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Bleeding
Dr. Mashael Shebaili
Asst. Prof. & Consultant
Ob/Gyne Department
Normal menstruation
Rhythm: regular from 21-35
days
Duration: 3-7 days
Amount: between 30-50 mls
Flow: non clotted fluid blood
Disorders in rhythm, amount
or duration
Menorrhagia
Polymenorrhea
Oligomenorrhea
Metrorrhagia
Causes of Menorrhagia
DUB
Pelvic pathology
Medical
Clotting defect
Dysfunctional uterine
bleeding
Definition: uterine bleeding in
the absence of an organic
disease
Incidence: 10-20% usually at
extremes of reproductive life.
Diagnosis (by exclusion)
History
General examination
Abdomino-pelvic examination
Investigations (mainly to
exclude organic causes)
Treatment
I. Medical treatment
A. Non-steroidal anti-inflammatory
drugs
Mechanism of action: inhibit
cyclo-oxygenase enzyme and the
production of prostaglandins
Phospholipids phospholipase A2
arachidonic acid cyclo-oxygenase
prostaglandins
Possible Pathophysiology
1) Shift in the endometrium conversion
of the endoperoxide from vaso-
constrictor PGF2a
2) Increase in the level and activity of the
endometrium fibrinolytic system
3) Effect of other endometrial derived
factors as cytokines, growth factors
and endothelins.
Effectiveness:
1. Decrease measured menstrual
loss by 40% in 75% of patients
2. Relief dysmenorrhoea
3. Little effect on regularity of cycle
or duration of bleeding
Side effects:
Mainly mild gastrointestinal
tract irritation
The treatment should start
immediately with the start of
bleeding.
B. Antifibrinolytic agents
Mechanism of action:
Prevent conversion of
plasminogen into plasmin which
dissolve the fibrin clots occluding
the blood vessels.
Effectiveness:
Reduce measured loss by
40-50%. The effect is dose
related. It should be given
with the start of
menstruation and continue
for 3-4 days.
Comparative studies suggested
that tranexemic acid is more
effective than PG synthetase
inhibitors (Milsom et al.1991;
Bonnar and Shepard 1996).
Side effects:
1. Mild gastrointestinal tract
irritation
2. Serious adverse effect has been
documented (intracranial
thrombosis central venous
stasis retinopathy) but they are
extremely rare.
3. No such complications occurred
in Scandinavia over 19 years (1st
line of treatment there
side effects
Gonadotrophin releasing hormone agonist
Mechanism of action: produce down
1. Needs experience