1. Fawaz Edris MD, RDMS, FRCSC, FACOG, AAACS

2. INTRODUCTION 1/3 of outpatient visits Most after menarche or perimenopausal Multiple causes, but mostly: Pregnancy related (always R/O) Structural uterine pathology (fibroids, polyps, adenomyosis)fibroids Anovulation Disorder of hemostasis Neoplasia Trauma Infection More than 1 !! (myoma + cancer) Non gynecological source (urethra, rectum)

3. MENSTRUAL CYCLE Mechanism: Estrogen  Ovulation  Preogesteron  withdrawal  menstruation 24 - 35 days, lasting 2 to 7 days, flowing <80 mL/cycle Predictable cyclic menses reflect regular ovulation DUB vs. AUB DUB: anovulation – no anatomical or systemic disease – by exclusion

4. PATTERNS OF AUB Menorrhagia: excessive (>80 mL/cycle) or prolonged menstrual bleeding (>7 days) Amenorrhea: absence of bleeding ≥ 3 usual cycles Oligomenorrhea: bleeding with interval > 35 days Polymenorrhea: bleeding with interval < 24 days Metrorrhagia: light bleeding at irregular intervals Menometrorrhagia: heavy bleeding at irregular intervals Intermenstrual bleeding: bleeding between menses Premenstrual spotting: light bleeding preceding menses Post coital spotting: vaginal bleeding within 24h of intercourse

5. HISTORY What is the nature of the bleeding (frequency, duration, volume, relationship to activities such as coitus) Quantity – number of pads, soakness Quantity Intermenstrual bleeding - structural lesion (endometrial polyp, fibroid, cervical neoplasia) Menometrorrhagia - anovulatory bleeding Regular cyclic periods – ovulatory Menorrhagea - bleeding diathesis, fibroid, adenomyosis.fibroid

6. HISTORY Are there symptoms of ovulation? (molimina) When did the bleeding start? Menorrhagia since menarche - Bleeding diathesis Perimenarcheal and perimenopausal - Anovulation Perimenopausal - polyps, adenomyosis, and fibroids Were there precipitating factors, such as trauma?

7. HISTORY Any associated symptoms? Lower abdominal pain, fever, vaginal discharge - infection (endometritis, vaginitis) Changes in bladder or bowel function - mass effect from a local neoplasm or nonuterine bleeding Headaches, breast discharge, visual disturbances - prolactinoma or other cranial tumor Hirsutism or hair loss, acne – PCOS Cold or Hot intolerence, Constipation or diarrhea - thyroid disease

8. HISTORY Is there a personal or family history of a bleeding disorder? bleeding associated with surgery, dental extraction, childbirth, or bruising (>5 cm)/epistaxis/bleeding gums once or twice a month Does she have a systemic disorder? chronic liver or renal disease, thrombocytopenia - menorrhagia Any medications? Anticoagulants – menorrhagia IUCD or OCP - intermenstrual bleeding

9. HISTORY Is she having coital relations? Pregnancy related Always do pregnancy test Change in weight, eating disorder, excessive exercise, illness, or stress? Anovulatory bleeding

10. PHYSICAL EXAMINATION Speculum and pelvic examinations Bleeding site: vulva, vagina, cervix, urethra, or anus Any suspicious findings (mass, laceration, ulceration, vaginal discharge, foreign body) Assess the size, contour, and tenderness of the uterus fibroids, adenomyosis, pregnancy, or infection Examine the adnexa for an ovarian tumor Evaluate for pain - infection

11. PHYSICAL EXAMINATION General examination Signs of systemic illness, such as fever Ecchymoses Enlarged thyroid gland Hyperandrogenism (hirsutism, acne, clitoromegaly, or male pattern balding) Acanthosis nigricans - insulin resistance and anovulation. Galactorrhea - hyperprolactinemia.

12. LABORATORY EVALUATION Pregnancy test in all reproductive age women Intrauterine pregnancy Ectopic Gestational trophoblastic disease Cervical cytology Any visible cervical lesion should be biopsied

13. LABORATORY EVALUATION Endometrial biopsy - endometrial cancer hyperplasia All women > 35 years 18 and 35 years if with risk factors for endometrial cancer (family or personal history of ovarian, breast, colon, or endometrial cancer; tamoxifen use; chronic anovulation; obesity; estrogen therapy; prior endometrial hyperplasia; diabetes) Always r/o pregnancy then do in second half of cycle Secretory endometrium - ovulation Proliferative endometrium – anovulation Inflammation of the endometrium - endometritis

14. ADDITIONAL LAB. EVALUATION Hemoglobin/hematocrit TSH Coagulation tests Platelet count – thrombocytopenia Coagulation testing - PTT, PT, factor VIII, and von Willebrand factor antigen and activity STD: Gonorrhea, Chlamydia, trichomonads Prolactin level Androgen levels: Testosterone, DHEAS

15. ADDITIONAL LAB. EVALUATION Ultrasound Fibroids, adenomyosis, endometrial lining, ovaries Saline infusion sonography (sonohysterography)sonohysterography Fibroids, polyps Hysteroscopy

16. MANAGEMENT Is bleeding ovulatory or anovulatory? Ovulatory  treat the underlying cause Anovulatory Acute management Estrogen: Oral or IV D&C (temporary measure – not therapeutic) Ongoing management Replace Progesterone Progesterone: pills (continuous or cyclical), injections OCP Other measures Thin the endometriam: hormonal IUCD Remove the endometriam: Ablation Remove the organ: Hysterectomy

17. MANAGEMENT If bleeding persists after treatment Additional etiologies  continue to evaluate

18. Thank you