Benha University Hospital, Egypt

E-mail: elnashar53@hotmail.com

DEFINEAny deviation in normal frequency, duration or amount of menstruation in women of reproductive age.

NORMAL MENSESFrequency: 21-35 dDuration: 3-7 dVolume: 30-80 ml

CLINICAL TYPESPolymenorrhoea: frequent (<21 d) menstruation, at regular intervalsMenorrhagia: Excessive (>80 ml) & / or prolonged menstruation, at regular intervalsMetrorrhagia: Excessive (>80 ml) & / or prolonged menstruation at irregular intervals.Menometrorrhagia: both.Intermenstual bleeding: episodes of uterine bleeding between regular menstruationsHypomenorrhoea: scanty menstruation.Oligomenorrhoea: infrequent menstruation (>35 d)

CAUSES. Dysfunctional uterine bleeding. Pregnancy complications: Abortion, Ectopic pregnancy, Trophoblastic disease. Genital disease:. Tumors: Benign: fibroid, polyps (cervical, endometrial, fibroid)

Malignant: cervical, endometrial, ovarian (estrogen secreting)

. Infection: PID

. Endometriosis, adenomyosis

. IUCD

. Marked uterovaginal prolapse or retroversion

. Extragenital:

. Endocrine: hypo- or hyperthyroidism

. Haematological: Idiopathic thrombocytopenic purpura, Von-Willebrand disease. Chronic systemic disease: liver failure, renal failure, hypertension with uterine artery atherosclerosis.. Iatrogenic: Sex hormones, anticoagulants.. Emotional: (change of country, climate & work; stress; psychosomatic disorders) . Obesity: [increased peripheral estrogen conversion]

Dysfunctional uterine bleedingDefine

Abnormal uterine bleeding in absence of pelvic organ disease or a systemic disorder

Incidence60 % of AUB

Pathology Endocrine abnormality Endometrium

Anovulatory90% Insufficient follicles Inadequate proliferative or atrophic Persistent follicles Proliferative or hyperplastic Ovulatory10% Short proliferative phase Normal Long proliferative phase Normal Insufficient C. luteum Irregular or deficient secretory leading to short luteal phase Persistent C luteum leading to Irregular shedding long luteal phase

Risk of endometrial cancerChronic anovulation has 3 times increased risk (Coulam,1989). Chronic proliferation of the endometrium leading to adenomatous hyperplasia, leading to atypical adenomatous hyperplasia, leading to endometrial carcinoma. Transition can take up to 10 yrs or more.

DiagnosisAim: 1. Nature & severity of bleeding2. Exclusion of organic causes3. Ovulatory or anovulatoryHow:

I. History:1. Personal: age, wishes of the patient2. Menstrual3. Obstetric4. Past5. Present: amount, duration, color, smell, relation to sexual intercourse, associated symptoms

II. Examination:1. General: pallor, endocrinopathy, coagulopathy, pregnancy2. Abdominal: liver, spleen, pelvic abdominal mass3. Pelvic: origin of the bleeding, cause

III.InvestigationsSystemic:1. CBC (for all, Grade A)2. BHCG3. Prolactin & TSH4. Prothrombin time, partial thromboplastin time, bleeding time, platelets, Von Willebrand factor

Local:1. Pap smear2. Endometrial biopsy3. D & C4. Hysteroscopy5. U/S

Assessment of the amount of the bleeding:50% of excessive menstruation have normal amount of blood loss by objective methods1.Subjective methods: history of passage of clots, flooding, use of large number of pads, do not reflect the actual blood loss2.Semiobjective:i.Iron deficiency anemiaii.Menstrual calendar (August,1996) III. Pictorial blood loss chart(Higham,1990):

Menstrual calender (August,1996)

Saturday 7 14 21 28Sunday 1 8 15 22 29Monday 2 9 16 23 30Tuesday 3 10 17 24 31Wednesday 4 11 18 25Thursday 5 12 19 26Friday 6 13 20 27

