DOCSLIB.ORG

The Two FIGO Systems for Normal and Abnormal Uterine

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
The Two FIGO Systems for Normal and Abnormal Uterine Received: 18 May 2018 | Revised: 23 July 2018 | Accepted: 6 September 2018 | First published online: 10 October 2018 DOI: 10.1002/ijgo.12666 FIGO SPECIAL ARTICLE Gynecology The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions Malcolm G. Munro1,2,* | Hilary O.D. Critchley3 | Ian S. Fraser4 | for the FIGO Menstrual Disorders Committee 1Departments of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Abstract University of California, Los Angeles, CA, USA Background: The International Federation of Gynecology and Obstetrics (FIGO) sys- 2 Kaiser Permanente, Los Angeles Medical tems for nomenclature of symptoms of normal and abnormal uterine bleeding (AUB) Center, Los Angeles, CA, USA in the reproductive years (FIGO AUB System 1) and for classification of causes of AUB 3MRC Centre for Reproductive Health, The University of Edinburgh, The Queen’s Medical (FIGO AUB System 2; PALM- COEIN) were first published together in 2011. The pur- Research Institute, Edinburgh, UK pose was to harmonize the definitions of normal and abnormal bleeding symptoms 4School of Women’s and Children’s Health, Royal Hospital for Women, University of New and to classify and subclassify underlying potential causes of AUB in the reproductive South Wales, Randwick, NSW, Australia years to facilitate research, education, and clinical care. The systems were designed to *Correspondence be flexible and to be periodically reviewed and modified as appropriate. Malcolm G. Munro, Kaiser Permanente, Objectives: To review, clarify, and, where appropriate, revise the previously Los Angeles Medical Center, Los Angeles, CA, USA. published systems. Email: [email protected] Methodology and outcome: To a large extent, the process has been an iterative one Participating Members of the FIGO Menstrual involving the FIGO Menstrual Disorders Committee, as well as a number of invited Disorders Committee, 2015–2018 are listed contributions from epidemiologists, gynecologists, and other experts in the field from at the end of the paper. around the world between 2012 and 2017. Face- to- face meetings have been held in Rome, Vancouver, and Singapore, and have been augmented by a number of telecon- ferences and other communications designed to evaluate various aspects of the sys- tems. Where substantial change was considered, anonymous voting, in some instances using a modified RAND Delphi technique, was utilized. KEYWORDS Abnormal uterine bleeding; Adenomyosis; Anovulatory bleeding; Arteriovenous malformation; Coagulopathy; Endometrial hyperplasia; Endometrial polyp; FIGO; Heavy menstrual bleeding; Heavy uterine bleeding; Intermenstrual bleeding; Irregular menstrual bleeding; Irregular uterine bleeding; Isthmocele; Leiomyoma; Menorrhagia; Metrorrhagia; PALM-COEIN 1 | INTRODUCTION origin.1–9 Approximately one third of women are affected at some time in their life.3,6 Many of the published studies are restricted to estimates The worldwide impact of abnormal uterine bleeding (AUB) in the repro- of the prevalence of the symptoms of heavy menstrual bleeding (HMB); ductive years is substantial, with a prevalence of approximately 3%–30% when other symptoms, particularly those of irregular and intermenstrual among reproductive aged women. The reasons for the wide spectrum bleeding are included, the prevalence rises to 35% or higher.9 of estimates are unclear but vary with age, being higher in adolescents Available evidence suggests that as many as half of affected women and in the fifth decade of life, and varying somewhat with country of do not seek medical care, even if they have access to a healthcare Int J Gynecol Obstet 2018; 143: 393–408 wileyonlinelibrary.com/journal/ijgo © 2018 International Federation of | 393 Gynecology and Obstetrics 394 | MUNRO ET AL. provider,4,5,8 a circumstance that may explain the variation in reported and management, but also to be flexible enough to provide effective prevalence. The manifestations vary from modest to severe disruption linkages with laboratory and research aspects. of work productivity and quality of life,10,11 and increasing maternal The present report updates the FIGO recommendations for both morbidity and mortality for pregnant women with pre- existing AUB- FIGO- AUB Systems 1 and 2, including clarifications on terminologies related anemia.12,13 and definitions, as well as modifications in the PALM- COEIN system In 2011, recognizing the international need created by the impact that include reassignment of some entities, and guidance for subclas- of AUB, the International Federation of Gynecology and Obstetrics sification of leiomyomas, much of which has been preliminarily