Irregular menstruation is a menstrual disorder that can manifest as irregular cycle lengths or metrorrhagia

Irregular menstruation is a menstrual disorder that can manifest as irregular cycle lengths or metrorrhagia

1. KURSK STATE
MEDICAL UNIVERSITY
ABNORMALITIES OF MENSTRUAL
CYCLE
and
ABNORMAL UTERING BLEEDING
Doct. Of Med sci
KhardikovA V

2. DEFINICION
•AUB-BLEEDING,
carachterised–by excesive
volume or prolonged bloodlossand
disturbances of cycle.
•AUB АМК–all acyclic and
excessive cyclic bleedings from
uterus, only exception –pregnancy.

3. Epidemiology
One of the most common health concerns of women.
Because most cases are associated with anovulatory
menstrual cycles,
adolescents and perimenopausal women are particularly
vulnerable.
About 20% of affected individuals are in the adolescent
age group.
50% of affected individuals are aged 40-50 years.
In a study of 400 perimenopausal women, the most
common type of bleeding pattern was menorrhagia
(67.5%), and the most common pathology was simple
endometrial hyperplasia without atypia (31%).

5. Physiology of menstrual cycle
Menstrual cycle is a normal physiological cyclic process
occurred in women after reaching menarche
( reproductive age )
It is a periodic vaginal bleeding due to separation of
uterine f. layer of endometrium( menstruation )
Normal menstrual cycle last for 28 days ±7 days
Duration of menstruation is 3 –5 days ( 1 –8 days )
Average blood lost is 60 –80 ml

6. Abnormal Uterine Bleeding
Abnormal menstrual bleeding refers to
abnormalities in amount, frequency, duration
or regularity of bleeding
Types of uterine bleeding
1.Organic
2.Non-organic / Functional

7. Terms included :-
1.Metrorrhagia
Irregular, frequent bleeding
But not excessive in amount
2.Menorrhagia
Prolonged or excessive bleeding
At regular interval
3.Meno-metrorrhagia
Prolonged or excessive
At irregular interval
4.Polymenorrhea
At regular interval but more than normal frequency
Less than 21days per cycle

8. 3.Oligomenorrhea
At regular interval but decreased in frequency
More than 35 days per cycle
4.Amenorrhea
Abscent of menstruation for more than 6 months
5.Hypermenorrhea
Menstrual bleeding more than 80 ml
6.Hypomenorrhea
Menstrual bleeding less than 30 ml
7.Intermenstruation
Bleeding between regular menstrual cycle
8.Postmenopausal bleeding
Uterine bleeding that occurs more than 1 year after
the last menses in a woman with ovarian failure

9. classification
PALM
Polip
Adenomyosis
Leyomyoma
malignancy
COEIN
Coagulopathy
Ovulation problem
endometrial problems
Iatrogenic
Nonspecific

10. Classifica
tion

11. Structural
Causes
Polyps –AUB (P)
◦endocervical or endometrial
Detected by ultrasound or
sonohysterography
Often irregular, light bleeding

12. POLYPS
FUNCTIONAL
FIBROTIC
ADENOMATOSIS

14. Other causes for bleeding
Endometriosis
Endometriosis is a condition in which tissue that looks and acts
like endometrial tissue is found in places other than the lining of
the uterus, such as ovaries, tubes, bowels, outer surface of the
uterus and other pelvic structures. Endometriosis may also
develop on body tissues located anywhere in the abdomen. These
tissues respond to the cycle of changes brought on by the female
hormones just as the endometrium normally responds in the
uterus. Endometriosis can cause pelvic pain, dysmenorrhea, and
infertility.

15. Structural
Causes
Adenomyosis –
AUB (A)
Controversial as a
cause of bleeding
Diagnosed with
ultrasound, MRI,
pathology

16. Organic type of bleeding
Eg. Fibroid, tumour, polyps, myoma
Produce symptoms like hypermenorrhea,
menorrhagia
Pathogenesis :-
1.Fibroid must grow towards uterine cavity
2.Resulting protrusion and distortion of cavity
3.Compression and congestive alteration
4.Result excessive bleeding

17. Structural
Causes
Leiomyoma –
AUB (L)
Submucous
Intramural
Subserosal
Diagnosed with
exam, ultrasound,
MRI, CT
Heavy, regular
bleeding

19. MALIGNANCY
CERVICAL
ENDOMETRIAL
UTERINE
TBD
OTHERS

22. Non-structural
causesCOEIN
Coagulopathies or bleeding
disorders
Ovulatorydysfunction
Endometrial
Iatrogenic sources
(medications, smoking)
Not yet classified

