Abnormal and Excessive Menstrual Bleeding : Abnormal and Excessive Menstrual Bleeding Dr Prasanna Kumar Shetty, MD
Asst Prof Dept of OBG
KSHEMA Definitions : Definitions Menorrhagia: (hypermenorrhoea) regular
bleeding at normal intervals which is either excessive in amount (>80ml) or duration(>7days) or both.
Polymenorrhoea: cyclic bleeding where the cycle is reduced to 21 days or less and remains constant at that frequency (epimenorrhoea) Definitions : Definitions Metrorrhagia: Irregular, acyclical bleeding from the uterus. Amount of bleeding is variable. Bleeding from any part of genital tract is included under this heading in clinical practice.
Oligomenorrhoea: Menstrual bleeding occurring more than 35 days apart and which remains constant at that frequency Definitions : Definitions Hypomenorrhoea: when the menstrual bleeding is unduly scanty and lasts for less than 2 days.
Dysfunctional Uterine bleeding (DUB): Abnormal uterine bleeding without any clinically detectable organic pelvic pathology- tumour, inflammation or pregnancy. Common Causes of Abnormal Uterine or Vaginal Bleeding : Common Causes of Abnormal Uterine or Vaginal Bleeding Abnormal menstrual bleeding.
Postmenopausal, Precocious, delayed menopause Non-menstrual
Breakthrough Bleeding Menorrhagia : Menorrhagia Symptom of underlying pathology
Congestion, increased surface area or hyperplasia of the endometrium
Fibroid uterus, Adenomyosis, Pelvic Endometriosis, IUCD, Chronic tubo-ovarian mass, granulosa cell tumour of ovary.
Common causes: DUB, Fibroid, Adenomyosis, Chronic PID Menorrhagia : Menorrhagia Systemic: Liver Dysfunction,
Endocrine: Hypothyroidism, hyperthyroidism
Blood Dyscrasias: ITP, leukaemias, von Willebrand’s disease
Functional: disturbed hypothalamo-pituitary axis. Menorrhagia : Menorrhagia Long duration of flow, passage of big clots, use of increased no of sanitary pads, pallor, low Hb%
Treatment: Definitive treatment of the cause of menorrhagia as the case maybe, eg: fibroid: myomectomy or hysterectomy, removal of IUCD, treatment of hypothyroidism. Polymenorrhoea : Polymenorrhoea Causes: dysfunctional, during adolescence, preceding menopause and following delivery/abortion. ?hyperstimulation of ovary by pituitary gonadotrophins
Ovarian hyperaemia: PID, ovarian endometriosis
Treatment: Hormonal Metrorrhagia : Metrorrhagia Causes: DUB- adolescence, following childbirth/abortion and perimenopause
Carcinoma cervix and endometrial carcinoma
Contact bleeding: Ca cervix, mucous polyp of cervix, vascular erosion of cervix esp during pregnancy, infections: chlamydia metrorrhagia : metrorrhagia Causes of Intermenstrual bleeding: urethral caruncle, ovular bleeding, breakthrough bleeding (pill use), IUCD in utero, decubitus ulcer (prolapse)
Treatment: directed to underlying cause
Malignancy to be excluded prior to any definitive treatment. Oligomenorrhoea : Oligomenorrhoea Common causes: Age related- adolescence, preceding menopause
Stress & exercise related
Endocrine: PCOD, hyperprolactinaemia, hyperthyroidism
Androgen producing tumours- ovarian, adrenal
Tubercular endometritis: late cases. Hypomenorrhoea : Hypomenorrhoea Local causes: uterine synechiae or endometrial tuberculosis
Endocrinal: oral contraceptives
Systemic: malnutrition EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING : EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING Differential diagnosis
Reproductive tract pathology: cervicitis, cervical neoplasia, endometritis, endometrial polyps, endometrial hyperplasia, uterine leiomyomas, adenomyosis, uterine sarcomas, ovarian neoplasms (estrogen producing) EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING : EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING Medications:
Psychotropic medications Trauma
. Endocrine gland dysfunction
Hyperthyroidism EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING : EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING Ovulatory dysfunction
Shortened follicular phase
Luteal Phase deficiency
Prolonged corpus luteum function Pregnancy-related conditions
Gestational trophoblastic neoplasms EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING : EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING Systemic disease
Von Willebrand’s disease
Renal disease EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING : EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING Complete History
Current bleeding history
Drug history EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING : EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING Complete Physical Examination: detects organic causes of bleeding, signs of anovulation
General physical examination-thyroid enlargement, galactorrhoea, ecchymosis, purpura EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING : EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING Gynaecological examination- including Pap smear detects organic causes of abnormal bleeding
Laboratory studies: not all tests necessary in all patients
Complete blood count EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING : EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING Contd.
Coagulation profile: PT, PTT, BT
Androgen profile: Testosterone, DHEA, OH-progesterone-in women with anovulatory bleeding and hirsutism EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING : EVALUATION AND DIAGNOSIS OF ABNORMAL UTERINE BLEEDING Diagnostic studies
Endometrial biopsy- all women >40 with chronic anovulatory bleeding
D and C
Hysteroscopy, or direct visualization of endometrial cavity