pub- (FIGO), published a pair of systems and a set of clinical recommenda- lished.18–20 These changes represent structured deliberative processes tions with the aim of informing and aiding clinicians and investigators in that include use of a modified RAND Delphi process applied to the the design and interpretation of investigations into AUB in the repro- attendees of a series of FIGO Menstrual Disorders Committee (MDC) ductive years, as well as the provision of evidence- based clinical care.14 sponsored expert meetings. To allow this report to function inde- The present manuscript was designed to provide a detailed update pendently, and to provide context, there exists substantial but neces- on the FIGO recommendations concerning terminologies, definitions, sary overlap with the original publication,14 and with other subsequent and underlying causes of AUB in the reproductive years. Revised ter- and related publications produced by the MDC since 2011.18–24 minologies and definitions of normal menstrual parameters, and the The FIGO MDC is currently working on subclassification systems for symptoms of AUB were initially published in 2007,15,16 while the sem- adenomyosis and endometrial polyps. The adenomyosis subclassifica- inal 2011 publication14 presented both systems—Terminology and tion system is the most advanced and will be published soon in prelimi- Definitions (FIGO- AUB System 1) and Classification of Causes of AUB in nary form with planned validation studies to follow. The polyp system is the Reproductive Years, the PALM- COEIN system (FIGO- AUB System being developed but a release date has not yet been determined. There 2). From the beginning, it was determined that these recommendations is consideration for subclassification systems for AUB- C, - O, - E, and –I, should be flexible and subject to ongoing regular review to incorpo- but these initiatives are still in the very early stages of development. rate results of new research and analysis. These review periods were It is important that clinicians recognize that these FIGO systems relate intended to broadly coincide with the triennial FIGO World Congresses. solely to assessment and management of nongestational AUB. There are The first key recommendations, published simultaneously in 2007 other causes of genital tract bleeding and urinary tract or gastrointestinal in Fertility Sterility and Human Reproduction,15,16 recommended a bleeding that do not come from the uterus. These can usually be identi- substantial revision of existing terminologies and definitions for the fied by an appropriate case history and physical examination. description of AUB features and, by doing so, redefined the normal parameters of menstrual bleeding. Recommended was the abolition of terms (largely of Latin and Greek origin) such as menorrhagia, metror- 2 | ACUTE VERSUS CHRONIC rhagia, and dysfunctional uterine bleeding, which were poorly defined, NONGESTATIONAL AUB IN THE used internationally in a disparate manner, and had no consistent REPRODUCTIVE YEARS meaning for the general and academic communities.15–17 The second key publication14 presented a novel and pragmatic In the original system,14 FIGO introduced the concept of nonges- approach to classification of the underlying causes of AUB in non- tational acute AUB in the reproductive years, distinguishing it from pregnant women. No such systematic classification of underlying chronic AUB—an approach endorsed by the American College causes existed at that time. This 2011 manuscript introduced the of Obstetricians and Gynecologists.25 These definitions remain PALM- COEIN classification based on clinical-­ and imaging- based unchanged for 2018. Chronic nongestational AUB in the reproductive stratification of causes into “structural” pathologies that can be years is defined as bleeding from the uterine corpus that is abnormal “imaged” and/or defined histopathologically (Polyps, Adenomyosis, in duration, volume, frequency, and/or regularity, and has been pre- Leiomyomas and Malignancy or atypical endometrial hyperplasia; sent for the majority of the preceding 6 months. Acute AUB, on the PALM). The remaining causes were categorized as “non- structural”, other hand, is defined as an episode of heavy bleeding that, in the in that they cannot be imaged, but clinical assessment with detailed opinion of the clinician, is of sufficient quantity to require immediate history and appropriate physical examination, sometimes supported intervention to minimize or prevent further blood loss. Acute heavy by laboratory testing, can largely imply or make a diagnosis of cause menstrual bleeding may present in the context of existing chronic (Coagulopathies, Ovulatory disorders, primary Endometrial disorders, AUB or can occur in the absence of such a background history.
