Physiology of the normal

menstrual cycle and AUB

Dr. Getnet
Introduction
• The normal menstrual cycle is a tightly
coordinated cycle of stimulatory and
inhibitory effects that results in the release
of a single mature oocyte from a pool of
hundreds of thousands of primordial
oocytes.
• A variety of factors contribute to the
regulation of this process including
– Hormones,
– paracrine and
– autocrine factors that are still being identified
PHASES of MENSTRUAL CYCLE 
•  By convention, the first day of menses
represents the first day of the cycle (day 1).
• The cycle is divided into two phases:
follicular and luteal.
• Follicular phase; begins with the onset of
menses and ends on the day of the
luteinizing hormone (LH) surge.
– Ranges 14 – 21 days
• luteal phase; begins on the day of the LH
surge and ends at the onset of the next
menses
– Duration is 14 day( constant)
• In comparison, there is significantly more
cycle variability for the first 5 – 7 years
after menarche and for the last 10 years
before cessation of menses 
• menstrual-cycle length peaks at about age
25 to 30 years and then gradually declines
MENSTRUAL CYCLE
 AUB
• Definition
• Any deviation in normal frequency, duration, amount or
timing of menstruation in women of reproductive age
Duration greater than 7 days
Flow greater than 80 ml / cycle
Occur more frequently than every 21 days or less
frequently than every 35 days.
Intermenstrual bleeding or postcoital spotting
 Patterns of Abnormal Uterine Bleeding
• Menorrhagia
– is heavy and/or prolonged menstrual flow with
regular patterns
• Soaking through a pad every hour
• Soaking through bed clothes
• Below normal ferritin, Anemia
– Most commonly caused by;
• Submucous myomas
• complications of pregnancy
 Cont`d
• Adenomyosis
• IUDs
• endometrial hyperplasias
• malignant tumors
• dysfunctional bleeding
 Cnt’d
• Polymenorrhea
– Menses at intervals less than 21 days
– Commonly caused by
• anovulation
• rarely with a shortened luteal phase
• Metrorrhagia
– Menses at irregular intervals and frequent
– Commonly caused by
• Endometrial polyps
• endometrial and/or cervical carcinomas
• exogenous estrogen administration
 Cnt’d
• Hypomenorrhea
– Periods with unusually light flow
– Commonly caused by
• An obstruction such as hymenal or cervical stenosis
• Uterine synechiae
• OCP use
• Menometrorrhagia
– Menses with heavy, irregular bleeding
 Cnt’d
• Oligomenorrhea
– Menses at intervals greater than 35 days
– associated with
• anovulation,
• either from endocrine causes
• systemic causes
Causes of AUB
Diagnosis : the differential diagnosis for all
women presenting with AUB can encompassed
by the mnemonic (PHIMIC).
P= pregnancy,
H= hormone,
I = iaterogenic,
M = mechanical,
I = infection and
C = cancers.

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I) Pregnancy
• should be considered in any women
presents with AUB unless she had
hysterectomy or above 60 yrs.
• Even women who have had BTL, in their
50 s and have not menstruating for 1-2
yrs.
• Pregnancy related AUB include:
abortion, ectopic pregnancy, GTD, . .
• Mgt: depend on the cause

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II) Hormones :
• grouped under four categories.
– coagulation disorder: von
willibrand,leukemia,ITP aplastic anemia.
– hyperprolactinemia
– thyroid disorders
– chronic anovulation (hypothalamic,
adrenal ,polycystic ovary syndrome ,
perimenopuse).

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a)Coagulation disorder are most common in girls
who are with in 1 year of first menstrual cycle.
• Vonwillbiran disease needs to be excluded on
every girls presenting with excessive AUB with
hypovolumic symptoms.
• They should also evaluated for bone marrow
abnormalities, aplastic anemia, ITP.
b) hyperprolactinema is significant cause of AUB,
high level cause alteration of in hypothalamus
leading to decrease level of GnRH leading to
ovarian dysfunctions.
– it is reasonable to do MRI of sella tursica if level of
prolactin above 60ng/ml.
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c) a women life time risk to develop thyroid
disease is 15 % and in excess or deficient
will affect the menstrual cycle of the
women.
• The most common disorder is
hypothyroidism &approximately 2/3 of
cases will develop AUB
– Hyperthyroidism => amenorrhea
– Hypothyroidism => menorrhagia
• Any women who develop AUB,
postpartum deperssion,premenstrual
syndrome should be screened for thyroid
disease. ( TSH, T3, T4, thyroid scan.

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Contii…
d)The most common hormonal disorder
causing AUB is estrogenized anovulation.A
women can present with any thing from
complete secondary amenorrhea to frank
hemorrhage.
• Therefore characteristics of menstrual flow
is of no diagnostic advantage.

