1. DYSFUNCTIONAL UTERINE BLEEDING AHMED ABDULWAHAB

2. Definition. Definition. It is abnormal vaginal bleeding in the child bearing period where no organic pathology is found like fibroid, malignancy pregnancy. It is abnormal vaginal bleeding in the child bearing period where no organic pathology is found like fibroid, malignancy pregnancy. It is almost always a problem in the hypothalamic-pituitary-ovarian hormonal axis resulting in ovulation problems. It is almost always a problem in the hypothalamic-pituitary-ovarian hormonal axis resulting in ovulation problems.

3. Diagnosis by exclusion. Diagnosis by exclusion. It is a common gynecological problem that usually occurs at the extreme of reproductive life, menarche and perimenopause. And mostly attributable to anovulation so deficient corpus luteum and hence lack of progesterone that ultimately results in irregular uterine bleeding. It is a common gynecological problem that usually occurs at the extreme of reproductive life, menarche and perimenopause. And mostly attributable to anovulation so deficient corpus luteum and hence lack of progesterone that ultimately results in irregular uterine bleeding.

4. Polymenorrhea. Abnormal frequent menses < 21 days. Polymenorrhea. Abnormal frequent menses < 21 days. Menorrhagia. Excessive and-or prolonged menses more than 80 ml and or ore than 7 days that occurs at a normal intervals. Menorrhagia. Excessive and-or prolonged menses more than 80 ml and or ore than 7 days that occurs at a normal intervals. Metrorrhagia. Irregular episodes of uterine bleeding. Metrorrhagia. Irregular episodes of uterine bleeding. Oligomenorrhea infrequent menses more than 35 days. Oligomenorrhea infrequent menses more than 35 days.

5. Since diagnosis is by exclusion a good effort is made to rule out any organic causes. Since diagnosis is by exclusion a good effort is made to rule out any organic causes. A good history is made to exclude. A good history is made to exclude. -Iatrogenic. -Iatrogenic. Exogenous estrogen, OCP. Exogenous estrogen, OCP. Aspirin, heparin, warfarin, tamoxifen,IUCD. Aspirin, heparin, warfarin, tamoxifen,IUCD.

6. Blood dyscrasias. Blood dyscrasias. Thrombocytopenia, leukemia, von willebrands disease.. Thrombocytopenia, leukemia, von willebrands disease.. Systemic disorders. Systemic disorders. Hepatic renal and thyroid diseases. Hepatic renal and thyroid diseases. Trauma. Trauma. Laceration abrasion and foreign body. Laceration abrasion and foreign body.

7. Cont. Cont. Local organic causes. Local organic causes. Pregnancy complications Pregnancy complications Uterine leiomoymas and endometrial polyp Uterine leiomoymas and endometrial polyp Endometrial and cervical malignancy. Endometrial and cervical malignancy. Adenomyosis. Adenomyosis. Endometritis. Endometritis. Endometrial hyperplasia Endometrial hyperplasia

8. Laboratory evaluation. Laboratory evaluation. CBC, platelet count, coagulation profiles. CBC, platelet count, coagulation profiles. Serum iron Serum iron.pregnancy test, thyroid function test, liver function test,. Diagnostic procedures. Cervical cytology, endometrial sampling, hysteroscopy and pelvic imaging.

9. Management. Management. In young girls and when organic causes are usually excluded observation is recommended especially when it is not threatening the health of the patient In young girls and when organic causes are usually excluded observation is recommended especially when it is not threatening the health of the patient Otherwise can be given hormonal thereby in form of OCP, or progesterone. Otherwise can be given hormonal thereby in form of OCP, or progesterone.

10. In older patients and after exclusion of organic causes medical treatment is tried first, hormones, NSAIDS. In older patients and after exclusion of organic causes medical treatment is tried first, hormones, NSAIDS. Hormonal intrauterine contraceptive device. Hormonal intrauterine contraceptive device. Surgical. Surgical. Endometrial ablation, laser, endometrial resection,. Endometrial ablation, laser, endometrial resection,. Hysterectomy. Hysterectomy.

11. POST MENOPOSAL BLEEDING Any bleeding after the menopause should be viewed as abnormal until proven otherwise. Any bleeding after the menopause should be viewed as abnormal until proven otherwise. Causes. Causes. Atrophic vaginitis is responsible for the majority of the cases due to loss of structural integrity within the vagina secondary to hypo estrogenic state. Atrophic vaginitis is responsible for the majority of the cases due to loss of structural integrity within the vagina secondary to hypo estrogenic state.

12. Endometrial hyperplasia in 15 %. Endometrial hyperplasia in 15 %. Endometrial polyp in 10%. Endometrial polyp in 10%. Endometrial malignancy in 7- 10 %. Endometrial malignancy in 7- 10 %. Cervical malignancy. Cervical malignancy. Uterine sarcoma is very uncommon. Uterine sarcoma is very uncommon.

13. It is very important to exclude any underline pathology. It is very important to exclude any underline pathology. In all cases endometrial sampling will be required. In all cases endometrial sampling will be required. A throrugh examination looking for signs of systemic disease is extremely important A throrugh examination looking for signs of systemic disease is extremely important Pelvic examination should include the estrogenic status of the vagina and cervix Pelvic examination should include the estrogenic status of the vagina and cervix

14. Cervical smear is a routine is routinely done. Cervical smear is a routine is routinely done. Ultrasound as an initial step and an endometrial thickness of 4 mm and more will require more investigations. Ultrasound as an initial step and an endometrial thickness of 4 mm and more will require more investigations. Outpatient aspiration can be used. Outpatient aspiration can be used. Hysteroscopically directed biopsy should be performed in cases of continuous bleeding despite a normal aspiration sample. Hysteroscopically directed biopsy should be performed in cases of continuous bleeding despite a normal aspiration sample.

15. Treatment. Treatment. Is directed toward the underline cause. Is directed toward the underline cause. If no pathology is found then hypoestrogenic atrophic state is the most likely cause and can be treated with either systemic or local hormonal replacement. If no pathology is found then hypoestrogenic atrophic state is the most likely cause and can be treated with either systemic or local hormonal replacement.