Load more

Recommended publications
  • Intermenstrual Bleeding (Bleeding Between Periods)
    Intermenstrual Bleeding (Bleeding between periods) What is Intermenstrual bleeding? This is unscheduled bleeding that can occur in between periods. There are many different causes of bleeding between periods but seek medical advice if you are experiencing this, even if it is for reassurance in many situations. What is the nature of bleeding? Bleeding that occurs randomly without any relation to your monthly period should not be ignored, unless the cause is known. The bleeding may be light blood, spotting, a bloody or dark brown vaginal loss or heavy bleeding mimicking a period. Mid cycle pain and bleeding Mittelschmerz is one-sided, lower abdominal pain associated with ovulation, about 14 days before your next menstrual period. In most cases, mittelschmerz does not require medical attention and may be associated with light vaginal bleeding for a day or so. It may not occur every month. If you are concerned, seek advice. Spotting in the lead up to or at the end of the period Usually, this just suggests that levels of progesterone fall slightly more slowly in some cycles and can lead to spotting seen in the lead up to the proper menstrual flow. This is usually not a concern. Spotting or a brown vaginal loss as the period finishes is also not abnormal, unless lasting for days or associated with other symptoms. (See information on a normal menstrual cycle under the leaflet on Irregular Periods) What are the possible causes of bleeding between periods? (not an exhaustive list) Hormonal contraceptives, such as the combined or progesterone only pill, implant, injection, intrauterine system, patch, ring can all cause bleeding between cycles, especially in the first few months of starting them.
    [Show full text]
  • Epidemiology of Menstrual Disorders in Developing Countries: a Systematic Review
    BJOG: an International Journal of Obstetrics and Gynaecology DOI: 10.1046/j.1471-0528.2003.00012.x January 2004, Vol. 111, pp. 6–16 REVIEW Epidemiology of menstrual disorders in developing countries: a systematic review Introduction Information on the prevalence of menstrual complaints in the past three months was obtained in seven countries In developing countries, priority setting in the health (Table 1). These data permit cross national comparisons sector traditionally focuses on the principal causes of mor- in so far as similar questions with a similar time reference tality. More recently, the Global Burden of Disease approach were asked. However, no definitions were provided and incorporates assessment of morbidity and quality of life in considerable variation in the interpretation of questions identifying priorities. Yet, although investigations in various among individuals and across cultures is likely. developing countries reveal that women are concerned by Approximately a dozen subsequent surveys, including menstrual disorders, little attention is paid to understanding community-based, clinic-based and one national census, or ameliorating women’s menstrual complaints.1 Menstrual include some information on menstrual morbidities6–29 dysfunction, like other aspects of sexual and reproductive (Table 2). A few health surveys of special populations, health, is not included in the Global Burden of Disease such as factory workers in Vietnam17 and medical students estimates2,3 and, even as reproductive health programs in Venezuela,27,28 have also included relevant questions expand their focus to address gynaecologic morbidity, the on menstrual disorders. These surveys vary consider- utility of evaluating and treating menstrual problems is ably in the definition of and reference period for men- not generally considered.
