MENSTURAL

IRREGULARITIES
LARAIB KANWAL
SHAZMINA AKBAR
ABDUL JABBAR
  INTRODUCTION
 PHYSIOLOGY
 DEFINATION
 DISORDERS OF
MENSTURAL
REGULARITY
 AMENORRHEA &
OBECTIVES: 
OLIGOMENORRHEA
IMB & PCOS
 PREMENSTURAL
SYNDROME
 HMB
 DYSMENORRHEA
 HISTORY
 QUIZ
 Introduction:

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 PHYSIOLOGY

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Disorders of menstural
regularities
 Abnormal Uterine Bleeding
• Disorders of menstrual bleeding are termed as Abnormal
Uterine Bleeding.
• Types of abnormal Uterine bleeding::
• HMB : Excessive menstrual blood loss.
• IMB: Bleeding between periods often seen with endometrial
and cervical polyp.
• PCB: Bleeding after sex , often associated with cervical
abnormalities.

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 • PMB: Bleeding more than one year after cessation of periods,
exclude endometrial pathology and vaginal atrophy.
• BEO: "Bleeding of endometrial origin " a diagnosis of
exclusion which has replaces the term "dysfunctional uterine
bleeding".

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 Heavy Menstrual Bleeding
• Most common type of menstrual bleeding disorder.It replaces
the older term " Menorrhagia".
• HMB is defined as " Blood loss of greater than 80 ml per
period".
• Of women of reproductive age , 20-30 % suffer from HMB.

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 Symptoms associated with HMB

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 Presenting Complains
• Soaking through one or more sanitary pads or tampons every
hour for several consecutive hours.
• For controlling menstrual flow , double sanitary protection is
required and used.
• At night there is need to change the sanitary protection.
• Bleeding for longer than a weak.
• Passing blood clots larger than a quarter.
• Restricting daily activities due to heavy Menstrual flow.
• Symptoms of anemia, such as tiredness, fatigue and shortness
of breath.
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 History of HMB
• What age did menses start?
• Cycles are regular or irregular?
• How many days does each cycle last?
• In case of Menorrhagia, ask the patient how many times she
changes tampon or pad in a day?
• Does she having any flooding?
• Does she have any excessive clot production?

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 • Dysmenorrhea?
• Intermenstrual bleeding?
• Post coital bleeding?
• Symptoms of anemia?
• Contraception?
• Pelvic inflammatory disease (PID)?
• Vaginal discharge?
• Pressure symptoms on bladder and bowel?
• Coagulation disorders?

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 Examination
• General physical examination.
• Signs of anemia.
• Abdominal examination
• Pelvic examination
• Pap smear.

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 Investigations
• Investigations for HMB according to NICE guidelines.Investigations
• Complete blood count (CBC)
• Coagulation screen
• Pelvic ultrasound scan
• High vaginal and endocervical swab
• Thyroid function test
• Endometrial biopsy (EB ) if risk factors are present.
• Transvaginal ultrasound
• Hormone testing should not be performed.

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 Outpatient hysteroscopy with guided
biopsy
• EB biopsy attempt fails.
• EB biopsy sample is insufficient for histopathology assessment.
• TVUSS is inconclusive for example to establish the exact location of
a submucosal or intramural fibroid.
• There is an abnormality on TVUSS amenable to treatment (e.g
suggested endometrial polyp or submcosal fibroid).
• If patient fails to tolerate an outpatient procedure , if the cervix needs
to be dilated to enter the cavity or for treatment of Large polyp or
submcosal fibroid , then a hysteroscopy proceeding to treat under
general anesthetic may be required.

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 Indications of EB in HMB
• An EB or outpatient hysteroscopy is indicated if there is
• PMB and endometrial thickness on TVUSS > 4 mm
• HMB over 45 years
• HMB associated with IMB.
• Treatment failure.
• Prior to ablative technique.

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 Management
• When selecting appreciate Management for the patient, it is
important to consider and discuss:
• Patient preference of treatment.
• Risks and benefits of each Option.
• Contraceptive requirements.
• Current contraception
• Past medical history.
• Any contraindications to medical therapies for HMB

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 • Suitability for an anesthetic.
• Previous surgical history on uterus.
• Medical management:
• The national institute for health and care excellence (NICE) guidelines suggest
following order::
• Levonorgestrel intrauterine system.(LNG- IUS)
• Tranexamic acid , an antifibrinolytic that reduces blood loss by 50 % .
• OR Mefanemic acid , which inhibit prostaglandin synthesis and reduces blood
loss by 30%
• OR COCP (combination oral contraceptive ) which will induce slightly lighter
periods

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 • Norethisterone day 6 to 26 of menstrual cycle.
• Gonadotrophin -releasing hormone (GNRH) agonists:
• These drugs act on the pituitary to stop the production of
• of estrogen which results in amenorrhea.
• Surgical Management.
• 1. Endometrial ablation
• The first generation techniques including transcervical
• resection of the endometrium with electrical diathermy or rollerball ablation
have largely been replaced by newer second generation techniques including
::

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 • Impedance controlled endometrial ablation.
• Thermal uterine balloon therapy.
• Umbilical artery embolization.
• Myomectomy
• Transcervical resection of fibroid.
• Hysterectomy

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 Acute HMB Management
• Admit the patient.
• Perform pelvic examination.
• FBC , coagulopathy screen, biochemistry.
• Intravenous access, or resuscitation or transfusion required.
• Tranexamic acid oral or oral .
• TVUSS
• High doses of progestogen to arrest bleeding.
• Consider suppression with GnRH
• Long term plan with diagnosis has been made.

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Thank you