Menstrual disorders are common reasons for women to see their doctor. They include menorrhagia (excessive bleeding), dysmenorrhea (painful periods), and amenorrhea/oligomenorrhea (absent or infrequent periods). Menorrhagia is defined as blood loss over 80ml and affects around 5% of women annually. It can be caused by pelvic issues, systemic diseases, or dysfunctional uterine bleeding. Treatment involves addressing the underlying cause, using medications like NSAIDs or hormonal drugs, or pursuing surgical options like endometrial ablation or hysterectomy if medications fail. A thorough history, examination, and testing are required to diagnose the cause and properly manage menorrhagia.

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 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 •

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 cent of 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. Defined as Menorrhagia in the absence of organic (pelvic,-
. systemic) pathology
.Is a diagnosis of exclusion-

9. .PG E2 and PG F2α-1
.Fibrinolytic system-2
.Blood Vessels of the endometrium-3
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-

10. :Ovulatory DUB
Endometrial dysfunction:
). - PG’s imbalance:- (decrease PGF2a : increase PGE2 ratio
.Increased fibrinolytic activity-
Ineffective contraction of myometrial -
. vessels

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
12

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
..
. 13

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 -
15

16. 16

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

18. :Medical treatment
:A- Non-Hormonal drugs
non-steroidal anti-inflamatory drugs: Is the most- 1
commonly used.
(: »» Mefenamic acid (Ponstan
Is the most common drug used by adolescent -
. female; for dysmenorrhea as well
capsules daily, from day 1 to day 3 -
. 5 of the cycle
.It decreases menstrual blood loss by 25% -
.Side effects: gastritis, gastric ulcer -
18

19. :Antifibrinolytic-2
:Tranexamic acid»»
capsule daily, from day 1 to day 5 of the 3 -
. 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**
19

20. :B- Hormonal Drugs
:Progestogens-1
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 -
20

21. :Combined oral contraceptive pill- 2
.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
21

22. Danazol:- 3
- 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
22

23. GnRH analogues:- 4
. - 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
23

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
.mcg of levonorgestrol daily 20 -
%.It decreases menstrual blood loss by 80–90 -
of women are amenorrhoeic after one year of insertion. 30% -~
- 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
24

25. :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

26. Endometrial ablation .1
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

27. 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%

28. 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

29. 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

30. 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 hysterectomy
:Total hysterectomy may be achieved using three main techniques
abdominal hysterectomy•
vaginal hysterectomy•
. laparoscopically assisted hysterectomy•

31. Thank you