23. COAGULOPATHY
LEUCEMIA
TROMBCYTOPENIA
OTHERS

24. Functional type of bleeding
Eg. Ovarian cyst, suprarenal, thyroid ( hormonal
organ involvement )
Hyperestrogenism due to deficit in progesterone
1.Absolute
2.Relative
In 1
st
phase of ovulatory cycles, estrogen causes
proliferative effect of endometrium
In 2
nd
phase, counter balance by progesterone
secretion
But progesterone deficit maybe due to
1.Luteal insufficiency
2.Persistant anovulatory cycle

25. Ovarian Cysts
There two major types of ovarian cyst
Persistent follicular cysts
Persistent luteal cysts (luteinized unruptured
follicle).

26. Patho-physiological changes
during functionalbleeding
Most functional(or dysfunctional) uterine bleeding
characterized byabsolute or relative hyperestrogenism
[too much estrogen] due to a deficiency of
progesterone.
in the first phase of the normal ovulatory cycles, the
estrogens produceremarkable proliferative effects in
the endometrium
after ovulation and in the second phase,
counterbalanced and opposedby the anti-proliferative
and secretoryactions of progesterone upon this tissue.
organicorganic

27. Pathogenesis :-
1.Corpus luteum fails to form
2.Failure of normal cyclic progesterone secretion
3.Continuous unopposed estradiol production
4.Overgrowth of endometrium
5.Without pregnancy, endometrium proliferates
6.Excessive outgrow of blood supply
7.Necrosis
8.Overproduction of uterine blood flow

28. Persistent Follicular Cysts
With a persistent follicular cyst (which is the least common of
the two functional cysts), the growth and development of the
follicle is abnormal probably because of outside stress and its
hormonal effects.
The follicle may grow to a certain size but does not grow any
further and stays a follicle. Sometimes this can go on for
several weeks.
When it does this, it can cause a considerable amount of
discomfort and pain and the woman may present to the
doctor with pelvic pain (often on one side or the other).

29. Pelvic ultrasound will reveal the presence of a
cyst.
To know whether or not it is a follicular cyst by
ultrasound, one also needs to evaluate the lining
of the uterus (the endometrium).
If it is in the proliferative phase (the
preovulatory phase) by ultrasound examination,
Persistent Follicular Cysts

30. Persistent Luteal Cysts
With the persistent luteal cyst (or the luteinized
unruptured follicle), the follicle grows and
develops to a certain point where it would
normally rupture and release the egg.
However, at that point, it does not rupture and
does become luteinized (that is, it causes a
corpus luteum to be formed without the follicle
rupturing).

31. Persistent Luteal Cysts
Progesterone is then produced and eventually the cycle
comes to an end. In this case, the unruptured folicle
remains on the ovary as a cystic structure and usually
increases in size as a woman gets closer and closer to
her menstrual flow.
This cystic structure can reach 5 to 6 cm in size and
become very painful and it is not uncommon then to
present her physician with acute abdominal pain.

32. ENDOMETRIAL PROBLEMS
ENDOMETRITIS
NON SENSITIVITY
OTHERS

33. IATROGENIC, OTHERS
TRAUMA

34. AMENORRHOEA

35. DEFINITION
Amenorrhoea is defined as
absence of menstruation
for 6 months or more.

36. CLASSIFICATION
False Amenorrhea (Cryptomenorrhea)
True Amenorrhea
Physiological.
Pathological–Primary, Secondary

37. PRIMARY AMENORRHOEA
1. No menstruation by the age of 14 years accompanied by
failure to grow properly or develop sec. sexual
characteristics.
2.No menstruation by age of 16 when growth and sexual
development are normal.
SECONDARY AMENORRHOEA
Secondary absence of menses for six months (or greater
than 3 times the previous cycle interval) in a women who
has menstruated before.
Pregnancy, lactation or hysterectomy must be excluded
Prepubertaland post-menopausal conditions are also to
be excluded as physiological causes
______MEDICALLY INDUCED

38. FALSE AMENORRHOEA
(CRYPTOMENORRHOEA)
In this condition, there is periodic shedding
of the endometrium and bleeding but the
menstrual blood fails to come out from the
genital tract due to obstruction in the
passage.

39. FALSE AMENORRHOEA
(CRYPTOMENORRHOEA)
This Obstruction Could be Due to:
Vaginal Imperforated hymen.
Vaginal septum.
Absence of vagina
Cervix
Could be congenital or acquired atresia.

