Frequency of menses. Duration of menses 3 days to 7 days. Flow/amount of menses Average blood loss with menstruation is 60-80cc.

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3 Frequency of menses 24 days (0.5%) to 35 days (0.9%) Age 25, 40% are between 25 and 28 days Age 25-35, 60% are between 25 and 28 days Teens and women over 40 s cycles may be longer apart Duration of menses 3 days to 7 days Usually 4-6 days Flow/amount of menses Average blood loss with menstruation is 60-80cc.

4 Menorrhagia (hypermenorrhea): heavy or prolonged uterine bleeding that occurs at regular intervals. Some sources define further as the loss of 80 ml blood per cycle or bleeding > 7 days. Metrorrhagia: irregular menstrual bleeding or bleeding between periods Menometrorrhagia: metrorrhagia associated with > 80 ml Polymenorrhea: uterine bleeding occurring at regular intervals of less than 21 days

5 Hypomenorrhea: periods with unusually light flow, often associated with hypogonadotropic hypogonadism (athletes, anorexia). Also may be associated with Asherman s syndrome Oligomenorrhea: Menses are > 34 d apart. Most commonly caused by PCOS, pregnancy, and anovulation Amenorrhea: Primary amenorrhea Secondary amenorrhea No menses for 3-6 months Dysfunctional Uterine Bleeding: excessive uterine bleeding with no demonstrable organic cause. It is most frequently due to abnormalities of endocrine origin, particularly anovulation.

6 pregnancy Hormones Iatrogenic Mechanical Infection cancer

7 Organic Systemic Reproductive tract disease Iatrogenic Inorganic (Dysfunctional) Anovulatory Ovulatory

8 Systemic Disease Coagulopathy Von Willebrand s disease Prothrombin deficiency Leukemia Sepsis ITP Hypersplenism Hypothyroidism Frequently associated with menorrhagia as well as intermenstrual spotting Incidence 0.3% to 2.5% among women with menorrhagia

9 Reproductive tract disease : Gestational events Abortions Ectopic pregnancies Trophoblastic disease Malignancy Cervical cancer Endometrial cancer Estrogen producing ovarian tumors

10 Anatomic uterine abnormalities Leiomyomata Submucosal Intramural Endometrial polyps Adenomyosis Iatrogenic Causes of AUB Intra-uterine device Oral and injectable steroids drugs Infection Endometritis Cervicitis

11 In late perimenopausal patients, ovarian function may be wildly sporadic, so long episodes of amenorrhea, hot flashes, and even laboratory determinations interpreted as menopausal (increased follicle-stimulating hormone [FSH], decreased estradiol) may be followed by some bleeding, staining, or spotting that may represent agonal episodes of ovarian function. any bleeding, spotting, or staining after 12 months of amenorrhea should be viewed as endometrial cancer until proven otherwise and endometrial evaluation becomes mandatory.

13 curettage in the hospital with anesthesia was the gold standard. First described in 1843, it was once the most common operation performed on women in the world. Even 50 years ago, it was understood that the technique missed endometrial lesions in many cases, especially those that were focal (polyps) In the 1970s, vacuum suction curettage devices first allowed for endometrial sampling without anesthesia in an office setting. Such procedures, although office based, were cumbersome and resulted in great patient discomfort. Subsequently, cheaper, smaller, less painful plastic catheters with their own internal pistons to generate suction became popular.

