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A quick

overview on
Menstrual
irregularity
And a newer approach to
abnormal uterine
bleeding

Menstruation
Menstruation is the periodic discharge of blood
and mucosal tissue from the inner lining of the
uterus through the vagina due to, orderly cyclic
hormone production and parallel proliferation of
the uterine lining preparing for implantation of the
embryo.
The time frame from the start of one menstrual
episode to the start of next menstrual episode is
called Menstrual Cycle.
The number of days the menstrual bleeding
persists is called menstrual Period.

The parameters of Normal


Menstruation
Duration of flow 3-7 days

(average 4 days)

Cycle length 21 - 35 days

(average 29 days)

(28 days +/- 7 days}

Blood loss < 80 ml

(average 30-35 ml)

Any deviation from this


normal parameter is
abnormal menstruation

When will we call it Abnormal


Menstruation??

Duration of flow

more than 7 days (If flow is normal) or


more than 5 days (if flow is heavy)
Less than 2 days

Menstrual cycle is
Less than 21 days
More than 35 days

Flow is heavy
blood loss of greater than 80 ml
Passing of large blood clot during menstruation
Enough flow to soak a pad or tampon every hour for 3
consecutive hours. (Each soaked tampon holds 5ml of blood)
Night time bleeding that requires getting up to change pads or
tampons

Here are the


Classic
Terminologies
we used to
Describe
Abnormal
Menstruation

Dysmenorrhoea
Menorrhagia
Polymenorrhea
Polymenorrhagia
Oligomenorrhoea
Hypomenorrhoea
Metrorrhagia
Metropathia
Haemorrhagica

Parameters of Classic terminologies


Description

Cycle

Period

Normal
menstruation

Normal period of
menstruation

21 35 days

3 7 days

Dysmenorrhoea

Painful menstruation 21 35 days


as to hamper day to
day life

3 7 days + PAIN

Menorrhagia

Normal Cycle with


Excessive amount /
Period of bleeding

21 35 days

>7 days + normal flow


>5 days + heavy flow

Polymenorrhoea

Decreased Cycle
with normal period

Less than 21 days

3 7 days

Polymenorrhagia

Decreased cycle with Less than 21 days


Excessive amount /
Period of bleeding

>7 days + normal flow


>5 days + heavy flow

Parameters of Classic terminologies


Description

Cycle

Period

Oligomenorrhoea

prolonged Cycle with


normal period

more than 35 days

3 7 days

Hypomenorrhoea

prolonged Cycle with more than 35 days


Decreased period

Less than 2 days

Metropathia
Haemorrhagica

A special type of
anovulatory uterine
bleeding

6 - 8 weeks of
amenorrhoea
followed by

2 8 weeks of
bleeding which is
painless and life
threatening

Metrorrhagia

Irregular, acyclical
bleeding

Can not be specified


into definative cycle

Can not be specified


into definative
period

Classic approach to diagnose a case of


Menstrual Irregularity

Fibroid
PID
Adenomyosis
Endometrosis
Dysmenorrhoea

DUB

Reproductive age

Painless
To diagnose exclude

Pubertal age

Menorrhagia
(Regular/Cyclical)

Hypothyroidism
(TSH, T4)
Bleeding disorder
(BT, CT)

Abortion
Ectopic Pregnancy
Molar Pregnancy
IUCD in utero
Break through bleeding

Peri menopausal age


Ca cervix
Endometrial polyp
Endometrial carcinoma
HRT treatment if
Stopped abruptly

Metrorrhagia
(Irregular/Acyclical)

The problems of Classic terminology And the


move to refine it
Over the past decade it has become
abundantly clear that many terms used to
describe menstrual symptoms and causes of
abnormal menstrual bleeding are ill defined
and confusing.

The problems of Classic terminology And the


move to refine it
So, a formal initiative was established with an
international workshop in Washington, D.C., in
2005, Which yielded the FIGO (International
Federation of Gynecology and Obstetric)
Classification in 2009 at Cape town.
This Classification looks to refine the Ill
defined Terminologies to a better defined well
demarcated territory of Newer Terminology
That Is, ABNORMAL UTERINE BLEEDING

ABNORMAL UTERINE
BLEEDING
Abnormal Uterine Bleeding is defined as
bleeding from the uterine corpus that is
abnormal in regularity, volume, frequency, or
duration and occurs in the absence of
pregnancy in women of reproductive age.