    [Show full text]
  • Changes Before the Change1.06 MB
    Changes before the Change Perimenopausal bleeding Although some women may abruptly stop having periods leading up to the menopause, many will notice changes in patterns and irregular bleeding. Whilst this can be a natural phase in your life, it may be important to see your healthcare professional to rule out other health conditions if other worrying symptoms occur. For further information visit www.imsociety.org International Menopause Society, PO Box 751, Cornwall TR2 4WD Tel: +44 01726 884 221 Email: [email protected] Changes before the Change Perimenopausal bleeding What is menopause? Strictly defined, menopause is the last menstrual period. It defines the end of a woman’s reproductive years as her ovaries run out of eggs. Now the cells in the ovary are producing less and less hormones and menstruation eventually stops. What is perimenopause? On average, the perimenopause can last one to four years. It is the period of time preceding and just after the menopause itself. In industrialized countries, the median age of onset of the perimenopause is 47.5 years. However, this is highly variable. It is important to note that menopause itself occurs on average at age 51 and can occur between ages 45 to 55. Actually the time to one’s last menstrual period is defined as the perimenopausal transition. Often the transition can even last longer, five to seven years. What hormonal changes occur during the perimenopause? When a woman cycles, she produces two major hormones, Estrogen and Progesterone. Both of these hormones come from the cells surrounding the eggs. Estrogen is needed for the uterine lining to grow and Progesterone is produced when the egg is released at ovulation.
    [Show full text]
  • Abnormal Uterine Bleeding: a Management Algorithm
    J Am Board Fam Med: first published as 10.3122/jabfm.19.6.590 on 7 November 2006. Downloaded from EVIDENCED-BASED CLINICAL MEDICINE Abnormal Uterine Bleeding: A Management Algorithm John W. Ely, MD, MSPH, Colleen M. Kennedy, MD, MS, Elizabeth C. Clark, MD, MPH, and Noelle C. Bowdler, MD Abnormal uterine bleeding is a common problem, and its management can be complex. Because of this complexity, concise guidelines have been difficult to develop. We constructed a concise but comprehen- sive algorithm for the management of abnormal uterine bleeding between menarche and menopause that was based on a systematic review of the literature as well as the actual management of patients seen in a gynecology clinic. We started by drafting an algorithm that was based on a MEDLINE search for rel- evant reviews and original research. We compared this algorithm to the actual care provided to a ran- dom sample of 100 women with abnormal bleeding who were seen in a university gynecology clinic. Discrepancies between the algorithm and actual care were discussed during audiotaped meetings among the 4 investigators (2 family physicians and 2 gynecologists). The audiotapes were used to revise the algorithm. After 3 iterations of this process (total of 300 patients), we agreed on a final algorithm that generally followed the practices we observed, while maintaining consistency with the evidence. In clinic, the gynecologists categorized the patient’s bleeding pattern into 1 of 4 types: irregular bleeding, heavy but regular bleeding (menorrhagia), severe acute bleeding, and abnormal bleeding associated with a contraceptive method. Subsequent management involved both diagnostic and treatment interven- tions, which often occurred simultaneously.
