1. No intermenstrual bleeding/pre- or post-menstrual bleeding

1. Amenorrhoea: absence or abnormal stoppage of the menses (a symptom not a disease)
2. Oligomenorrhoea: abnormally infrequent menstruation
3. Polymenorrhoea: abnormally frequent menstruation

• Change in duration

1. Hypomenorrhoea: diminution of menstrual flow or duration
2. Menorrhagia (> 10d)

• Change in volume

1. Hypomenorrhoea: diminution of menstrual flow or duration
2. Menorrhagia

• Intermenstrual bleeding

• Intermenstrual bleeding
• Amenorrhoea / oligomenorrhoea
• Menorrhagia
• Hypomenorrhoea

• Ovulation bleeding: due to drop in hormone level
• Endometrial polyp
• Fibroid polyp

• Polyp
• Cervicitis
• CIN/CA (cervical intraepithelial neoplasm)

• VIN/CA (vaginal intraepithelial neoplasm)

P/E:

• Vaginal examination: lesions in vaginal and vulval region?
• Cervical smear: polyps, growths, subclinical change/ changes at histological level [only take if no obvious lesion seen]
• Biopsy of obvious growth: cervical smear not good enough (surface of growth may be dried out, therefore not true indicate of underlying histopathology)

• Hysteroscopy if persistent

1. Look inside uterine cavity
2. Any polyps?

• Cervical polyp - avulsion, f'up for further bleeding
• CIN/CA:

1. Colposcopy: microscope that magnifies view of cervix, abnormal staining, vascularisation?
2. Excision: diathermy (take large area of abnormality out); laser; cryotherapy
3. Radiotherapy

• Endometrial / fibroid polyp: hysteroscopic excision

• Pituitary failure
• Increased Prolactin
• Stress
• Wt loss/ Obesity
• Ix: FSH, LH, Prolactin ® high FSH: causes ovarian failure (high input signal - FSH - causes ovarian overworking); need to check FSH:LH ratio (N = 1:1) (PCOS 1:3)
• Prolactin: if elevated, re-check (prolactin is a stress hormone - eg. During vaginal, cervical, breast examination)

• Hypothyroid
• Cushing

Ix: T4

• Imperforate hymen: hymen bulges forward (also in rectum); bulky uterus (collection of blood)
• Congenital absence
• Atresia of cervix/ vagina
• Acquired: eg. TB (endometrium destroyed)

Ix: P/E

• Ovarian failure
• PCOS: PolyCystic Ovarian Syndrome

[USS]

DIAG: Transvaginal scanning

PCOS

• Infertility

[Ovulation induction]

• Increased endometrial ca: after a few years (unopposed oestrogen action has long-term stimulatory effect on endometrium -> hyperplastic) (If present for a few years, increase 7x chance; give progesterone Tx)
• PCOS

[Regular bleed]

• Osteoporosis: need HRT
• Ovarian failure
• Anorexia nervosa

[HRT]

1. Increased Prolactin
2. Increased FSH
3. Normal FSH/ LH

1. Hyperprolactinaemia - Bromocriptine
2. PCOS/ Hypothalamic - Wt reduction, Drugs, Surg (esp. PCOS)
3. Ovarian failure - Donor eggs (ethics)

Weight reduction

• Clomiphene citrate
• Gonadotrophin releasing hormone agonist--pulsatile manner via a pump
• Gonadotrophin injection
• Insulin sensitising agents (metformin)

Surgery: Ovarian drilling

• Bleeding disorders: clotting factor, platelet

• Fibroid/ fibroid polyp
• Adenomyosis
• IUCD
• CA
• DUB

• Polyp
• CA

• CA

• Abnormal bleeding (usu. amount) from the uterus in the absence of organic disease of the genital tract
• Abnormal bleeding from the uterus unassociated with tumour, inflammation or pregnancy
• Diagnosis by exclusion

Systemic

• Low platelet count
• Hypothalamic-pituitary causes
• Hyperprolactinaemia
• Thyroid/adrenal dysfunction
• Most of the cycles are ovulatory (therefore most causes are not systemic; they are local

• Failure in vasoconstriction (increased PGE2/PGF2)
• Thrombotic plugs fails to form (prostacyclin)
• Excessive fibrinolysis (plaque formed but does not hold)
• Failure in vascular endothelial proliferation
• Delay in endometrial regeneration

• Presenting symptoms: meaning, duration, previous investigations/ treatment
• Symptoms of anaemia (b/c difficult to measure blood loss; determines Tx type and urgency)
• Other menstrual characteristics: pain during menstruation (fibroids, endometriosis - pain severe)
• Medical problems
• Current medication (drugs leading to clotting dysfunction)

• Signs of anaemia
• Any bleeding disorder: eg. Bruises
• Any thyroid enlargement
• Vaginal examination: local lesions
• Cervix
• Uterine size and regularity: irregularity suggests fibroids

• Cervical smear
• Blood
• Complete blood counts
• Thyroid function
• Endometrial aspiration: histology
• US: upper genital tract
• Hysteroscopy/curettage: look at endometrial lining

DIAG: Endometrial aspiration

DIAG: US examination - Fibroid

• Right: different echogenicity

 DIAG: Transvaginal scanning - Fibroid polyp

DIAG: Hysteroscopy - Adenocarcinoma, Polyp

• Exclusion of organic causes
• Explanation/counselling
• Observation
• Control of bleeding pattern
• Treating anaemia

• D&C: no long-term effects
• Premarin (IV)
• For women with excessive bleeding (may cause shock)

• NSAID eg. Ponstan
• Anti-fibrinolytic agents eg. transamine
• Hormones eg. Progestogen, combined pills, danazol, GnRHa (prime endometrium, make lining thin)
• Progestogen releasing IUCD

• Hysterectomy - abdominal, vaginal, laparoscopic approach
• Endometrial ablation-resection, laser, microwave

• Excessive uterine curettage -> uterine adhesion
• Hypomenorrhoea, amenorrhoea, infertility, recurrent abortion
• HSG / hysteroscopy (dangerous: uterus has adhesions, telescope may go through uterus; therefore performed in tertiary institute with speciality care)
• Mx
• Hysteroscopic lysis of adhesion (cannot perform 'blind' lysis)
• IUCD-in-situ: After removing adhesions, put something in uterus to cover up raw areas (prevents further adhesions forming)
• Hormonal therapy for 3 mo (stimulate endometrium to reepithelialise the area to prevent further adhesions forming)