Caution
Abnormal Uterine Bleeding excludes the
following situations:
AUB Excludes Gravid patients. A pregnancy test is a
must before trying out for AUB.
AUB deals only with women of reproductive age that
is from definitive onset of Menstruation to
menopause. So, pre-pubertal bleeding or post
menopausal bleeding is not included in AUB.
Lower genital tract bleeding due to any cause is
opted out of AUB. So, cervical or vaginal tears or
malignancies must be excluded first.

Types of AUB
Heavy Menstrual Bleeding
Acute
AUB is defined as an episode of heavy bleeding that, in the
opinion of the clinician, is of sufficient quantity to require
immediate intervention to prevent further blood loss

Chronic
chronic AUB is defined as bleeding from the uterine corpus
that is abnormal in volume, regularity, and/or timing, and
has been present for the majority of the past 6 months

Intermenstrual Bleeding
occurs between clearly defined cyclic and predictable
menses.

Differential Diagnosis of AUB


AUB
Structural
P- Polyp (AUB-P)
A- Adenomyosis (AUB-A)
L- Leiomyoma (AUB-L)
M- Malignancy &
Hyperplasia (AUB-M)

Non-Structural
C- Coagulopathy (AUB-C)
O-Ovulatory dysfunction
(AUB-O)
E- Endometrial (AUB-E)
I- Iatrogenic (AUB-I)
N- Not yet classified (AUB-N)

P- Polyp (AUB-P)
Polyps are epithelial proliferations
comprised of a variable vascular,
glandular, and fibromuscular and
connective tissue components and
are often asymptomatic.
Yet, it is generally accepted that at
least some polyps contribute to the
genesis of AUB.

For the basic classification system,


polyps are categorized as being
either present or absent.

A- Adenomyosis (AUB-A)
The relationship between
adenomyosis and the
genesis of AUB is unclear,
though undeniable.

As there exists both


sonographic and magnetic
resonance imaging (MRI)based diagnostic criteria,
adenomyosis has been
included in the
classification system

L- Leiomyoma (AUB-L)
An Important cause
of AUB I has its own
primary, secondary
and tertiary
classification system

M- Malignancy & Hyperplasia (AUB-M)


Although relatively
uncommon, atypical
hyperplasia and
malignancy are
important potential
causes of, or findings
associated with AUB
and must be considered
in nearly all women of
reproductive age

C- Coagulopathy (AUB-C)
coagulopathy
encompasses the spectrum
of systemic disorders of
hemostasis that may be
associated with AUB.
Coagulation Disorders

Inherited
von willibrands
haemophilia

Acquired

Drug Induced

ITP

Heparin

DIC

Warferin

Leukemia

Aspirine

O-Ovulatory dysfunction (AUB-O)


Ovulatory dysfunction can contribute to the genesis
of AUB.
Although most ovulatory disorders elude a defined
etiology, many can be traced to Endocrinopathies
(e.g. polycystic ovary syndrome, hypothyroidism,
hyperprolactinemia, mental stress, obesity, anorexia,
weight loss, or extreme exercise such as that
associated with elite athletic training).
Also, unexplained ovulatory disorders frequently
occur at the Extremes of reproductive age.

E- Endometrial (AUB-E)
When AUB occurs in the context of predictable and cyclic
menstrual bleeding, typical of ovulatory cycles, and
particularly when no other definable causes are
identified, the mechanism is probably a primary disorder
of the endometrium.
Indeed, high-quality evidence has demonstrated
deficiencies in local production of vasoconstrictors such
as endothelin-1 and prostaglandin F2, and/or
accelerated lysis of endometrial clot because of excessive
production of plasminogen activator.
the diagnosis of endometrial disorders should probably
be determined by exclusion of other identifiable
abnormalities in women of reproductive age who seem
to have normal ovulatory function.

I- Iatrogenic (AUB-I)
Drugs that may contribute to
AUB:
Hormonal therapy (estrogen,
progesteron, androgens, Etc )
the use of anticoagulant drugs
such as warfarin, heparin, and
low molecular weight heparin
Systemic agents that interfere
with dopamine metabolism
have the potential to cause AUB
Tricyclic antidepressants
phenothiazines

N- Not yet classified (AUB-N)


Chronic endometritis
Arteriovenous malformations
Myometrial hypertrophy, Etc

Notation for FIGO Classification

Notation for FIGO Classification

So, FIGO Notation for our patient


would be.