Abnormal Uterine

Bleeding
Dr. Mashael Shebaili
Asst. Prof. & Consultant
Ob/Gyne Department

Normal menstruation
Rhythm:

regular from 21-35

days
Duration:
Amount:
Flow:

3-7 days

between 30-50 mls

non clotted fluid blood

Disorders in rhythm, amount

or duration
Menorrhagia
Polymenorrhea
Oligomenorrhea
Metrorrhagia

Causes of Menorrhagia
DUB
Pelvic

pathology

Medical
Clotting

defect

Dysfunctional uterine
bleeding
Definition: uterine bleeding in
the absence of an organic
disease
Incidence: 10-20% usually at
extremes of reproductive life.

Diagnosis (by exclusion)

History
General

examination

Abdomino-pelvic
Investigations

examination

(mainly
exclude organic causes)

to

Treatment
I. Medical treatment
A. Non-steroidal anti-inflammatory

drugs
Mechanism of action: inhibit cyclooxygenase enzyme and the
production of prostaglandins
Phospholipids phospholipase A
arachidonic acid cyclo-oxygenase
prostaglandins
2

Possible Pathophysiology
1) Shift

in the endometrium conversion

of the endoperoxide from vasoconstrictor PGF2

2) Increase

in the level and activity of the

endometrium fibrinolytic system

3) Effect

of other endometrial derived

factors as cytokines, growth factors
and endothelins.

:Effectiveness
1.

Decrease measured menstrual

loss by 40% in 75% of patients

2.

Relief dysmenorrhoea

3.

Little effect on regularity of cycle

or duration of bleeding

:Side effects
Mainly

mild gastrointestinal

tract irritation
The

treatment should start

immediately with the start of

bleeding.

B. Antifibrinolytic agents
Mechanism of action:
Prevent

conversion

of

plasminogen into plasmin which

dissolve the fibrin clots occluding
the blood vessels.

Effectiveness:
Reduce

measured loss by
40-50%. The effect is dose
related. It should be given
with
the
start
of
menstruation and continue
for 3-4 days.

Comparative

studies suggested

that tranexemic acid is more

effective
inhibitors

than

PG

(Milsom

synthetase
et

al.1991;

Bonnar and Shepard 1996).

Side effects:
1.

Mild
gastrointestinal
irritation

tract

2.

Serious adverse effect has been

documented
(intracranial
thrombosis central venous
stasis retinopathy) but they are
extremely rare.

3.

No such complications occurred

in Scandinavia over 19 years (1st
line of treatment there

4.

Should not prescribed for women

with

history

embolism.

of

thrombo-

II. Hormonal treatment:

1. Oral contraceptive pills

One of the most effective treatments

available for both menorrhagia and
dysmenorrhoea

Can be used safely in women over 40

years if they are of low risk category

Mechanism of action:
Mainly locally by inducing endometrial
atrophy with reduction in both PG synthesis
and fibrinolysis.

Side effects:

i.

That of oral contraceptive pills in general

ii.

Socially unaccepted in single unmarried

women.

2.Progestogens

Norethisterone medroxyprogesterone acitate.

Are the most commonly prescribed
preparations in UK because it was
wrongly thought that the majority of
women with DUB are anovulatory

Mechanism of action:

1.

In anovulatory cycle it induce secretory

changes but in ovulatory cycle it
produce minimal changes

2.

Norethisterone is given as 5mg t.d.s. for

21 days while Provera is given as 10 mg
for 10-14 days during luteal phase.

Effectiveness:

1.

If given in high dose for 21 days

especially in anovulatory cycle it reduce
menstrual loss by 80% (Irvin et al.,
1998)

2.

In anovulatory cycle it convert irregular,

unpredictable bleeding into regular
controlled one which is an attractive
feature for many women.

Side effects:
Usually minimal as abdominal
bloating and weight gain

Progesterone releasing devices

Produce marked reduction in menstrual
blood loss up to 80%
Mechanism

of action: mainly locally

leading to atrophic endometrium with

very minimal systemic effect

 Effectiveness:

Scandinavian

study

(milson et al.,1991) showed decreased

menstrual loss by 90%.
Side

effects: irregular bleeding is

common especially in the in the early

months.

Danazol:

Is an extremely effective drug for

treatment of menstrual problems but its

use is limited by its high androgenic
side effects

Gonadotrophin releasing hormone agonist

Mechanism of action: produce down
regulation

of

pituitary

gland

that

decrease gonadotrophins and ovarian

steroids
Effectiveness:

relief amenorrhoea in

90% of cases. Also relief PMS

Side effects:

Hypo-estrogenic state and osteoporosis

(add estrogen and progesterone if used
for long period)

Unless used to prepare the patient for

endometrial ablation it is not accepted
by most patients for long term.

