Masaryk University Schol of Medicine
and Brno University Hospital
Department of Obstetrics and Gynecology
Head: Prof. Pavel Ventruba, DrSc.,MBA
General Medicine Obstetrics and Gynecology
Seminary 2017 – 2018 – Autumn Semester
Irregular uterine bleeding

Irregular uterine bleeding
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Gynekologicko - porodnická klinika
FN Brno a Masarykovy univerzity
Přednosta: prof. MUDr. P. Ventruba, DrSc.
Doc. MUDr. M. Pohanka
General Medicine
Obstetrics and Gynecology Seminary  2015 – Autumn Semester
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Menstrual cycle
The length of the cycle: 25- 32 (35) dní
The length of the bleeding: 3-5 dní, max. 7 dní,
Blood lost:  1 ml/kg
• ovarian cycle results in endometrial changes
• Cycle phases:
• menstruation
• prolipheration
• secretion

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Menstrual cycle disorders
• symptomatic (according to the clinical       symptoms)
• pathogenetical (according to pathogenesis)
• ethiological (according to the ethiology)

Frequency disorders
• Polymenorrhoea  (less than 22 days)
• Oligomenorrhoea (more than 35 days)
• Amenorrhoea  (no bleeding)
• primary amenorrhoea
• secundary amenorrhoea

Intensity and length disorders
• Hypomenorrhoea  (less than 2 tampons/day)
• Hypermenorrhoea (more than 5 tampons/day, more than 8 days)
• Menorrhagia  (more than 5 tampons/day, bleeding less than 7 days)

Intensity and length disorders
• Premenstrual  bleeding
• Ovulation bleeding
• Postmenstrual  bleeding

Irregular uterine bleeding
 Metrorrhagia - dysfunctional bleeding
• ovarian function disorder
• follicle persistence, corpus luteum absence
• estrogens elevation, gestagens shortage
• irregular endometrium shedding
• glandular cystic endometrial hyperplazia

Stromaglandular dissotiation



Cystic glandular hyperplazia



Amenorrhoea
Physiological (before menarche, gravidity, post menopause)
Pathological  (primary, secundary)
A. according to disorder level
•   anatomical malformations
•   ovarian disorders
•   pituitary gland disorders
•  CNS disorders (hypothalamus, suprahypothalamus)

Amenorrhoea
B. according to ovarian structure
• normal ovulating ovaries
• anovulating  ovaries (regulation centres disorders)
• afunctional  ovaries (dysgenesis)
Cryptomenorrhoea - anatomical obstruction

Menstrual cycle classification
according to  WHO
I.  Hypogonadotropical normoprolactinemia ovarian insufficiency
     (Kallman syndrom, anorexia nervosa, Sheehan syndrom)
II. Normogonadotropical normoprolactinemia ovarian insufficiency
     IIa.- anovulation, corpus luteum insufficiency
     IIb.- normogonadotropin normoprolact. amenorea (hyperandrogenemia)
III. Hypergonadotropin ovarian insufficiency (Turner sy,POF)
IV. Anatomical amenorea (Rokytanski sy)
V.  Hyperprolaktinemia (prolactinoms)
VI. Dysfunctional hyperprolactinemia (thyreoid gland, stress)
VII. Organic destruction of  hypothalamus (kraniofaryngeom)

Diagnosis
Menstrual  calendar (bazal temperature)
Hormonal examinations
• basal: FSH, LH, prolactin, 17-betaestradiol, progesteron, testosteron, SHBG
• comprehensive:glandula thyreoidea, adrenal gland
• functional  cytology
Ultrasound - morphology of  endometrium, uterus, ovaries
Endometrial biopsy - abrasion, microabrasion

Diagnosis
Endometrial  histology
menstruation 1. - 4. day
early proliferation 5. - 8. day
advanced proliferation 9. - 11. day
late proliferation  12. - 14. day
early secretion 16. - 18. day
advanced secretion 19. - 22. day
late secretion 23. - 24. day
secretion in regresion 25. - 28. day

Diagnosis
Hysteroscopy  (diagnostical, operative)
Laparoscopy (diagnostical, biopsie)
X-ray methods - CT, MRI
Genetics
Endocrinology
Hematology

Diagnosis
Funkctional tests
•Progesteron test
•Estrogen - progesteron test
•Gonadotropin test
•Clomifen citrate test
•Metoklopramid test

Therapy
Stop the bleeding
• hormonal - estrogens, gestagens
• surgery -  uterine abrasion, hysteroscopy
Prevention - gestagens