1. Prof Lindeque Abnormal excessive uterine bleeding

2. Everybody bleeds... Excessive bleeding is common Treatment may have varied success A mother and daughter issue - sometimes people expect the worst Few people like menstruation to begin with

3. Modern definitions Group name: heavy menstrual bleeding Cyclic excessive bleeding: o Short cycle; n volume; polimennorrhoea o Bleeds more days than normal: hypermenorrhoea o More volume, more days: menorrhagia Acyclic bleeding: metrorrhagia Acyclic excessive bleeding: menometrorrhagia

4. Types of AEUB 1 Organic causes: Pathology detected on examination (list follows) 2 DUB: dysfunctional uterine bleeding Healthy woman, no pathology, n examination Whether she ovulates (1/3) or is anovulatory (2/3)

5. Age does matter Adolescents: >80% dysfunctional, anovulatory DUB: Unripe HT-pit-ovar axis: produces Estrogen, not Progesterone An- or oligomenorrhoea or otherwise disorderly cycle <20% have pathology: bleeding disorders (ITP, Von Willebrandt, leukemia, HIV platelet dysfunction) Have to do: clinical exam incl. PR, FBC, platelets, HIV Management: HORMONAL: best is OC pill

6. Reproductive years: 20-45 Biggest groups: organic pathology; pregnancy ox Gynae pathology: fibroids, adenomiosis, endometrial hyperplasia, polyps, some ovarian or uterine tumours, few cervical lesions, endometriosis, PID, pregnancy, cx of miscarriages, molar pregnancy, ectopic, secondary PPH Systemic disorders: bleeding disorders, thyroid dysfunction, systemic disease,medication, hyperprolactinaemia

7. Reproductive years Anovulatory DUB: common: oligo- or anovulation due to stress, PCOS, weight changes, exercise Ovulatory DUB: less common: [short luteal phase with cycle every 2-3 wks]; [persistent corpus luteum (postponed bleeding then massive bleeding)]

8. Reproductive years Management Medical: Document bleeding Mirena progestogen containing IUCD (NICE no 1) Cyclokapron (60% reduction, NICE no2), OC 40% reduction (NICE no 3), NSAIDS 40% reduction Surgical: completed families, failed medication Endometrial destruction: ablation, resection: 50% amenorrhoea over 5 years (better initially) Hysterectomy: 100% amenorrhoea rate

9. Perimenopausal: 45-55+/- Important: organic lesions: must exclude malignancies and pregnancy cx Most common: anovulation (tired ovaries) Management: clinical examination Tests: cervical smears, endometrial biopsy, endometrial ultrasound, pregnancy test Management: Mirena, E+P hormone Rx, NSAID; surgical: hysterectomy

10. So: approach to a patient with AEUB Hx: menarche, menses as adolescent, describe bleeding: volume, clots; pain,contraception. Obstetric, medical, surgical, medication Examination: general,thyroid, breasts, systems, gynae in detail, decide: organic causes or FUB Tests FBC, pregnancy, cytology, TSH, PRL, endometrial assessment Treatment: according to etiological diagnosis