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Bleeding
Dr. Mashael Shebaili
Asst. Prof. & Consultant
Ob/Gyne Department
Normal menstruation
Rhythm: regular from 21-35
days
Duration: 3-7 days
Amount: between 30-50 mls
Flow: non clotted fluid blood
Disorders in rhythm, amount
or duration
Menorrhagia
Polymenorrhea
Oligomenorrhea
Metrorrhagia
Causes of Menorrhagia
DUB
Pelvic pathology
Medical
Clotting defect
Dysfunctional uterine
bleeding
Definition: uterine bleeding in
the absence of an organic
disease
Incidence: 10-20% usually at
extremes of reproductive life.
Diagnosis (by exclusion)
History
General examination
Abdomino-pelvic examination
Investigations (mainly to
exclude organic causes)
Treatment
I. Medical treatment
A. Non-steroidal anti-inflammatory
drugs
Mechanism of action: inhibit cyclo-
oxygenase enzyme and the
production of prostaglandins
Phospholipids phospholipase A
2
Norethisterone medroxy-
progesterone acitate.
Are the most commonly prescribed
preparations in UK because it was
wrongly thought that the majority of
women with DUB are anovulatory
Mechanism of action:
1. In anovulatory cycle it induce secretory
changes but in ovulatory cycle it
produce minimal changes
2. Norethisterone is given as 5mg t.d.s. for
21 days while Provera is given as 10 mg
for 10-14 days during luteal phase.
Effectiveness:
1. If given in high dose for 21 days
especially in anovulatory cycle it reduce
menstrual loss by 80% (Irvin et al.,
1998)
2. In anovulatory cycle it convert irregular,
unpredictable bleeding into regular
controlled one which is an attractive
feature for many women.
Side effects:
side effects
Gonadotrophin releasing hormone agonist
Mechanism of action: produce down
1. Needs experience
A. History
Personal history
(a) Age: The commonest age incidence for carcinoma of
uterus is 55-70 years while that for carcinoma of the
vulva is 60-70 years.
(b) parity: some tumours are more common among
nulliparae e.g. endometrial and ovarian carcinoma.
Present history
Ask about the amount, character and duration of
bleeding, duration of menopause, and the presence of
other symptoms as pain and foul discharge, urinary and
gastrointestinal symptoms (malignant invasion of bladder
or bowel).
Past history
(a)Oestrogen therapy.
(b) diseases as diabetes mellitus,
hypertension and blood diseases as
leukemia.
Endometrial carcinoma is more common
in diabetic hypertensive patients.
Family history
Carcinoma of the body of the uterus and
ovary have a familial tendency
B. General Examination
(I) Signs of anaemia.
(2) signs of bleeding disorders.
(3) presence of cachexia.
(4) examination of heart and chest for
secondaries.
(5) estimation of blood pressure
C Abdominal Examination
For a pelvi-abdominal mass and ascites
which is common with ovarian malignancy.
D.Pelvic Examination
To detect a local cause for bleeding. The
urethra and anal canal are excluded as
being the source of bleeding.
E. Special Investigations
1. Transvaginal sonography. It excludes the
presence of an ovarian tumour or a
lesion in the uterus as endometrial carcinoma.
2. Cervical smear. Taken in absence of bleeding
to detect the presence of malignant
cells which may come from the cervix,
endometrium, tubes, or ovaries.
3. Endometrial biopsy. It must be done in every
case of postmenopausal bleeding, as
it is the only sure method to exclude
endometrial carcinoma.
Endometrial biopsy is taken by one of three methods;
Fractional uterine curettage,
Endometrial aspiration, or
Hysteroscopy.
4. Biopsy is taken from any suspected lesion in
the vulva, vagina, or cervix.
5. Laboratory tests. These are done according to
the clinical findings and include:
a. Complete blood count.
b. Platelet count, bleeding time, coagulation
time, estimation of clotting factors if a
bleeding disorder is suspected.
Treatment
It is treatment of the cause.
If no cause can be detected the patient
should be followed up.
If bleeding recurs it is better to do
hysterectomy and bilateral salpingo-
oophorectomy which may reveal a missed
early carcinoma of uterus or tube .
Thank you