    [Show full text]
  • Too Much, Too Little, Too Late: Abnormal Uterine Bleeding
    Too much, too little, too late: Abnormal uterine bleeding Jody Steinauer, MD, MAS July, 2015 The Questions • Too much (& too early or too late) – Differential and approach to work‐up – Does she need an endometrial biopsy (EMB)? – Does she need an ultrasound? – How do I stop peri‐menopausal bleeding? – Isn’t it due to the fibroids? • Too fast: She’s hemorrhaging—what do I do? • Too little: A quick review of amenorrhea Case 1 A 46 yo G3P2T1 reports her periods have become 1. What term describes increasingly irregular and heavy her symptoms? over the last 6‐8 months. 2. Physiologically, what Sometimes they come 2 times causes this type of per month and sometimes there bleeding pattern? are 2 months between. LMP 2 3. What is the months ago. She bleeds 10 days differential? with clots and frequently bleeds through pads to her clothes. She occasionally has hot flashes. She also has diabetes and is obese. Q1: In addition to a urine pregnancy test and TSH, which of the following is the most appropriate test to obtain at this time? 1. FSH 2. Testosterone & DHEAS 3. Serum beta‐HCG 4. Transvaginal Ultrasound (TVUS) 5. Endometrial Biopsy (EMB) Terminology: What is abnormal? • Normal: Cycle= 28 days +‐ 7 d (21‐35); Length=2‐7 days; Heaviness=self‐defined • Too little bleeding: amenorrhea or oligomenorrhea • Too much bleeding: Menorrhagia (regular timing but heavy (according to patient) OR long flow (>7 days) • Irregular bleeding: Metrorrhagia, intermenstrual or post‐ coital bleeding • Irregular and Excessive: Menometrorrhagia • Preferred term for non‐pregnant bleeding issues= Abnormal Uterine Bleeding (AUB) – Avoid “DUB” ‐ dysfunctional uterine bleeding.
    [Show full text]
  • An Intramural Uterine Fibroid Became Submucosal in the Puerperium – Proposed Probable Mechanism: a Case Report Elie Nkwabong
    Nkwabong Journal of Medical Case Reports (2018) 12:88 https://doi.org/10.1186/s13256-018-1624-0 CASEREPORT Open Access An intramural uterine fibroid became submucosal in the puerperium – proposed probable mechanism: a case report Elie Nkwabong Abstract Background: Vaginal prolapse of a large uterine fibroid is a rare phenomenon in a woman who delivered vaginally recently, given that this fibroid might have obstructed labor. The author presents a case report of a vaginally prolapsed large pedunculated submucosal uterine myoma in a woman with a recent uncomplicated vaginal delivery. Case presentation: A 25-year-old black African woman had four intramural uterine fibroids of diameters 62 to 94 mm diagnosed in April 2013 with standard ultrasound scan. She got pregnant in July 2014. An ultrasound scan done on 31 August 2014 at 10 weeks’ gestation identified four intramural uterine fibroids, with sizes varying from 70 to 150 mm. Her pregnancy was well followed up, without any complications. She had an uneventful vaginal delivery on 10 April 2015. During uterine exploration, indicated for retention of parts of fetal membranes, no pedunculated submucosal fibroid was found. On 15 May 2015, she consulted for difficult micturition and partial urinary retention that occurred 2 days ago. A vaginally prolapsed 10 cm uterine fibroid was diagnosed. Forty-eight hours after administration of intravenously administered broad spectrum antibiotics, the myoma was successfully twisted off by means of vaginal route under general anesthesia, which relieved her symptoms. Conclusions: To the best of our knowledge, this is the first case of vaginally prolapsed large submucosal uterine fibroid in a woman who delivered vaginally recently.