40. TRUE AMENORRHOEA
Physiological
Physiological causes of amenorrhea indicate the absence of menstruation due to natural
conditions:
1.Before Puberty
The age of puberty is 12–14 years. The physiological amenorrhea is before
the pubertal age. It is because the pituitary gonadotrophins are not
adequate enough to stimulate the ovarian follicles for effective
steroidogenesis and the estrogen levels are not sufficient enough to cause
bleeding from the endometrium.
2.During Pregnancy
If a women of child bearing age complains of amenorrhea then it is likely
that she is pregnant. During this period large amount of estrogens and
progesterone are secreted from the trophoblasts (Link to glossary) which
suppresses the pituitary gonadotrophins hence no maturation of the
ovarian follicles.

41. TRUE AMENORRHOEA
3.During Lactation
Due to high levels of some hormones and low levels of others, there
is no menstruation. If the patient does not breast feed her baby, the
menstruation returns by 6th week following delivery in about 40
percent and by 12th week in 80 percent of cases. If the patient
breast feeds her baby, the menstruation may be suspended in about
70 percent until the baby stops breast feeding.
4.Following Menopause
The menopausal age is 45–50 years. During this period no more
follicles are available in the ovaries for the gonadotrophins to act.
Due to which there is cessation of estrogen production from the
ovaries with rise of pituitary gonadotrophins.

42. DIAGNOSTICS OF ABNORMALITIES OF
MENSTRUAL CYCLE

43. Investigation
A.Laboratory
perform a CBC with platelets
prothrombin time ( PT )
activated partial thromboplastin time ( aPTT )
liver function tests ( if other signs indicate liver disease )
Pregnancy must be ruled out by urine and/or serum human
chorionic gonadotropin, before consideration of any imaging
studies
Consider thyroid function tests. FSH, TSH, DHEAS, and
prolactin levels
Tests to determine ovulatory status: Because hormonal
irregularities can contribute to abnormal bleeding,ovulatory
testing may be recommended

44. Transvaginal ultrasound
Consider if the patient may be pregnant or may have anatomic
problems or polycystic ovarian syndrome
An ultrasound uses sound waves to measure an organ's shape
and structure.
Ultrasound cannot distinguish between different types of
abnormalities ( eg, polyps versus cancer ) and further testing
may be necessary.
Pelvic ultrasonography to evaluate for fibroids or other
structural lesions that may cause abnormal vaginal bleeding.

45. Saline infusion sonography or sonohysterography
In this test, a transvaginal ultrasound is performed after sterile
saline is instilled into the uterus.
This procedure gives a better picture of the inside of the uterus,
and small lesions can be more easily detected.
Imaging tests
A computed tomography (CT) scan or magnetic resonance
image (MRI) are non-invasive tests that are sometimes used to
determine if fibroids or other structural abnormalities of the
uterus are present.
Hysteroscopy
During hysteroscopy, a small scope is inserted through the cervix
and into the uterus. Tissue samples may be taken.
In most cases, hysteroscopy is performed along with a D&C.

46. B. Instrumental
Endometrial biopsy
Tests that assess the endometrium (lining of the uterus) to rule out
endometrial cancer and structural abnormalities such as uterine fibroids or
polyps.
A biopsy may also be performed in women younger than 35 if they have risk
factors for endometrial cancer.
During the biopsy, a thin instrument is inserted through the vagina into the
uterus to obtain a small sample of endometrial tissue.
Perform endometrial biopsy for the following patients:
All patients older than 35 years
Obese patients
Patients with diabetes mellitus
Patients with hypertension
Patients with suspected polycystic ovarian disease

47. Dilation and curettage (D&C)
It can be both therapeutic and diagnostic. It may be the treatment of choice
when bleeding is severe, and it allows more extensive sampling of the uterine
cavity and also has a higher sensitivity than endometrial biopsy.
Although mostly an office or intraoperative procedure, hysteroscopy can be
used in place of D&C and allows direct visualization of the endometrial cavity
with directed biopsy.
D&C is indicated in the following situations:
Patients at high risk for endometrial hyperplasia and carcinoma.
Consider D&C rather than endometrial biopsy if suspected diagnosis is
endometritis, atypical hyperplasia, or carcinoma.
Perform in patients having heavy, uncontrolled bleeding.
Perform if histologic examination is required but biopsy is contraindicated.
Perform if medical curettage fails.
It can sometimes be used as a treatment for prolonged or excessive bleeding
that is due to hormonal changes and that is unresponsive to other treatments.

