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.

-There are many Latin words to describe abnormal vaginal bleeding .

-The classic terms are still in use and 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.

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 cent of women between the ages of 30 and 49 consult their general practitioner

with this complaint .

-Systemic pathology 5%.

-Pelvic pathology 35%.

-Dysfunctional Uterine Bleeding (DUB) 60%.

-Thyroid: hypothyroidism.

-Coagulation disorder: ITP, VWD, leukemia...

-Advanced liver diseases.

-Drugs: Warfarin, Heparin, Aspirin, Tamoxifine, and hormones.

-Fibroid (sub-mucosal).-Endometriosis.

-Adenomyosis.-Chronic PID.

-Copper releasing IUCD.-Endometrial hyperplasia and malignancy.

-Ovarian tumors; Estrogen producing.

-Defined as Menorrhagia in the absence of organic (pelvic, systemic) pathology .

-Is a diagnosis of exclusion.

1-PG E2 and PG F2α. 2-Fibrinolytic system.

3-Blood Vessels of the endometrium.

-The most important is prostaglandin release and Fibrinolytic system any disturbance in them bleeding.

-Disturbance in prostaglandin release such as if PGE2 increased (it is a vasodilator) will lead to bleeding and increased PG F2α which will cause spasmodic or primary dysmenorrhea.

-Also, if too much fibrinolytic system activity menorrhagia.

Ovulatory DUB:Endometrial dysfunction:- PG’s imbalance:- (decrease PGF2a : increase PGE2 ratio) .

-Increased fibrinolytic activity.

-Ineffective contraction of myometrial vessels.

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 .

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How to approach a case with DUB?

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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.

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- 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).

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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.

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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

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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 1 to day 5 of the cycle.

- It decreases menstrual blood loss by 25%. - Side effects: gastritis, gastric ulcer.

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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.

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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 of the cycle.

- It decreases menstrual blood loss by 25%. - No serious side effects .

- So its safe to use .

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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…

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3 -Danazol: - It is an androgen analogue (17-α–ethinyl testosterone. - Also, has antiestrogentic & antiprogestrogenic.

- Depression of the HPO- axis and has a direct suppressive effect on endometrium. - Decreases menstrual blood loss by 80 – 100%.

- Side effects: » Hoarseness of voice. » Hirsutism and acne . » Increase muscle mass.

» Cliteromegaly. » Breast atrophy.

» Hypooestrogenic: Menopausal symptoms.

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4 -GnRH analogues:

- 3.75mg IM monthly, for 4 months. - Decreases Menstrual blood loss by 80- 100%.

- Depression of the HPO- axis; Menopausal symptoms .

- Major risk: Osteoporosis if used more than 6 months.

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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 80–90.% ~ - 30% of women are amenorrhoeic after one year of insertion.

- It decreases the incidence of PID. - Doesn’t increase risk of ectopic pregnancy.

- Side effects: breakthrough bleeding & spotting for the first 3-6 months after insertion.

Surgical treatments for menorrhagia: Surgical treatment is normally restricted to women for whom

medical treatments have failed.

Womem contemplating surgical treatment for menorrhagia should be certain that their family is complete .

Women wishing to preserve their fertility for future attempts at childbearing should therefore be advised to have the LNG-IUS rather than endometrial ablation or hysterectomy.

1.Endometrial ablation All endometrial destructive procedures employ the principle that

ablation of the endometrial lining of the uterus to sufficient depth prevents regeneration of the endometrium .

-During normal menstruation, the upper functional layer of the endometrium is shed, whilst the basal 3 mm of the endometrium is retained.

-In endometrial ablation, the basal endometrium is destroyed, and thus there is little or no remaining endometrium from which functional endometrium can regenerate.

There is a variety of methods by which endometrial ablation can be achieved, including the following:

Methods performed under direct visualization at hysteroscopy:

•Laser •Diathermy

•Transcervical endometrial resection.

Methods performed non-hysteroscopically (i.e. without direct visualization of the endometrial cavity at the time of the procedure)

•Thermal uterine balloon therapy •Microwave ablation

• Heated saline.

All the above operations are performed through the uterine cervix. Most take around 30-45 minutes to perform, and in the majority of cases the patient can return home that evening. The mean reduction in MBL associated with endometrial ablation is around 90%.

The complications associated with endometrial ablation include -uterine perforation.

-Haemorrhage .

-fluid overload .

-Around 4 per cent of women have some sort of immediate complication .

-In 1 per cent of women, the complications arising during the procedure are sufficiently serious to prompt either laparotomy or another unplanned surgical procedure.

-Hysterectomy involves the removal of the uterus. It is an

extremely common surgical procedure.

- Hysterectomy can be 'total', in which the uterine cervix is also removed, or 'subtotal', in which the cervix is retained .

Hysterectomy is often accompanied by bilateral oophorectomy (removal of both ovaries) .

The precise choice of operation should be determined after detailed discussion between the doctor and patient. In terms of the treatment of menorrhagia, it is removal of the uterus that effects a cure, and '-thus removal of the cervix and/ or ovaries is an 'optional extra.

The main perceived advantage of oophorectomy is a reduced risk of ovarian cancer .

-Additionally, women with pelvic pain and/or severe premenstrual syndrome in addition to their menorrhagia may find that hysterectomy and bilateral salpingo-oophorectomy is more effective at treating their symptoms than hysterectomy alone .

-These advantages have to be set against the adverse effects of oestrogen loss on bone density for women who do not take hormone replacement therapy (HRT) after oophorectomy.

Mode of hysterectomyTotal hysterectomy may be achieved using three main techniques:

•abdominal hysterectomy •vaginal hysterectomy

•laparoscopically assisted hysterectomy .

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