    [Show full text]
  • FIGO Classification System (PALM-COEIN)
    International Journal of Gynecology and Obstetrics 113 (2011) 3–13 Contents lists available at ScienceDirect International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo SPECIAL COMMUNICATION FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age Malcolm G. Munro a,b,⁎, Hilary O.D. Critchley c, Michael S. Broder d, Ian S. Fraser e; for the FIGO Working Group on Menstrual Disorders a Department of Obstetrics and Gynecology, University of California, Los Angeles, USA b Kaiser Permanente, Los Angeles Medical Center, Los Angeles, USA c Centre for Reproductive Biology, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK d Partnership for Health Analytic Research, Beverly Hills, USA e University of Sydney, Queen Elizabeth II Research Institute for Mothers and Infants, Sydney, Australia article info abstract Article history: There is general inconsistency in the nomenclature used to describe abnormal uterine bleeding (AUB), in Received 27 November 2010 addition to a plethora of potential causes—several of which may coexist in a given individual. It seems clear Accepted 7 January 2011 that the development of consistent and universally accepted nomenclature is a step toward rectifying this unsatisfactory circumstance. Another requirement is the development of a classification system, on several Keywords: levels, for the causes of AUB, which can be used by clinicians, investigators, and even patients to facilitate Abnormal uterine
    [Show full text]
  • Fact Sheet Intermenstrual Bleeding [IMB]
    Fact Sheet Intermenstrual bleeding [IMB] Intermenstrual Bleeding (IMB) is bleeding or Hormone therapy (HRT) after menopause – spotting that happens in-between your periods. The this is a common and harmless cause of irregular usual menstrual cycle is 28 days, although the time bleeding which may happen just after starting between periods can vary from 21-35 days. HRT. It usually settles after a few months of taking the HRT. Bleeding at times in between periods is not normal, Some types of contraception but it is very common; in fact most women will have The Oral Contraceptive Pill (‘the pill’) - any this type of bleeding at some time in their lives. type of OCP, mini-pill or the contraceptive ring can cause intermenstrual bleeding. When IMB IMB is not the same as ‘irregular’ periods which is happens on contraception it is called when the period itself comes at infrequent or breakthrough bleeding (BTB). It is important to unpredictable times (closer than 21 days or further know that this type of bleeding often happens apart than 35 days). for the first three months after you start the pill but then it usually settles. It can also happen if What are reasons for Intermenstrual Bleeding? you miss taking a pill, or have vomiting or IMB is common and there are quite a number of diarrhoea while on the pill. Remember that if possible causes - many are completely harmless you have missed a pill, or have vomiting or but some can be serious. Causes of IMB include: diarrhoea, you may not be protected from Pregnancy – problems which can happen in falling pregnant so extra contraception, like a early pregnancy, like miscarriage or ectopic condom, is required.
    [Show full text]
  • Heavy Menstrual Bleeding
    Heavy Menstrual Bleeding See also: • Intermenstrual Bleeding • Postcoital Bleeding • Post Menopausal Bleeding Disclaimer Contents Disclaimer ............................................................................................................................................................................................ 1 Red Flags ............................................................................................................................................................................................. 2 Background .................................................................................................................................................. 2 About Heavy Menstrual Bleeding (HMB) ................................................................................................................................ 2 Assessment ................................................................................................................................................... 2 Practice Point - Exclude other causes ....................................................................................................................... 2 History .................................................................................................................................................................................................. 2 Volume of blood loss .....................................................................................................................................................................
    [Show full text]
  • Management of Menorrhagia
    Management of Menorrhagia CLINICAL PRACTICE GUIDELINES DECEMBER 2004 MOH/P/PAK/95.04 MANAGEMENT OF MENORRHAGIA i Management of Menorrhagia MINISTRY OF HEALTH MALAYSIA ACADEMY OF MEDICINE MALAYSIA GUIDELINES DEVELOPMENT AND OBJECTIVES Guidelines Development The work group for the development of these guidelines comprised Obstetricians and Gynaecologists from various Ministry of Health and Ministry of Education facilities. These guidelines were adapted from other international guidelines on management of menorrhagia or heavy menstrual bleeding and modified to suit the local situation. These include guidelines from New Zealand, Canada and the Royal College of Obstetrics and Gynaecologists, UK. A systematic review of current evidence was carried out. Ranking of evidence are based on a modified version of those used by the Catalonia Agency for Health Technology Assessment (CAHTA) Spain; the classification of recommendation was emulated from those used by the Scottish Intercollegiate Guidelines Network (SIGN). The ranking of evidence is based on a modified version of that suggested by the Catalonia Agency for Health Technology Assessment and Research (CAHTAR) Spain, while the grading of recommendations in these guidelines emulates those used by the Scottish Intercollegiate Guidelines Network (SIGN).The draft guidelines were posted on both the Ministry of Health Malaysia and Academy of Medicine, Malaysia websites for comment and feedback. These guidelines have also been presented to the Technical Advisory Committee for Clinical Practice Guidelines and Health Technology Assessment and Clinical Practice Guidelines Council, Ministry of Health Malaysia for review and approval. Objectives The aim of this guideline is to aid doctors in general practice and gynaecologists in clinical decision making, by providing well-balanced information on the management of patients with menorrhagia.