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III) Iatrogenic
• cause appears to increase as many drugs
used for cancer, renal transplant causes
AUB.
• Physician should inquires prescription
history over the last six months or use of
over- the-counter medication.
• Drugs that affects menstrual cycle are
predinsolone, tamoxifen, heparin and
Depo-Provera.
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IV) Mechanical

• uterine leyomyoma is most common cause

of AUB, submucous or interacavitery
myoma causes AUB.
• Management extend from OCP, GnRH
agonist myomectomy & hysterectomy.
• endometrial polyp are found up to 50% of
presenting as AUB, best diagnosed by
hysteroscopy and SIS (saline infusion
sonography)

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V) Infection:

• acute &chronic endometritis can cause

AUB.
• Endocervicits known cause of AUB
particularly intermenstrual bleeding or
postcoital bleeding.

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VI) cancer :
• endometrial and cervical ca are uncommon yet very
important cause of AUB.
• Cervical ca presents with post coital bleeding &irregular
menstrual bleeding.
• Even patient has normal pap smear with in previous yrs
it is prudent to reapt pap smear.
• Endometrial ca possible in women with AUB above
35yrs.(endometrial biopsy should be done).
• therapy of cervical/endometrial ca depend on staging of
disease.
• complex endometrial hyperplasia with atypia is usually
managed by simple hysterectomy.

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• Read on mgt of each condition

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Management of AUB
I) AUB prepubertal girls:
*management is directed to cause, if symptom
persists with discharge suspect foreign body
* skin lesion, vaginal &ovarian tumor should be
managed by consultation.
- neonate: it is b/c of estrogen withdrawal. It is selflimiting
II) AUB in adolescent girls : during the first two years it is
anovulatory.
*goal of management is to base therapy on
appropriate diagnosis.
*in the absence of diagnosis the assumption is
that of anovulation or DUB .

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Contii…

a)Anovulatory mild bleeding :

• Mild AUB with normal Hb are best treated
by rest, reassurane & frequent follow up.
• Patient with AUB & mild anemia benefit
from hormonal therapy.(low dose OCP
used in manner for contraception)
b) Acute bleeding (moderate): acutely
bleeding stable not requiring
hospitalization.

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Contii…
• Requires high dose of hormones that are much
higher than those in OCP.
• An effective regimen is patient given 4pills
containing 35 micro gram ethyl estradiol for 4
days followed tid for seven days, two pills for 11
days then 1 pill a day there after.
• Strong advice need to be given not discontinue
it cause severe recurrent bleedings.
• patient should be warned to expect heavy
withdrawal bleeding can be controlled by
instituting OCP 3-6 cycles if women is sexually
active others can be reassured.
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Contii…
• C) acute severe bleeding: hospitalization depend on rate
of bleeding and severity of anemia.
• Cause severe menorrhagia is coagulation
disorder(PT,PTT, BT, von willebrnad disease, platelet
disorder &hematological malignancies suspected.
• No need of transfusion unless the patient
hemodynamically unstable.
• for patient diagnosis of DUB made by exclusion
hormonal therapy makes possible to avoid surgical
interventions( D&C, operative hysteroscopy &
laparoscopy.)

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Contii…
• III) reproductive age group: pregnancy related
bleedings should always be considered as part of
evaluation of AUB.
a) Non surgical management:
i) non-hormonal : NSAIDs mefenamic acid &ibuprofen
may show decrease in menstrual flow by 30-50 %.
ii) Hormonal treatment:
– oral contraceptive is well known to control menstrual bleeding
prevent iron deficiency anemia.
– in Europe some clinician put IUCD containing norgestral that
deliver progestin to prevent bleeding and pain.

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Contii…
b)surgical management :
•Reserved to situations where medical therapy has
failed or there is contraindications to use it.
•D&C some times appropriate both diagnostic and
therapeutic method.
•Surgical options range from
hyseroscopic,laprascopic resection of
myoma,myomectomy, laser ablation &
hysterectomy.
• surgical option rather than hysterectomy should
include a shorter recovery time and less early
morbidities, symptoms can recur or persist.

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Conti…
• IV)postmenopusal age :
• Etiology :
* exogenous hormone (30%).
* atrophic vaginaitis/endometritis (30%)
*endometrial ca (15%)
*endometrial /cervical polyp (10%)
*endometrial hyperplasia (15%)
*miscellaneous (cervical, uterine
sarcoma e.t.c ( 10%)

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Contii…
• Management of atrophic vaginaitis is topical or
systemic estrogen,
• Cervical or endometrial polyps can be excised.
• Benign hyperplasia ( simple cystic,
adenomatous hyperplasia with out atypia can be
managed by D&C and progestin therapy.
• Patient with complex hyperplasia with atypia
treated with simple hysterectomy.
• endometrial, cervical or vulvar malignancies
treated based on staging of diseases.

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Thank you !
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