Normal menstruation typically occurs every 28 days ±7 days.

Cycles with intervals longer than 35 days describe a state of oligomenorrhea.

Menorrhagia is defined as prolonged or heavy cyclic menstruation. Objectively, menses lasting longer than 7 days or exceeding 80 mL of blood loss.

Metrorrhagia describes intermenstrual bleeding.

Hypomenorrhea there is diminished flow or shortening of menses.

Finally, the term withdrawal bleeding refers to the predictable bleeding that results from an abrupt decline in progesterone levels.

Causes

Dysfunctional uterine bleeding

1. Anovulatory

• Perimenarchal—immature hypothalamic-pituitary- ovarian axis
• Perimenopausal—insensitive ovarian follicles
• Drugs—hypothalamic depressants, sex steroids

2.Ovulatory

Organic lesions

• Pregnancy-associated causes—implantation spotting, abortion, ectopic pregnancy, gestational trophoblastic disease, postabortal or postpartum infection
• Anatomic uterine lesions
• Neoplasm—leiomyoma, polyp, endometrial hyperplasia, cancer
• Atrophic endometrium
• Infection—sexually transmitted disease, tuberculosis, chronic endometritis
• Mechanical causes—intrauterine device, perforation
• Arteriovenous malformation
• Partial outflow obstruction—congenital müllerian defect, Asherman syndrome
• Anatomic nonuterine lesions
• Ovarian lesions—hormone-producing neoplasm
• Fallopian tube lesions—salpingitis, cancer
• Cervical and vaginal lesions—cancer, polyp, infection, atrophic vaginitis, foreign body, trauma

Systemic abnormalities

• Exogenous hormone administration—sex steroids, corticosteroids
• Coagulopathies
• Hepatic failure
• Chronic renal failure
• Endocrinopathies—hypothyroidism, hyperthyroidism, adrenal disorders, diabetes mellitus, hypothalamicpituitary disorders, polycystic ovarian syndrome, obesity

INCIDENCE

Abnormal uterine bleeding affects 10 to 30 percent of reproductive-aged women and up to 50 percent of perimenopausal women.

Childhood

In this age group, the vagina, rather than the uterus, is the most common source of bleeding. Vulvovaginitis is the most frequent cause. Precocious puberty, accidental exogenous ingestion, or ovarian neoplasms should be considered in these children.

Adolescence

In this age group, abnormal uterine bleeding results from anovulation and coagulation defects, pregnancy, sexually transmitted diseases, and sexual abuse should be considered.

Reproductive Age

With increased sexual activity, rates of bleeding related to pregnancy and sexually transmitted diseases ,leiomyomas and endometrial polyps also increase with age.

Perimenopause

Abnormal uterine bleeding is a frequent clinical problem, accounting for 70 percent of all gynecologic visits by peri- and postmenopausal women.

Menopause

Bleeding after menopause typically originates from benign disease, atrophy of the endometrium or vagina,Benign endometrial polyps, malignant neoplasms, especially endometrial carcinoma.

PATHOPHYSIOLOGY

The endometrium consists of two distinct zones, the functionalis layer and the basalis layer .The basalis layer is beneath the functionalis, lies in direct contact with the myometrium, and is less hormonally responsive. The basalis serves as a reservoir for regeneration of the functionalis following menses. In contrast, the functionalis layer lines the uterine cavity, undergoes dramatic change throughout the menstrual cycle, and ultimately sloughs during menstruation.

Blood reaches the uterus via the uterine and ovarian arteries.

At the end of each menstrual cycle, progesterone levels drop and lead to release of lytic matrix metalloproteinases. These enzymes break down the stroma and vascular architecture of the functionalis layer. Subsequent bleeding and sloughing of this layer constitute menstruation.

SYMPTOMS

Menorrhagia and Metrorrhagia

Postcoital Bleeding

Pelvic Pain Because of the role of prostaglandins in both menorrhagia and dysmenorrhea, it seems logical that painful cramping would commonly accompany abnormal bleeding

DIAGNOSIS

Laboratory Evaluation

Blood CBC,β –hCG, serum ferritin and serum iron levels ,total iron-binding capacity, platelet count, partial thromboplastin time, and prothrombin time,Thyroid profile T3,T4,TSH,CA 125,LFT,RFT,CRP,FBS,PPBS,HBA1C

Ultrasound abdomen

Cytological Examination Both cervical and endometrial cancers can cause abnormal bleeding. Evidence for these tumors can often be found with Pap smear screening.

Endometrial Biopsy

Treatment

Homeopathy medicine