cervix Cervicitis Condyloma. HSV,chlamidia. Polyps Benign growths:
Ectropion
Endometriosis
Cancer:
Invasive carcinoma
Metastatic (uterus, choriocarcinoma)
Infection:
Cervicitis
Condyloma. HSV,chlamidia.

8. Vagina Benign growths: Gartner's duct cysts Polyps
Adenosis (aberrant glandular tissue)
Cancer
Vaginitis/infection:
Bacterial vaginosis
Sexually transmitted diseases
Atrophic vaginitis

9. Vulva Sexually transmitted diseases Skin tags Angiokerataoma Cancer
Benign growths
Skin tags
Sebaceous cysts
Condylomata
Angiokerataoma
Cancer
Infection:
Sexually transmitted diseases

10. Upper genital tract disease
Fallopian tube cancer
Ovarian cancer
Pelvic inflammatory disease
Pregnancy complications

11. Trauma Sexual intercourse Sexual abuse Foreign bodies (including IUD).
Pelvic trauma (eg, motor vehicle accident)
Straddle injuries

12. Drugs Contraception: Oral contraceptives Copper intrauterine device
Depo-Provera
Hormone replacement therapy
Anticoagulants
Tamoxifen
Corticosteroids
Chemotherapy
Dilantin
Antipsychotic drugs
Antibiotics (eg, due to toxic epidermal necrolysis or Stevens-Johnson syndrome)

13. Systemic disease Crohn's disease Behcet's syndrome
Pemphigoid Pemphigus
Erosive lichen planus
Lymphoma
Coagulation disorders:
von Willebrand's disease

14. Thrombocytopenia or platelet dysfunction
Acute leukemia
Some factor deficiencies
Advanced liver disease
Thyroid disease
Hyperprolactinemia
Polycystic ovary syndrome
Chronic liver disease
Cushing's syndrome

15. Systemic disease Hormone secreting adrenal and ovarian tumors
Renal disease
Emotional or physical stress
Smoking
Excessive exercise

16. Systemic disease Diseases not affecting the genital tract Urethritis
Bladder cancer
Urinary tract infection
Inflammatory bowel disease
Hemorrhoids
Vascular tumors and anomalies in the genital tract

18. Endocrine Causes hypothyroidism and hyperthyroidism .
With hypothyroidism : Menorrhagia, are common.
Hyperthyroidism can result in oligomenorrhea or amenorrhea. and it also can lead to elevated levels of plasma estrogen.
Hypothalamic dysfunction, hyperprolactinemia, premature ovarian failure, and primary pituitary disease, irregular bleeding also may result in their presence.

19. Endocrine Causes.
Diabetes mellitus can be associated with Anovulation, obesity, insulin resistance, and androgen excess .
Polycystic ovary syndrome is present in 5% to 8% of adult women and undiagnosed in many women .
Because androgen disorders are associated with significant cardiovascular disease, the condition should be diagnosed promptly and treated.

20. Anatomic Causes
Uterine leiomyomas. cumulative prevalence of greater than 80% in black women and nearly 70% in white women. are estimated to be clinically significant in at least 25%of women of reproductive age.
Endometrial polyps. :are a cause of intermenstrual bleeding, irregular bleeding, and Menorrhagia, although as with leiomyomas, most endometrial polyps are asymptomatic.
Endometrial polyps can regress spontaneously.
the chance of malignancy is less than 5% and likely approximates 0.5%

21. Abnormal bleeding intermenstrual or postcoital, Cervical lesions.
endocervical polyps.
infectious cervical lesions, such as condylomata, herpes simplex virus, ulcerations, chlamydial cervicitis, or cervicitis caused by other organisms.

22. Coagulopathies and Hematologic Causes
A complete blood count will be helpful in detecting anemia, significant problems such as leukemia or disorders associated with thrombocytopenia.
Alcoholism .
von Willebrand's disease.
Oral contraceptive ,

23. Infectious Causes Cervicitis:
chlamydial cervicitis, can experience irregular
bleeding and postcoital spotting
Endometritis can cause excessive menstrual flow.
woman who seeks treatment for menorrhagia and increased menstrual pain and has a history of light-to-moderate previous menstrual flow may have an upper genital tract infection or PID (endometritis, salpingitis, oophoritis).
chronic endometritis will be diagnosed when an endometrial biopsy is obtained for evaluation of abnormal bleeding in a patient without specific risk factors for PID.

24. Neoplasia invasive cervical cancer.
cervical lesion should be evaluated by biopsy, testing may be falsely negative with invasive lesions as a result of tumor necrosis.
Unopposed estrogen of the endometrium: cystic hyperplasia to adenomatous hyperplasia, hyperplasia with cytologic atypia, and invasive carcinoma.
Vaginal neoplasia is uncommon

25. Diagnosis
exclusion of pregnancy.CBC diff. PT,PTT, prothrombin time and partial prothrombin time ,von Willebrand´s disease .
possible malignancy.
imaging studies. measurements of endometrial thickness are significantly Less useful in premenopausal than postmenopausal women.
Sonohysterography is especially helpful in visualizing intrauterine problems such as polyps or submucous leiomyoma.
CT scanning and MRI, are not as helpful in the initial evaluation of causes of abnormal bleeding and should be reserved for specific indications.

26. Endometrial Sampling
Endometrial sampling should be performed to evaluate abnormal bleeding in women who are at risk for endometrial polyps, hyperplasia, or carcinoma. D & C, Hysteroscopy, endometrial sampling,

27. Management medical therapy . surgical management .
endometrial ablation
hysterectomy

28. Nonsurgical Management
NSAIDs . Mefenamic acid 500 mg three times per day
Naproxen 500 mg at onset and three to five hours later, then 250 to 500 mg twice a day
Ibuprofen 600 mg once per day.
Antifibrinolytics; tranexamic acid .amincaproic acid.
Levonorgestrel-containing intrauterine devices .
Oral contraceptives, Ocs E²>35mcg than 20mcg.
For patients in whom estrogen use is contraindicated, progestins, both oral and parenteral, can be used to control excessive bleeding .

29. medroxyprogesterone acetate, administered from days 5 to 26 of the cycle .
Depot formulations of medroxyprogesterone acetate
Oral, parenteral, or intrauterine delivery of progestins may be used in selected women with atypical endometrial hyperplasia who wish to maintain their fertility, continued monitoring every 3 month is indicated .
Danazol .
Gonadotropin-releasing hormone analogues .
levonorgestrel-containing IUS .

30. Surgical Therapy D&C . Endometrial ablation or resection .
Hysterectomy .
Hysteroscopy .
Laparoscopy .
Uterine artery Embolization .
Magnetic resonance guided focused ultrasonography ablation .

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