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REPRODUCTIVE AGE GROUP
Normal Menses
The mean duration of menses is 4.7
days; 89% of cycles last 7 days or
longer.
 The average blood loss per cycle is
35 ml .
 the blood content of menses varies
over the days of bleeding, but on
average is close to 50% .
 Recurrent bleeding in excess of 80
ml /cycle results in anemia
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Prevalence
%5 of women between the age 30 and
49 years consult a physician for
menorrhagia .
 21 to %67 develops iron deficiency
anemia .
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Differential diagnosis
dysfunctional uterine bleeding (estrogen
breakthrough. Low levels of estrogen stimulation
whereas higher sustained levels result in episodes
of amenorrhea followed by acute, heavy bleeding.
 Pregnancy-related Bleeding.
In the United States, more than 50% of
pregnancies are unintended.
 EP.
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Differential diagnosis
Exogenous Hormones .
 Ocpill. contraceptive patch, vaginal ring, and
intramuscular regimens,
 Use of progestin-only methods—including DMPA,
progestin-only pills, the contraceptive implant,
and the levonorgestrel IUS. is associated with
relatively high rates of initial irregular and
unpredictable bleeding .
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Causes of abnormal genital tract
bleeding
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Genital tract disorders :
uterus
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polyps
endometrial hyperplasia
Adenomyosis
fibroids
adenocarcinoma
sarcoma
endometritis
anovulatory bleeding
Cervix
Benign growths:
Polyps
Ectropion
Endometriosis
Cancer:
Invasive carcinoma
Metastatic (uterus, choriocarcinoma)
Infection:
Cervicitis
Condyloma. HSV,chlamidia.
Vagina
Benign growths:
Gartner's duct cysts
Polyps
Adenosis (aberrant glandular tissue)
Cancer
Vaginitis/infection:
Bacterial vaginosis
Sexually transmitted diseases
Atrophic vaginitis
Vulva
Benign growths
Skin tags
Sebaceous cysts
Condylomata
Angiokerataoma
Cancer
Infection:
Sexually transmitted diseases
Upper genital tract
disease
Fallopian tube cancer
Ovarian cancer
Pelvic inflammatory disease
Pregnancy
complications
Trauma
Sexual intercourse
Sexual abuse
Foreign bodies (including IUD).
Pelvic trauma (eg, motor vehicle
accident)
Straddle injuries
Drugs
Contraception:
Oral contraceptives
Copper intrauterine device
Depo-Provera
Hormone replacement therapy
Anticoagulants
Tamoxifen
Corticosteroids
Chemotherapy
Dilantin
Antipsychotic drugs
Antibiotics (eg, due to toxic epidermal necrolysis or Stevens-Johnson
syndrome)
 Systemic
disease
Crohn's disease
 Behcet's syndrome
 Pemphigoid Pemphigus
 Erosive lichen planus
 Lymphoma
 Coagulation disorders:
 von Willebrand's disease

Thrombocytopenia or platelet dysfunction
Acute leukemia
Some factor deficiencies
Advanced liver disease
Thyroid disease
Hyperprolactinemia
Polycystic ovary syndrome
Chronic liver disease
Cushing's syndrome
Systemic disease
 Hormone
secreting adrenal and
ovarian tumors
 Renal disease
 Emotional or physical stress
 Smoking
 Excessive exercise
Systemic disease
Diseases not affecting the genital tract
 Urethritis
 Bladder cancer
 Urinary tract infection
 Inflammatory bowel disease
 Hemorrhoids
 Vascular tumors and anomalies in the
genital tract

Endocrine Causes
hypothyroidism and hyperthyroidism .
 With hypothyroidism : Menorrhagia, are
common.
 Hyperthyroidism can result in oligomenorrhea or
amenorrhea. and it also can lead to elevated levels
of plasma estrogen.
 Hypothalamic dysfunction, hyperprolactinemia,
premature ovarian failure, and primary pituitary
disease, irregular bleeding also may result in their
presence.