. Spotting

- Slight loss

O Moderate loss

Very heavy loss

Pictorial blood loss chart: (Higham,1990) Days of the bleeding Score

1 2 3 4 5 6 7 8 Towel

1 point

5 points

10 points

Clots 1p clot 1 point 5p clot 5 points

Flooding 5 points

Score >100 = Menorrrhagia

Endometrial biopsy:Indications: .Between 20 & 40.If endometrial thickness on TVS is >12mm, endometrial sample should be taken to exclude endometrial hyperplasia (Grade A). Failure to obtain sufficient sample for H/P does not require further investigation unless the endometrial thickness is >12 mm (Grade B)Aim: diagnosis of the type of the bleeding

Methods: As an outpatient procedure, without general anesthesia.1.Pipelle curette2.Sharman curette, Gravlee jet washer, Isac cell sampler3.Accrette4.vabra aspiratorAdvantages: An adequate & acceptable screening procedure in females under 40 yrs

D & C:Indications:1. Mandatory after 40 yrs 2. Persistent or recurrent bleeding between 20 & 40 yrsAim:1.Diagnosis of organic disease e.g. endometritis, polyp, carcinoma, TB, fibroid2.Diagnosis of the type of the endometrium: hyperplastic, proliferative, secretory, irregular ripening, shedding, atrophic. This provides a guide to etiology & treatment

3.Arrest of the bleeding, if the bleeding is severe or persistent, particularly hyperplastic endometrium. Curettage is essentially a diagnostic & not a therapeutic procedure.Disadvantages: 1.Small lesions can be missed2.The sensitivity of detecting intrauterine pathology is only 65%

Fractional curretage:

Indication: >40 yrs

Method: 3 samples: endocervical, lower segment & upper segment

Hysteroscopy:Indications: Mandatory after 40 yrs1. Erratic menstrual bleeding2. Failed medical treatment3. TVS suggestive of intrauterine pathology e.g. polyp, fibroid (Grade B)

Aim:1.Excellent view of the uterine cavity & diagnosis of polyps, submucous fibroid, hyperplasia.2.Biopsy of the suspected areas3.Treatment

Advantages over D &C1.The whole uterine cavity can be visualized 2.Very small lesions such as polyps can be identified & biopsed or removed3.Bleeding from ruptured venules & echymoses can be readily identified4.The sensitivity in detecting intrauterine pathology is 98% (Loffer,1989)5.Outpatient procedure

Disadvantages:1.Cost of the apparatus2.Lack of availability or experience

Ultrasonography:1. TAS: can exclude pelvic masses, pregnancy complications2. TVS: More informative than TAS. Measurement of the endometrial thickness is not a replacement for biopsy. All endometrial carcinoma in postmenopausal with endometrial thickness>4 mm (Osmers,1990)3. Saline sonography: an alternative to office hysteroscopy in selected cases. It is better tolerated than office hysteroscopy or HSG

TVS is recommended in:

1. Weight >90 Kg

2. Age > 40 yrs

3. Other risk factors for endometrial hyperplasia or carcinoma e.g. infertility, nulliparity, family history of colon or endometrial cancer, exposure to unopposed estrogen (Grade B)

TreatmentA. General

1. Menstrual calendar2. Treatment of iron deficiency anemia

B. MedicalI. Hormonal: 1.Progestagen2.Oestrogen3.COCP4.Danazol5.GnRh agonist6.Levo-nova (Merina)II. Non –hormonal1.Prostaglandin synthetase inhibitors (PSI)2.Antifibrinolytics3.Ethamsylate

C. Surgical1.Endometrial ablation2.Hysterectomy

Strategy of treatment <20 yrs 20-40 yrs > 40 yrs

Medical Always First resort after endometrial biopsy Temporizing & if surgery is refused or imminent menopause

Surgical Never Seldom, only if medical treatment fail First resort if bleeding is recurrent

Medical treatment:AntifibrinolyticsMechanism of action: The endometrium possess an active fibrinolytic system, & the fibrinolytic activity is higher in menorrhagia. Effect: Greater reduction of menstrual bleeding than other therapies (PSI, oral luteal phase progestagen & etamsylate)(Cochrane library,2002). Tranexamic acid is effective in treating menorrhagia associated with IUCD.

