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  • 1.

2.

  • Disorders of the menstrual cycle are one of the most common reasons for women to attend their general practitioner and, subsequently, a gynaecologist.
  • -Although rarely life threatening, menstrual disorders lead to major social and occupational disruption, and can also affect psychological well-being.
  • Menstrual disorders include:
  • 1 menorrhagia.
  • 2 dysmenorrhea.
  • 3 amenorrhoea/oligomenorrhoea.
  • 4 PCOD.
  • 5 postmenopausal bleeding.
  • 6 premenstrual syndrome .

3.

  • -There are many Latin words to describe abnormal vaginal bleeding.
  • - The classic terms are still in useand need definition.
  • Menorrhagia :an excessive loss of blood (>80ml) with regular menstruation.
  • Metrorrhagia : prolonged bleeding from the uterus.
  • Metro-menorrhagia :heavy and prolonged periods .
  • Polymenorrhoea:frequent menstruation .

4.

  • Menorrhagia:
    • Definition :
    • - Subjective : heavy Regular menstrual bleeding.
    • -Objective: menstrual blood loss more than 80 ml (more accurate), but not used in practice , just in researches.
  • -This definition is rather arbitrary, but represents the level of blood loss at which a fall in haemoglobin and haematocrit concentration commonly occurs.
  • Prevalence :
  • - Menorrhagia is extremely common.
  • Indeed, each year in the UK,5 per centof women between the ages of 30 and 49 consult their general practitioner with this complaint .

5.

  • - Systemic pathology 5%.
  • -Pelvic pathology 35%.
  • -Dysfunctional Uterine Bleeding (DUB) 60%.

6.

  • -Thyroid: hypothyroidism.
  • -Coagulation disorder: ITP, VWD, leukemia...
  • -Advanced liver diseases.
  • -Drugs: Warfarin, Heparin, Aspirin, Tamoxifine, and hormones.

7.

  • -Fibroid (sub-mucosal).
  • -Endometriosis.
  • -Adenomyosis.
  • -Chronic PID.
  • -Copper releasing IUCD.
  • -Endometrial hyperplasia and malignancy.
  • -Ovarian tumors; Estrogen producing.

8.

  • -DefinedasMenorrhagia in the absence of organic (pelvic, systemic) pathology.
  • -Is a diagnosis of exclusion.

9.

  • 1-PG E2 and PG F2.
  • 2-Fibrinolytic system.
  • 3-Blood Vessels of the endometrium.
  • -The most important is prostaglandin release and Fibrinolytic systemany disturbance in thembleeding.
  • -Disturbance in prostaglandin release such as if PGE2 increased (it is a vasodilator) will lead to bleeding and increased PG F2 which will cause spasmodic or primary dysmenorrhea.
  • -Also, if too much fibrinolytic system activity menorrhagia.

10.

  • Ovulatory DUB:
  • Endometrial dysfunction: - PGs imbalance:- (decrease PGF2a :increase PGE2 ratio).
  • - Increased fibrinolytic activity.
  • - Ineffective contraction of myometrialvessels.

11.

  • Hypothalamic Pituitary Ovarian hormonal axis:
  • -Most common age at presentation is less than 20 and more than 40years.
  • -Those who are less than 20 years ,this axis is still immature and they have anovulatory cycles.
  • -While those who are more than 40 years there are decrease in the number and quality of ovarian follicles with many anovulatory cycles.

12.

  • How to approach a case with DUB?

13.

  • History
  • - The hallmark of menorrhagia is the complaint of regular 'excessive' menstrual loss occurring over several consecutive cycles.
  • -this is largely a subjective definition and it can be hard for the woman to communicate in words how much blood she is losing
  • Discussion of the number of towels and tampons used per day may be useful - perhaps accompanied by a menstrual pictogram in selected cases.
  • -Of perhaps greater relevance is to determine the impact of the condition on the patient's lifestyle and quality of life.
  • -For example, the patient whose menorrhagia is so severe that she does not leave the house during her period clearly has a much greater problem (and may wish to pursue treatment further) than one to whom menorrhagia is a minor inconvenience.
  • . .
  • .