Endocrine Causes.
Diabetes mellitus can be associated with
Anovulation, obesity, insulin resistance,
and androgen excess .
 Polycystic ovary syndrome is present in 5%
to 8% of adult women and undiagnosed in
many women .
 Because androgen disorders are associated
with significant cardiovascular disease, the
condition should be diagnosed promptly and
treated.
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Anatomic Causes
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Uterine leiomyomas. cumulative prevalence of
greater than 80% in black women and nearly 70% in
white women. are estimated to be clinically significant
in at least 25%of women of reproductive age.
Endometrial polyps. :are a cause of
intermenstrual bleeding, irregular bleeding, and
Menorrhagia, although as with leiomyomas, most
endometrial polyps are asymptomatic.
Endometrial polyps can regress spontaneously.
the chance of malignancy is less than 5% and likely
approximates 0.5%
Abnormal bleeding
intermenstrual or postcoital,
 Cervical lesions.
 endocervical polyps.
 infectious cervical lesions, such as
condylomata, herpes simplex virus,
ulcerations, chlamydial cervicitis, or
cervicitis caused by other organisms.

Coagulopathies and Hematologic
Causes
A complete blood count will be
helpful in detecting anemia,
significant problems such as
leukemia or disorders associated
with thrombocytopenia.
 Alcoholism .
 von Willebrand's disease.
 Oral contraceptive ,
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Infectious Causes
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Cervicitis:
chlamydial cervicitis, can experience irregular
bleeding and postcoital spotting
Endometritis can cause excessive menstrual flow.
woman who seeks treatment for menorrhagia and
increased menstrual pain and has a history of
light-to-moderate previous menstrual flow may
have an upper genital tract infection or PID
(endometritis, salpingitis, oophoritis).
chronic endometritis will be diagnosed when an
endometrial biopsy is obtained for evaluation of
abnormal bleeding in a patient without specific
risk factors for PID.
Neoplasia
invasive cervical cancer.
 cervical lesion should be evaluated by biopsy,
testing may be falsely negative with invasive
lesions as a result of tumor necrosis.
 Unopposed estrogen of the endometrium: cystic
hyperplasia to adenomatous hyperplasia,
hyperplasia with cytologic atypia, and invasive
carcinoma.
 Vaginal neoplasia is uncommon
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Diagnosis
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exclusion of pregnancy.CBC diff. PT,PTT, prothrombin
time and partial prothrombin time ,von Willebrand´s
disease .
possible malignancy.
imaging studies. measurements of endometrial
thickness are significantly Less useful in
premenopausal than postmenopausal women.
Sonohysterography is especially helpful in visualizing
intrauterine problems such as polyps or submucous
leiomyoma.
CT scanning and MRI, are not as helpful in the initial
evaluation of causes of abnormal bleeding and should
be reserved for specific indications.
Endometrial Sampling
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Endometrial sampling should be performed to
evaluate abnormal bleeding in women who are
at risk for endometrial polyps, hyperplasia, or
carcinoma. D & C, Hysteroscopy, endometrial
sampling,
Management
medical therapy .
 surgical management .
 endometrial ablation
 hysterectomy
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Nonsurgical Management
 NSAIDs . Mefenamic acid 500 mg three times
per day
 Naproxen 500 mg at onset and three to five hours
later, then 250 to 500 mg twice a day
 Ibuprofen 600 mg once per day.
 Antifibrinolytics; tranexamic acid .amincaproic
acid.
 Levonorgestrel-containing intrauterine devices .
 Oral contraceptives, Ocs E²>35mcg than 20mcg.
 For patients in whom estrogen use is
contraindicated, progestins, both oral and
parenteral, can be used to control excessive
bleeding .
medroxyprogesterone acetate, administered from
days 5 to 26 of the cycle .
 Depot formulations of medroxyprogesterone
acetate
 Oral, parenteral, or intrauterine delivery of
progestins may be used in selected women with
atypical endometrial hyperplasia who wish to
maintain their fertility, continued monitoring every
3 month is indicated .
 Danazol .
 Gonadotropin-releasing hormone analogues .
 levonorgestrel-containing IUS .
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Surgical Therapy
D&C .
 Endometrial ablation or resection .
 Hysterectomy .
 Hysteroscopy .
 Laparoscopy .
 Uterine artery Embolization .
 Magnetic resonance guided focused
ultrasonography ablation .
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