ABNORMAL UTERINE BLEEDING 90 anovulatory 10 ovulatory HypermenorrheaMenorrhagia

ABNORMAL UTERINE BLEEDING • ❏ 90% anovulatory, 10% ovulatory • Hypermenorrhea/Menorrhagia • cyclic menstrual bleeding that is excessive in amount (>80 m. L) or duration (> 7 days) – – – adenomyosis endometriosis leiomyomata endometrial hyperplasia or cancer hypothyroidism

Hypomenorrhea • • decreased menstrual flow or vaginal spotting Oligomenorrhea episodic vaginal bleeding occurring at intervals > 35 days Polymenorrhea episodic vaginal bleeding occurring at intervals < 21 days Metrorrhagia uterine bleeding occurring between periods – organic pathology – endometrial/cervical polyps or cancer – estrogen withdrawal

• Menometrorrhagia • uterine bleeding irregular, and also excessive in amount – organic pathology – endocrine abnormality – early pregnancy • Postmenopausal Bleeding • any bleeding > 1 year after menopause • investigations – endometrial sampling - biopsy or D&C • hysteroscopy

DYSFUNCTIONAL UTERINE BLEEDING (DUB) • • abnormal bleeding with no organic cause rule out: blood dyscrasias thyroid dysfunction malignancy endometriosis PID fibroids polyps

Adolescent Age Group • DUB due to immature hypothalamus with irregular LH, FSH, estrogen and progesterone pattern • Reproductive Age Group • ❏ DUB due to an increase or decrease in progesterone level • Perimenopausal Age Group • DUB due to increased ovarian resistance to LH and FSH • treatment – if anemic, iron supplement – medroxyprogesterone acetate (Provera) 5 -10 mg

Mid-Cycle Spotting • ❏ may be physiologic due to mid-cycle fall of estradiol • Premenstrual Spotting • may be due to progesterone deficiency, endometriosis, adenomyosis and fibroids

POLYCYSTIC OVARIAN DISEASE • Pathogenesis of PCO • white, smooth, sclerotic ovary with a thick capsule, multiple follicular cysts • high androgens + obesity • chronic anovulation

Treatment – weight reduction – clomiphene, – progesterone (Provera) • for pregnancy – medical induction of ovulation – clomiphene citrate (Clomid)

DYSMENORRHEA • Primary • menstrual pain not caused by organic disease • may be due to prostaglandin-induced uterine contractions and ischemia • begins 6 months - 2 years after menarche • colicky pain in abdomen, radiating to the lower back, labia and inner thighs • begins hours before onset of bleeding and persists for hours or days • associated nausea, vomiting, altered bowel habits, headaches • treatment – Naproxen, must be started before/at onset of pain

Secondary • • • menstrual pain due to organic disease begins in women who are in their 20’s worsens with age associated dyspareunia, abnormal bleeding, infertility etiology – – – endometriosis adenomyosis fibroids PID ovarian cysts • IUD