45. Menstrual disturbances. Functional (dysfunctional) uterine bleeding

Covers the terminology of menstrual disorders, including amenorrhoea, oligomenorrhoea and heavy bleeding, with a table of amenorrhoea causes by level from hypothalamus to thyroid, and the basic tests used. It then introduces the FIGO PALM-COEIN classification of abnormal uterine bleeding in a two-column table, before explaining anovulatory bleeding and its link to unopposed oestrogen. The management section lists investigations, acute and long-term treatments, and surgical options.

Inside: 3 sections · 3 tables · 16 flashcards · 2 min

Topic 45 of 61 in the MU Sofia syllabus for Obstetrics and Gynecology (Medicine, Year 5). The free AceMed note covers it in 3 sections, about 172 words (2 min of reading), with 16 flashcards.

Disorders of the menstrual cycle

Causes of amenorrhoea

Basic tests: hCG, FSH and LH, prolactin, TSH, testosterone, oestradiol; pelvic ultrasound; a progestogen challenge (bleeding means oestrogen is present and the outflow is open).

Abnormal uterine bleeding (AUB)

FIGO classifies AUB with the PALM–COEIN system:

Dysfunctional (anovulatory) uterine bleeding

Now called AUB-O: bleeding without a structural cause, from anovulation. Without ovulation there is no corpus luteum and no progesterone, so the endometrium grows under unopposed oestrogen and breaks down irregularly. It is typical at the two ends of reproductive life (puberty and perimenopause) and in PCOS. Unopposed oestrogen over years raises the risk of endometrial hyperplasia.

Management

Exclude pregnancy, structural causes, coagulopathy; check Hb and ferritin; endometrial sampling if > 45 years or risk factors.
Acute heavy bleeding: resuscitate; high-dose progestogens or combined pill, tranexamic acid; D&C or hysteroscopy if it fails.
Long term: levonorgestrel IUS (first line for heavy bleeding), tranexamic acid, mefenamic acid, combined pill, cyclical progestogens.
Surgery when medical treatment fails and family is complete: endometrial ablation, hysterectomy.

No ovulation, no progesterone: unopposed oestrogen gives irregular heavy bleeding now and endometrial hyperplasia later.