Frequency of menses 24 days (0.5%) to 35 days

(0.9%) Age 25, 40% are between 25

and 28 days Age 25-35, 60% are between

25 and 28 days Teens and women over 40’s

cycles may be longer apart

Duration of menses 3 days to 7 days

Usually 4-6 days

Flow/amount of menses Average blood loss with

menstruation is 60-80cc.

Menorrhagia (hypermenorrhea): heavy or prolonged uterine bleeding that occurs at regular

intervals. Some sources define further as the loss of ≥ 80 mL blood per cycle or bleeding > 7 days.

Metrorrhagia:irregular menstrual bleeding or bleeding between periods

Menometrorrhagia: metrorrhagia associated with > 80 mL

Polymenorrhea: uterine bleeding occurring at regular intervals of less than

21 days

Hypomenorrhea:periods with unusually light flow, often associated with

hypogonadotropic hypogonadism (athletes, anorexia). Also may be associated with Asherman’s syndrome

Oligomenorrhea:Menses are > 34 d apart. Most commonly caused by PCOS, pregnancy,

and anovulation

Amenorrhea: Primary amenorrhea Secondary amenorrhea

• No menses for 3-6 months

Dysfunctional Uterine Bleeding: excessive uterine bleeding with no demonstrable organic cause. It is

most frequently due to abnormalities of endocrine origin, particularly anovulation.

pregnancyHormones

Iatrogenic

MechanicalInfection

cancer

Organic Systemic Reproductive tract disease Iatrogenic

Inorganic (Dysfunctional) Anovulatory Ovulatory

Systemic Disease Coagulopathy

Von Willebrand’s disease Prothrombin deficiency Leukemia Sepsis ITP

Hypersplenism

Hypothyroidism Frequently associated with menorrhagia as well as

intermenstrual spotting Incidence 0.3% to 2.5% among women with

menorrhagia

Reproductive tract disease :

Gestational events Abortions Ectopic pregnancies Trophoblastic disease

Malignancy Cervical cancer Endometrial cancer Estrogen producing ovarian tumors

Anatomic uterine abnormalities Leiomyomata Submucosal Intramural

Endometrial polyps Adenomyosis

Iatrogenic Causes of AUB Intra-uterine device Oral and injectable steroids drugs

Infection Endometritis Cervicitis

In late perimenopausal patients, ovarian function may be wildly sporadic, so long episodes of amenorrhea, hot flashes, and even laboratory determinations interpreted as menopausal (increased follicle-stimulating hormone [FSH], decreased estradiol) may be followed by some bleeding, staining, or spotting that may represent agonal episodes of ovarian function.

any bleeding, spotting, or staining after 12 months of amenorrhea should be viewed as endometrial cancer until proven otherwise and endometrial evaluation becomes mandatory.

curettage in the hospital with anesthesia was the gold standard. First described in 1843, it was once the most common operation performed on women in the world. Even 50 years ago, it was understood that the technique missed endometrial lesions in many cases, especially those that were focal (polyps)

In the 1970s, vacuum suction curettage devices first allowed for endometrial sampling without anesthesia in an office setting. Such procedures, although office based, were cumbersome and resulted in great patient discomfort.

Subsequently, cheaper, smaller, less painful plastic catheters with their own internal pistons to generate suction became popular.

Transvaginal Ultrasound :

Endometrial thickness should be measured on a sagittal (long axis) image of the uterus, and the measurement should be performed on the thickest portion of the endometrium, excluding the hypoechoic inner myometrium

Often, fibroids, previous surgery, marked obesity, or an axial uterus may make visualization suboptimal.

In these cases, ultrasound cannot be relied on to exclude disease. The next step for such patients with bleeding should be either hysteroscopy or saline infusion sonohysterography

Sonohysterography :

The use of fluid instillation into the uterus coupled with high-resolution transvaginal probes allows tremendous diagnostic enhancement with an inexpensive, simple, well-tolerated office procedure

The addition of saline infusion sonohysterography can reliably distinguish perimenopausal patients with dysfunctional abnormal bleeding (no anatomic abnormality) from those with globally thickened endometria or focal abnormalities

Hysteroscopy :

Hysteroscopy is a procedure in which a small endoscope is inserted into the vagina and through the cervix to view the uterine lining directly

It is useful in identifying and taking biopsies or removing endometrial polyps and submucous myomas

the most common cause of abnormal uterine bleeding in premenopausal women is oligoanovulation, which reflects dysfunction in the hypothalamic“pituitary“ovarian axis.

Also, as discussed previously, in addition to disturbances of ovulation, abnormal uterine bleeding may be caused by anatomic conditions including polyps, fibroids, hyperplasias, and even frank carcinoma, especially with increasing age

Any bleeding in postmenopausal women who are not on hormone therapy or uterine bleeding that persists longer than 6 months with continuous combined hormone therapy must be evaluated. The most common cause of such bleeding is endometrial atrophy

1- Hormonal Management :

Oral Contraceptives Low-dose combination oral contraceptive pills are considered to be the

first-line treatment of abnormal uterine bleeding when it occurs in otherwise healthy, nonsmoking, premenopausal women, regardless of their contraceptive status.

Continuous Progestin-Only Contraceptives Injectable long-acting medroxyprogesterone acetate in a depo form (DMPA)

will produce amenorrhea over time and provides contraception if needed.

Cyclic Oral Progestogen In the past, cyclic oral progestogen therapy (progestin or progesterone)

has been a standard medical therapy for dysfunctional anovulatorybleeding in perimenopausal women.

This usually entails administering cyclic progestogen for 12 to 14 days each month.

Parenteral Estrogen : For acute excessive abnormal uterine bleeding, the use of

intravenous estrogen works well to temporize a volatile situation

Gonadotropin-Releasing Hormone Agonists : (GnRH) agonists induce a reversible hypoestrogenic state

These agents are effective in reducing menstrual blood loss in premenopausal patients

They are limited by their expense and side effects including hot flashes, reduction of bone density, and temporary nature.

Dilation and Curettage : (D & C) D&C, by itself, is a blind surgical procedure that usually requires general

anesthesia. Because it is a blind procedure when performed without concurrent hysteroscopy, D&C can miss localized disease such as polyps, submucous myomas, or focal hyperplasias.

Endometrial Destruction : Adequate endometrial histologic evaluation should take place prior to an

ablative procedure. Ablative procedures may not successfully treat abnormal uterine bleeding

when the anatomic lesion is located in the uterine wall, such as intramural myomas that extend into the endometrial cavity or extensive adenomyosis.

Uterine Artery Embolization

Hysterectomy : Hysterectomy (total or supracervical) is the only definitive cure for benign

abnormal uterine bleeding that has failed to respond to medical treatment.