DR GREGORY HALLE
Gynaecologist - Obstetrician
General Hospital Douala
Postgraduate Training in Reproductive Health Research
Faculty of Medicine, University of Yaoundé 2007
? Cyle length: marked variability in women not using
? 5th-95th 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
? Acyclical bleeding – pre or postmenopausal bleeding.
? Duration of menstrual blood loss: 2-7 days, mean of 5
? 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.
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
When blood loss is excessive, lytic substances that are rapidly
consumed lead to the presence of clots in menstrual flow –
Excessive menstrual blood flow.
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.
PGI2 – potent vaso-dilator and weakly platelet antiaggregatory.
PGD2 – platelet aggregation inhibitor.
Thromboxane – potent vasoconstrictor and platelet inhibitor.
Prostanoids are thought to act at their site of synthesis.
Menorrhagia (hypermenorrhea): uterine bleeding excessive in both amount
and duration of flow, but occurring at regular intervals.
Oligomenorrhea: menstrual periods at intervals of more than 35 days.
Menometrorrhagia: uterine bleeding usually excessive and prolonged
occurring at frequent and irregular intervals.
Polymenorrhea: frequent but regular episodes of uterine bleeding occurring
at intervals of 21 days or less.
Metrorrhagia: uterine bleeding occurring at irregular intervals.
Hypomenorrhea: uterine bleeding that is regular but decreased in amount.
Intermenstrual bleeding: uterine bleeding, usually not excessive, occurring
at any time during the menstrual cycle other than during normal
Dysfunctional uterine bleeding
? Blood flow is usually excessive in duration, amount
? More common during the perimenarcheal and
? Usually episodes are transient and self limiting.
? During the reproductive years many factors might
disrupt and interrupt ovulation.
? Causes for disturbed function can be central,
intermediate, end organ, and physiologic.
Etiologic classification of
Central causes: immaturity of the hypothalamic-pituitary axis; functional or
chronic diseases; traumatic, toxic, and infectious lesions; polycystic ovarian
Pychological factors: anxiety, stress, emotional trauma; psychotrophic
drugs, drug addiction, exogenous steroid administration.
Intermediate causes: chronic illness, metabolic or endocrine diseases,
Peripheral causes: functional ovarian cyst, functional tumors, premature
Physiologic: perimenarcheal and perimenopausal.
uterine bleeding (DUB)
Adolescent DUB is primarily due to delayed, asynchronous or abnormal
hypothalamic maturation and inadequate positive feedback.
Usually associated with oligomenorrhoea, polymenorrhea or some
irregularity of menstruation due to delayed or failed ovulation with a failed
luteal phase support.
Uterine bleeding is occasionally severe and prolonged leading to severe
anaemia especially in truely anovulatory cycles.
In cases where this persists the existence of PCO must be excluded and the
teenager treated with cyclic hormones or oral contraceptives.
? In the reproductive age, psychologic causes of
menstrual disorers involve marital and sex life, a
detailed history might reveal significant events that
precedes anovulatory episodes.
? History of broken relationships, alcoholism or drug
addiction and school or social pressures.
? Polycystic ovarian syndrome common finding:
obesity, hirsutism, anovulatory cycles (failure of
follicular development), endometrial hyperplasia.