Prof FOMULU Joseph Nelson

PLAN1. Definition2. Clinical types of abnormal uterine bleeding

1. Menorrhagia2. Hypomenorrhoea3. Metrorrhagia4. Polymenorrhoea5. Menometrorrhagia6. Oligomenorrhoea7. Contact bleeding8. Amenorrhoea9. Dysmenorrhoea

3. Evaluation of abnormal bleeding1. Clinical history2. Physical exam3. Investigations

4. General principles of management

1- Definition

• Any bleeding from uterus that differs materially from that of the normal menstrual cycle in frequency of occurrence, in amount or in duration of flow.

• It applies to both menstrual and non menstrual disturbances due to– Organic disease either benign or malignant– Or to systemic or psychogenic origin

• Between menarche and menopause, almost every woman experiences one or more episodes of abnormal uterine bleeding.

2- Clinical types of abnormal uterine bleeding

Menorrhagia (hypermenorrhoea)Cyclical menstrual bleeding excessive in amount and/ or

prolonged in durationCauses:

Uterine fibroids Complication of undiagnosed pregnancy Adenomyosis Endometrial hyperplasia Malignant tumours Endometritis Dysfunctional bleeding

2- Clinical types of abnormal uterine bleeding Hypomenorrhoea (cryptomenorrhoea)

An abnormally small amount of menstrual flow usually spotting

Causes: Cervical stenosis Congenital transverse vaginal membrane Asherman syndrome Endometrial tuberculosis

PolymenorrhoeaPeriods occurring too frequently, usually less than 21 days

apart. Bleeding may or may not be abnormal in amountCauses: anovulation (endocrine disorders)

2- Clinical types of abnormal uterine bleeding

Metrorrhagia (intermenstrual bleeding)Bleeding occuring at any time between menstrual

periods ranging from slight spotting to haemorragic flow and from a single short episode to bleeding that continues for days

Causes: Endometrial polyps Endometrial and cervical cancers Exogenous oestrogen administration

2- Clinical types of abnormal uterine bleeding Menometrorrhagia

Uterine bleeding totally irregular in frequency and duration of episodes and excessive in amount.

Causes: Complications of pregnancy (abortion, hydatoform mole,

choriocarcinoma) Malignant genital tract tumours

OligomenorrhoeaMenstrual periods that occur more than 35 days apart.

Bleeding usually decreased in amount and durationCauses: Menopause, Anovulation, Pregnancy

complications, Oestrogen-producing tumors

2- Clinical types of abnormal uterine bleeding Contact bleeding

Self-explanatoryCauses:

Cervicitis Cervical cancer Cervical eversion (ectropion) Cervical polyps

Amenorrhoea Failure to menstruate which is:

Physiology (before puberty, during pregnancy, puerperum and after menopause)

Pathological Primary amenorrhoea: congenital malformations, genetic disorders. Secondary amenorrhoea

2- Clinical types of abnormal uterine bleeding

DysmenorrhoeaPainful menstruation, the commonest gynaecological

complaint, and leading cause of absenteism primary dysmenorrhoea: idiopathic causes (theories) secondary dysmenorrhoea: organic disease (PID,

endometriosis, fibroids, ...)

3- Evaluation of abnormal uterine bleeding

Clinical historyMany causes of bleeding will be strongly suggested by

history alone.Note amount of flow, duration of cycle, duration of

periods, number of episodes, LMP, menopause and any change in general health

Physical examinationGeneral health conditionGlandsAbdominal massesSize of the uterus/ovariesCervix

Evaluation of abnormal uterine bleeding

InvestigationsPap smearEndometrial BiopsyHysteroscopyD & CHormonal assaysUltrasoundLaparoscopy

4- General principles of management

A careful clinical history, physical and pelvic examination are vital.

Improved diagnostic technics and treatment have resulted in better care of patients with abnormal uterine bleeding.

ReferencesIntegrated Obstetrics and Gynaecology for

postgraduates by C.J. Dewhurst, 2nd edition by Blackwell Scientific Publications.

Obstetrics and Gynaecology (Scientific Foundations of) by Elliot E Philipp, Josephine Barns and Michael Newton International Edition (3rd edition)

Principles of Gynaecology, by Sir Norman Jeffwate, Butterworths, 4th edition.