Side effects: is dose related. Nausea , vomiting, diarrhea, dizziness. Rarely: transient color vision disturbance, intracranial thrombosis. But, no evidence that tranxemic acid increases the risk in absence of past or family history of thrombophilia. This treatment is not associated with an increase in side effects compared to placebo or other therapies (Cochrane library,2002).Dose: 3-6 gm /d for the first 3 days of the cycle

PSI:Mechanism; the endometrium is a rich source of PGE2 & PGF2œ & its concentrations are greater in menorrhagia. PSI decreases endometrial PG concentrations.Effect: PSI decreased menstrual blood by 24% & norethisterone by 20%. The beneficial effect of mefenamic acid on MBL & other symptoms e.g. dysmenorrhea, headache, nausea,

diarrhea & depression persists for several months.

Dose: Mefenamic acid 500 mg tds during menses. Side effects: nausea, vomiting, gastric discomfort, diarrhea, dizziness. Rarely: haemolytic anemia, thrombocytopenia. The degree of reduction of MBL is not as great as it is with tranxamic acid but PSI have a lower side effect profile.

Etamsylate:Mechanism of action: maintain capillary integrity, anti-hyalurunidase activity & inhibitory effect on PGDose: 500 mg qid, starting 5 days before anticipated onset of the cycle & continued for 10 days

Effect: 20% reduction in MBL. There is no conclusive evidence of the effectivness of etamsylate in reducing menorrhgea (Grade A)Side effects: headache, rash, nausea

Systemic progestagens:Norethisterone & medroxyprogesterone acetateEffect:Ovulatory DUB: not effective if given at low dose for short duration (5-10 days) in the luteal phase. Effective if NEA is given at higher dose for 3 w out of 4 w (5 mg tds from D5 to 26)Anovulatory DUB: usefulSide effects: weight gain, nausea, bloating, edema, headache, acne, depression, exacerbation of epilepsy & migraine, loss of libido

Intrauterine progestagensLevonorgestrel intrauterine system levonova,Mirena: Delivers 20ug LNG /d. for 5 yrMetraplant: T shaped IUCD & levonorgestrel on the shoulder & stemAzzam IUCD: Cu T & levonorgestrel on the stem

Effect; 1.Comparable to endometrial resection for management of DUB.2.Superior to PSI & antifibrinolytics3.May be an alternative to hysterectomy in some patients

Side effects;1.BTB in the first cycles2.20% develop amenorrhea within 1 yr3.Functional ovarian cystsSpecial indications: 1. Intractable bleeding associated with chronic illness2. Ovulatory heavy bleeding

The combined contraceptive pill:Effect: Reduce MBL by 50%Mechanism of action: endometrial suppressionSide effects; headache, migraine, weight gain, breast tenderness, nausea, cholestatic jaundice, hypertension, thrombotic episodes,

Danazol: synthetic androgen with antioestrogenic & antiprogestagenic activityMechanism; inhibits the release of pituitary Gnt & has direct suppressive effect on the endometriumEffect: reduction in MBL (more effective than PSI) & amenorhea at doses >400 mg/d

Side effects: headache, weight gain, acne, rashes, hirsuitism, mood & voice changes, flushes, muscle spasm, reduced HDL, diminished breast size. Rarely: cholestatic jaundice.It is effective in reducing blood loss but side effects limit it to a second choice therapy or short term use only (Grade A) Dose: 200 mg/d

GnRH analogSide effects; hot flushes, sweats, headache, irritability, loss of libido, vaginal dryness, lethargy, reduced bone density.

Surgical treatmentEndometrial ablationMethods:I.Hysteroscopic: 1. Laser2. Electrosurgical: a. Roller ball b. ResectionII.Non-hysteroscopic:1. Thermachoice2. Microwave.

Indications:1. Failure of medical treatment2. Family is completed3. Uterine cavity <10 cm4. Submucos fibroid <5 cm5. Endometrium is normal or low risk hyperplasia.

Complications of hysteroscopic methods1. Uterine perforation2. Bleeding3. Infection.4. Fluid overload5. Gas embolism

HysterectomyIndications:

1. Failure of medical treatment2. Family is completed

Routes:1. Abdominal 2. Vaginal 3. Laparoscopic

Advantages:1. Complete cure2. Avoidance of long term medical treatment3. Removal of any missed pathologyDisadvantages:1.Major operation2.Hospital admission3.Mortality & morbidity

Benha University Hospital

E-mail:elnashar53@hotmail.com