Fawaz Edris MD, RDMS, FRCSC, FACOG, AAACS

INTRODUCTION 1/3 of outpatient visitsMost after menarche or perimenopausalMultiple causes, but mostly:

Pregnancy related (always R/O)Structural uterine pathology (fibroids, polyps,

adenomyosis)AnovulationDisorder of hemostasisNeoplasiaTraumaInfectionMore than 1 !! (myoma + cancer)

Non gynecological source (urethra, rectum)

MENSTRUAL CYCLEMechanism: Estrogen Ovulation

Preogesteron withdrawal menstruation 24 - 35 days, lasting 2 to 7 days, flowing <80

mL/cycle Predictable cyclic menses reflect regular

ovulationDUB vs. AUB

DUB: anovulation – no anatomical or systemic disease – by exclusion

PATTERNS OF AUBMenorrhagia: excessive (>80 mL/cycle) or prolonged

menstrual bleeding (>7 days)Amenorrhea: absence of bleeding ≥ 3 usual cyclesOligomenorrhea: bleeding with interval > 35 daysPolymenorrhea: bleeding with interval < 24 daysMetrorrhagia: light bleeding at irregular intervalsMenometrorrhagia: heavy bleeding at irregular

intervalsIntermenstrual bleeding: bleeding between menses Premenstrual spotting: light bleeding preceding mensesPost coital spotting: vaginal bleeding within 24h of

intercourse

HISTORY What is the nature of the bleeding

(frequency, duration, volume, relationship to activities such as coitus)Quantity – number of pads, soaknessIntermenstrual bleeding - structural lesion

(endometrial polyp, fibroid, cervical neoplasia)Menometrorrhagia - anovulatory bleedingRegular cyclic periods – ovulatoryMenorrhagea - bleeding diathesis, fibroid,

adenomyosis.

HISTORYAre there symptoms of ovulation? (molimina)When did the bleeding start?

Menorrhagia since menarche - Bleeding diathesis

Perimenarcheal and perimenopausal - Anovulation

Perimenopausal - polyps, adenomyosis, and fibroids

Were there precipitating factors, such as trauma?

HISTORYAny associated symptoms?

Lower abdominal pain, fever, vaginal discharge - infection (endometritis, vaginitis)

Changes in bladder or bowel function - mass effect from a local neoplasm or nonuterine bleeding

Headaches, breast discharge, visual disturbances - prolactinoma or other cranial tumor

Hirsutism or hair loss, acne – PCOSCold or Hot intolerence, Constipation or diarrhea

- thyroid disease

HISTORYIs there a personal or family history of a bleeding

disorder? bleeding associated with surgery, dental

extraction, childbirth, or bruising (>5 cm)/epistaxis/bleeding gums once or twice a month

Does she have a systemic disorder?chronic liver or renal disease, thrombocytopenia -

menorrhagiaAny medications?

Anticoagulants – menorrhagiaIUCD or OCP - intermenstrual bleeding

HISTORYIs she having coital relations?

Pregnancy relatedAlways do pregnancy test

Change in weight, eating disorder, excessive exercise, illness, or stress? Anovulatory bleeding

PHYSICAL EXAMINATION Speculum and pelvic examinations

Bleeding site: vulva, vagina, cervix, urethra, or anus

Any suspicious findings (mass, laceration, ulceration, vaginal discharge, foreign body)

Assess the size, contour, and tenderness of the uterus fibroids, adenomyosis, pregnancy, or infection

Examine the adnexa for an ovarian tumor Evaluate for pain - infection

PHYSICAL EXAMINATION General examination

Signs of systemic illness, such as feverEcchymosesEnlarged thyroid glandHyperandrogenism (hirsutism, acne,

clitoromegaly, or male pattern balding)Acanthosis nigricans - insulin resistance and

anovulation. Galactorrhea - hyperprolactinemia.

LABORATORY EVALUATION Pregnancy test in all reproductive age

womenIntrauterine pregnancyEctopicGestational trophoblastic disease

Cervical cytology Any visible cervical lesion should be biopsied

LABORATORY EVALUATIONEndometrial biopsy - endometrial cancer

hyperplasia  All women > 35 years 18 and 35 years if with risk factors for endometrial

cancer (family or personal history of ovarian, breast, colon, or endometrial cancer; tamoxifen use; chronic anovulation; obesity; estrogen therapy; prior endometrial hyperplasia; diabetes)

Always r/o pregnancy then do in second half of cycle Secretory endometrium - ovulation Proliferative endometrium – anovulation Inflammation of the endometrium - endometritis

ADDITIONAL LAB. EVALUATION Hemoglobin/hematocrit TSHCoagulation tests 

Platelet count – thrombocytopeniaCoagulation testing - PTT, PT, factor VIII, and

von Willebrand factor antigen and activity STD: Gonorrhea, Chlamydia, trichomonadsProlactin level Androgen levels: Testosterone, DHEAS

ADDITIONAL LAB. EVALUATION Ultrasound

Fibroids, adenomyosis, endometrial lining, ovaries

Saline infusion sonography (sonohysterography)Fibroids, polyps

Hysteroscopy 

MANAGEMENT Is bleeding ovulatory or anovulatory? 

Ovulatory treat the underlying causeAnovulatory

Acute management Estrogen: Oral or IV D&C (temporary measure – not therapeutic)

Ongoing management Replace Progesterone

Progesterone: pills (continuous or cyclical), injections OCP

Other measures Thin the endometriam: hormonal IUCD Remove the endometriam: Ablation Remove the organ: Hysterectomy

MANAGEMENT If bleeding persists after treatment

Additional etiologies continue to evaluate

Thank you