    [Show full text]
  • Menstrual Problems
    --- ________________________________________________________________________________ MENSTRUAL PROBLEMS NORMAL MENSTRUATION Most young women will first menstruate (menarche) around the age of 12 years. If a young woman starts to menstruate under the age of 8-9 years or if she hasn’t menstruated by age 14 with no breast development or 16 years with breast development; then investigations should be performed. The menstrual length is calculated from day one of the periods to day one of the next cycle. Normal cycle length is 3-8 weeks with 1-7 days of bleeding. A women having fewer than 6 periods per year (“oligomenorrhoea”), or no periods for 6 months (“amenorrhoea”) needs to have some tests performed. Bleeding between periods is called “intermenstrual bleeding.” Some have a small bleed at ovulation. Sometimes intermenstrual bleeding needs to be investigated too. HEAVY PERIODS This is one of the commonest reasons for a woman needing to see a gynaecologist. Warning signs that the menstrual loss needs to be investigated include: • Passing menstrual clots • Flooding past sanitary protection • Anaemia and iron deficiency on blood testing The doctor will usually organise an ultrasound scan to see if there are any physical reasons for the heavy periods. These include fibroids (balls of muscle within the wall of the uterus), polyps inside the uterus and adenomyosis (the uterine lining grows into the wall). Blood tests may be ordered to check the blood count and iron stores and sometimes the thyroid. A sexually active woman should make sure that her pap smear is up to date and sometimes the doctor might want to do a cervical (vaginal) swab for infections.
    [Show full text]
  • MENSTRUAL DISORDERS DR GREGORY HALLE Gynaecologist - Obstetrician General Hospital Douala
    MENSTRUAL DISORDERS DR GREGORY HALLE Gynaecologist - Obstetrician General Hospital Douala Postgraduate Training in Reproductive Health Research Faculty of Medicine, University of Yaoundé 2007 NORMAL MENSTRUATION Cyle length: marked variability in women not using oral contraceptives. th th 5 -95 centile being 23 – 39.4 days. Mean duration 29.6 days. Cycle length decreases with advancing age. Abnormal menstruation: bleeding at any time outside normal menstruation and any variation outside the defined limits. Acyclical bleeding – pre or postmenopausal bleeding. NORMAL MENSTRUATION Duration of menstrual blood loss: 2-7 days, mean of 5 days. Excessive menstruation >7 days. Blood loss: difficult to evaluate. Racial differences. Average blood loss 40cc: 90% occurs 1-3 days. Pathological >80cc. Critical appraisal of menstrual blood loss is uncertain because of underestimation by some patients. NORMAL MENSTRUATION 50–75% of menstrual flow is blood, the rest is made up of fragments of endometrial tissue and mucus. Menstrual blood does not clot – Aggregation of endometrial tissue, red blood cells, degenerated platelets and fibrin. Endometrium contains large amounts of fibrin degradation products. When blood loss is excessive, lytic substances that are rapidly consumed lead to the presence of clots in menstrual flow – Excessive menstrual blood flow. NORMAL MENSTRUATION ROLE OF EICOSANOIDS Prostanoids are not stored but are synthesized in tissues as required. Prostaglandins PGF2alpha , PGE2, prostacylin(PGI2), thromboxane(TxA2) and leukotrienes all play an important role in menstruation. Phospholipids are released from cell membranes and converted to arachidonic acid by phospholipase A2. Cyclo-oxygenase converts arachidonic acid to unstable endoperoxides (PGG3 and PGH2) which are rapidly converted to by specific synthetases into: PG2 alpha - potent vasoconstrictor and weakly platelet antiaggregatory.
    [Show full text]