Surgical treatment
Suitable for older patients who have no
further wish to conceive.
I.Endometrial ablation/resection
To remove or destroy the endometrium
producing changes similar to Ashermans
syndrome (Laser electrocautary - roller
ball - diathermy microwave- hot
balloon).

Advantage over hysterectomy

1.

Short hospital stay and return to work

2.

50% of patients were amenorrhoeic,

30-40% experienced marked reduction
in menstrual loss

3.

70% or more were satisfied

Disadvantages:
1.

Needs experience

2.

Recurrence of about 20%

3.

Operative complications as perforation

4.

Post operative pain

II. Hysterectomy
Definitive
cure
for
(Abdominal, vaginal or
(total or subtotal)

menorrhagia
laparoscopic)

Disadvantages:
Mortality of 6/10000 procedures
2. Injury of ureter, bladder or bowel.
1.

POSTMENOPAUSAL
BLEEDING

POSTMENOPAUSAL BLEEDING
It is bleeding from the genital tract occurring 6
months or more after cessation of menstruation
in a woman above the age of 40.
It is a serious symptom because in about 25%
of cases, it is due to a malignant lesion in the
genital tract
Prevalence
About 7 per 1000 postmenopausal women.

Aetiology
(A)

General Causes
(1) Oestrogen therapy (25%). Oestrogen given for
menopausal symptoms may lead to withdrawal
bleeding.
(2) hypertension.
(3)
blood diseases as leukemia.
(4)

anticoagulant therapy.

(B)Local Causes
Vulva. Malignant tumour, fissured leucoplakia,
urethral caruncle, and direct trauma.
Vagina. Malignant tumour, senile vaginitis,
trophic ulcer in prolapse, and retained foreign
body or pessary in the vagina.
Cervix. Malignant tumour, erosion and ulcers.
Uterus. Malignant tumour, senile endometritis,
tuberculous eiidometritis, fibroid
.

F.tube carcinoma. This leads to a watery

vaginal discharge which finally becomes
blood stained
Ovary. Carcinoma with metastases in the
endometrium and oestrogenic ovarian
tumours.
(C) In about 15% of cases no cause is
found after physical examination and
uterine curettage which shows atrophic
endometrium

Diagnosis
A. History
Personal history
(a) Age: The commonest age incidence for carcinoma of
uterus is 55-70 years while that for carcinoma of the
vulva is 60-70 years.
(b) parity: some tumours are more common among
nulliparae e.g. endometrial and ovarian carcinoma.
Present history
Ask about the amount, character and duration of
bleeding, duration of menopause, and the presence of
other symptoms as pain and foul discharge, urinary and
gastrointestinal symptoms (malignant invasion of bladder
or bowel).

Past history
(a)Oestrogen therapy.
(b) diseases as diabetes mellitus,

hypertension and blood diseases as

leukemia.
Endometrial carcinoma is more common
in diabetic hypertensive patients.
Family history
Carcinoma of the body of the uterus and
ovary have a familial tendency

B. General Examination
(I) Signs of anaemia.
(2) signs of bleeding disorders.
(3) presence of cachexia.
(4) examination of heart and chest for
secondaries.
(5) estimation of blood pressure

C Abdominal Examination
For a pelvi-abdominal mass and ascites
which is common with ovarian malignancy.

D.Pelvic Examination
To detect a local cause for bleeding. The
urethra and anal canal are excluded as
being the source of bleeding.

E. Special Investigations
Transvaginal sonography. It excludes the
presence of an ovarian tumour or a
lesion in the uterus as endometrial carcinoma.
2. Cervical smear. Taken in absence of bleeding
to detect the presence of malignant
cells which may come from the cervix,
endometrium, tubes, or ovaries.
1.

3.

Endometrial biopsy. It must be done in every

case of postmenopausal bleeding, as
it is the only sure method to exclude
endometrial carcinoma.

Endometrial biopsy is taken by one of three methods;

Fractional uterine curettage,
Endometrial aspiration, or
Hysteroscopy.

4. Biopsy is taken from any suspected lesion in

the vulva, vagina, or cervix.
5. Laboratory tests. These are done according to
the clinical findings and include:
a. Complete blood count.
b. Platelet count, bleeding time, coagulation
time,
estimation of clotting factors if a
bleeding disorder is suspected.

Treatment
It is treatment of the cause.
If no cause can be detected the patient
should be followed up.
If bleeding recurs it is better to do
hysterectomy and bilateral salpingooophorectomy which may reveal a missed
early carcinoma of uterus or tube .

Thank you