14.

  • -It is also important to determine the duration of the current problem, and any other symptoms or factors of potential importance. The following symptoms should be enquired about specifically, as they may suggest a diagnosis other than DUB:
  • -Irregular, intermenstrual or postcoital bleeding,
  • -A sudden change in symptoms,
  • -Dyspareunia, pelvic pain or premenstrual pain,
  • - Excessive bleeding from other sites or in other situations (e.g. after tooth extraction) .

15.

  • Examination:
  • General examination :- general condition: does she look pale or not?
  • - Vitals.
  • - Weight.
  • -Thyroid.
  • -Lymph nodes: axillary and inguinal.
  • - Breast.
  • - Abdomen: Pelvi-abdominal mass/ ascites.
  • Pelvic examination :
  • - Speculum examination.
  • - Bimanual examination.

16. 17.

  • Treatment:
  • -Treat the cause if present.
  • 3 groups of patients with DUB: - Less than 20 years old. - More than 40 years old. - Between 20 and 40 years old

18.

  • Medical treatment:
  • A- Non-Hormonal drugs:
  • 1-non-steroidal anti-inflamatory drugs :Is the most commonly used. Mefenamic acid(Ponstan):
  • - Is the most common drug used by adolescent female; for dysmenorrhea as well.
  • - 3 capsules daily, from day 1to day 5 of the cycle.
  • - It decreases menstrual blood loss by 25%.
  • - Side effects: gastritis, gastric ulcer.

19.

  • 2-Antifibrinolytic:
  • Tranexamic acid:
  • - 3 capsule daily, from day 1 to day 5 of the cycle.
  • - It decreases menstrual blood loss by 50%.
  • - Main side effects; nausea and vomiting, ~ 25% of patients stop it because of these side effects.
  • - Rarely, it may cause cerebral thrombosis, so it is contraindicated in patient with risk factors for thromboembolism.
  • **In certain cases we may use both drugs .

20.

  • B-Hormonal Drugs:
  • 1-Progestogens:
  • - Norethisterone and Medoxyprogesterone acetate.
  • - It is the most common drug used for DUB. - 5 mg twice daily, from day 5 to day 25 ofthe cycle.
  • - It decreases menstrual blood loss by 25%.
  • - Noserious side effects.
  • - So its safe to use.

21.

  • 2- Combined oral contraceptive pill:
  • -1tab daily for 21 days, from day 5.
  • - It decreases menstrual blood loss by 50%.
  • - Minor side effects: Nausea , vomiting ,headache , irritability , increase in weight...
  • - Major side effects: HT , thromboembolism, cardiovascular

22.

  • 3- Danazol : - It is an androgen analogue (17-ethinyl testosterone.- Also, has antiestrogentic & antiprogestrogenic.
  • - Depression of the HPO- axis and has a directsuppressive effect on endometrium. - Decreases menstrual blood loss by 80 100%.
  • - Side effects:
  • Hoarseness of voice.
  • Hirsutismand acne.
  • Increase muscle mass.
  • Cliteromegaly.
  • Breast atrophy. Hypooestrogenic: Menopausal symptoms.

23.

  • 4- GnRH analogues : - 3.75mg IM monthly, for 4 months.
  • - Decreases Menstrual blood loss by 80- 100%.- Depression of the HPO- axis; Menopausalsymptoms.
  • - Major risk: Osteoporosis if used more than 6 months.

24.

  • Between 20 & 40 years old:
  • **Two lines of management:Medical:same as for the teenagers.
  • Levonorgestrol releasing IUCD(Mirena) If they desire contraception; very effective.
  • - 20 mcg of levonorgestrol daily.
  • - It decreases menstrual blood loss by 8090 %.
    • - ~30% of women are amenorrhoeic after one year of insertion. - It decreases the incidence of PID. - Doesnt increase risk of ectopic pregnancy.
  • - Side effects: breakthrough bleeding & spotting for the first 3-6 months after insertion.

25.

  • Surgical treatments for menorrhagia:
  • Surgical treatment is normally restricted to women for whom medical treatments have failed.