Transvaginal Ultrasound : Endometrial thickness should be measured on a sagittal (long axis) image of the uterus, and the measurement should be performed on the thickest portion of the endometrium,

14 Transvaginal Ultrasound : Endometrial thickness should be measured on a sagittal (long axis) image of the uterus, and the measurement should be performed on the thickest portion of the endometrium, excluding the hypoechoic inner myometrium Often, fibroids, previous surgery, marked obesity, or an axial uterus may make visualization suboptimal. In these cases, ultrasound cannot be relied on to exclude disease. The next step for such patients with bleeding should be either hysteroscopy or saline infusion sonohysterography

15 Sonohysterography : The use of fluid instillation into the uterus coupled with high-resolution transvaginal probes allows tremendous diagnostic enhancement with an inexpensive, simple, welltolerated office procedure The addition of saline infusion sonohysterography can reliably distinguish perimenopausal patients with dysfunctional abnormal bleeding (no anatomic abnormality) from those with globally thickened endometria or focal abnormalities

16 Hysteroscopy : Hysteroscopy is a procedure in which a small endoscope is inserted into the vagina and through the cervix to view the uterine lining directly It is useful in identifying and taking biopsies or removing endometrial polyps and submucous myomas

17 the most common cause of abnormal uterine bleeding in premenopausal women is oligoanovulation, which reflects dysfunction in the hypothalamic pituitary ovarian axis. Also, as discussed previously, in addition to disturbances of ovulation, abnormal uterine bleeding may be caused by anatomic conditions including polyps, fibroids, hyperplasias, and even frank carcinoma, especially with increasing age Any bleeding in postmenopausal women who are not on hormone therapy or uterine bleeding that persists longer than 6 months with continuous combined hormone therapy must be evaluated. The most common cause of such bleeding is endometrial atrophy

1- Hormonal Management : Oral Contraceptives Low-dose combination oral contraceptive pills are considered to be the first-line treatment of abnormal uterine bleeding when it occurs in otherwise

18 1- Hormonal Management : Oral Contraceptives Low-dose combination oral contraceptive pills are considered to be the first-line treatment of abnormal uterine bleeding when it occurs in otherwise healthy, nonsmoking, premenopausal women, regardless of their contraceptive status. Continuous Progestin-Only Contraceptives Injectable long-acting medroxyprogesterone acetate in a depo form (DMPA) will produce amenorrhea over time and provides contraception if needed. Cyclic Oral Progestogen In the past, cyclic oral progestogen therapy (progestin or progesterone) has been a standard medical therapy for dysfunctional anovulatory bleeding in perimenopausal women. This usually entails administering cyclic progestogen for 12 to 14 days each month.

19 Parenteral Estrogen : For acute excessive abnormal uterine bleeding, the use of intravenous estrogen works well to temporize a volatile situation Gonadotropin-Releasing Hormone Agonists : (GnRH) agonists induce a reversible hypoestrogenic state These agents are effective in reducing menstrual blood loss in premenopausal patients They are limited by their expense and side effects including hot flashes, reduction of bone density, and temporary nature.

20 Dilation and Curettage : (D & C) D&C, by itself, is a blind surgical procedure that usually requires general anesthesia. Because it is a blind procedure when performed without concurrent hysteroscopy, D&C can miss localized disease such as polyps, submucous myomas, or focal hyperplasias. Endometrial Destruction : Adequate endometrial histologic evaluation should take place prior to an ablative procedure. Ablative procedures may not successfully treat abnormal uterine bleeding when the anatomic lesion is located in the uterine wall, such as intramural myomas that extend into the endometrial cavity or extensive adenomyosis. Uterine Artery Embolization Hysterectomy : Hysterectomy (total or supracervical) is the only definitive cure for benign abnormal uterine bleeding that has failed to respond to medical treatment.

5/5/2010 FINANCIAL DISCLOSURE. Abnormal Uterine Bleeding. Is This A Problem? About me % of visits to gynecologist

5/5/2010 FINANCIAL DISCLOSURE. Abnormal Uterine Bleeding. Is This A Problem? About me % of visits to gynecologist Abnormal Uterine FINANCIAL DISCLOSURE I HAVE NO FINANCIAL INTEREST IN ANY OF THE PRODUCTS MENTIONED IN MY PRESENTATION Bryan K. Rone, M.D. University of Kentucky Obstetrics and Gynecology May 5, 2010 About