48. Treatment
The treatment of abnormal bleeding is based upon the underlying cause.
Birth control pill
Birth control pills are often used to treat uterine bleeding that is due to
hormonal changes or hormonal irregularities.
Birth control pills may be used in women who do not ovulate regularly to
establish regular bleeding cycles and prevent excessive growth of the
endometrium.
In women who do ovulate, they may be used to treat excessive menstrual
bleeding.
Nonsteroidal anti-inflammatory drugs ( NSAIDS, eg ibuprofen, naproxen
sodium ) may also be helpful in reducing blood loss and cramping in these
women.
During perimenopause, birth control pills or other hormonal therapy may be
used to regulate the menstrual cycle and prevent excessive growth of the
endometrium.

49. Progesterone
Progesterone is a hormone made by the ovary that is effective
in preventing excessive bleeding in women who do not ovulate
regularly.
A synthetic form of progesterone, called progestin, may be
recommended to treat abnormal bleeding.
Progestins are usually given as pills (eg, medroxyprogesterone
acetate, norethindrone ), and are taken one or more times daily
for two to three weeks. When the progestin is stopped, the
woman should expect to have uterine bleeding within 14 days.
In some cases, the progestin is given on a regular basis ( eg,
every few months ) to prevent excessive growth of the uterine
lining and heavy menstrual bleeding.

50. Intrauterine device
An intrauterine contraceptive device ( IUD ) that secretes
progestin ( eg, Mirena ) may be recommended for women who
do not ovulate regularly.
IUDs are inserted by a healthcare provider through the vagina
and cervix into the uterus. Most are made of molded plastic
and include an attached plastic string that projects through the
cervix, enabling the woman to check that the device remains in
place
Progestin-releasing IUDs decrease menstrual blood loss by 40
to 50 percent and decrease pain associated with periods.

51. NSAIDs and others
To decrease cramping pain and bleeding
Ibuprofen 600 –800 mg PO q 6 –8 hours
Naproxen 250 –500 mg q 12 hours
Others
Danazol, GnRH analog, antifibrinolytic

52. Surgery
Surgery may be necessary to remove abnormal
uterine structures ( eg, fibroids, polyps ). Women
who have completed childbearing and have heavy
menstrual bleeding can consider a surgical procedure
such as endometrial ablation.
Women with fibroids can have surgical treatment of
their fibroids, either by removing the fibroid(s) ( eg,
myomectomy ) or by reducing the blood supply of the
fibroids ( eg, uterine artery embolization ).

53. Surgical Treatment
1.D & C for immediate relief but not long term
2.Endometrium ablation by ressection
3.Hysterectomy for definite treatment
Eg. Cystectomy, myomectomy, laparascopic
surgery and endoscopic surgery

54. Surgical treatment
cystectomy
Myomectomy
Vaginal myomectomy
Hysterectomy
Vaginal hysterectomy
Laparoscopic surgery
Endoscopic surgery

56. Adolescenteage
Aethyology-acute and chronical
infections).
Abnormal diet.
Psychological factors, stress.
Hard physical work (training).
coagulativeproblems

57. Abnormal function of
hypotalamic-pituitary axis.
Abnormal acyclic production
and excretoionof releasing
hormones
Adolescenteage

58. treatment
uterotonics.
Activators of coagulation
Hormones COCP
Surgical haemostasis–curettage. INDICATIONS–
prolonged heavy bleedings, decreasing of BP,
tachycardia,Hb70g\l, Ht 20%
treatment of anemia.
Adolescenteage

59. Premenopausal period
45-55 years of age.
Most commonly factors:
Hypofunctionof ovaries
Disfunctionof regulating axis
Abnormal ratio estrogens\progesterone

60. Relative hyperestrogenemia,
hypoprogesteronemiaresult in:
Endometrial hyperplasure
polips
Premenopausal period

61. Premenopausal age
At present data are obtained, that in organism
productionofapoptosisinducersis decreasing, when
theratiobetweenestrogenmetabolites(2-
hydroxyoestronand 16α-hydroxyoestron) changesin
pery-and postmenopausal period and role of their
disproportion is established in activation of cell
proliferation.
One more possible mechanism of grouthof
pathological implants may be assotiatedwith
abnormalities of apoptrosisor anoikis

62. Postmenopausal bleedings
In cases of endometrium≥ 5 mm
95% cancer of endometrium

63. THANK YOU FOR
ATTENTION