OM HEALTH CAMPUS

AFFILIATED TO PURBANCHAL UNIVERSITY

GOPIKRISHNANAGAR, KATHMANDU
 
 

Case study presentation on “Metrorrhagia”

SUBMITTED TO: SUBMITTED BY:
Mrs. Mamata Bhandari Additi satyal
Roll no:01
BSN 3rd year
13th Batch
Submitted on :- 2077/06/ 07
ACKNOWLAGEMENT

As per the curriculum of B Sc. Nursing 3rd year, Gynaecologyy we

had to complete a case study presentation. This report is made for
the practical fulfillment for my case study. Firstly, I would like to
express my sincere gratitude to Om health campus for providing us
an opportunity to expose ourselves to do our practical field. I
would like to thank our principle madam MRs Sita devi kunwar
and Head of department MRs Meena Baniya for arranging us such
an environment to perform practical at hospital. I would like to
express sincere thank you to our supervisor Mrs. Mamata
Bhandari for her full guidance and support during our practical
session. Last but not the least; I would like to thank my friends
who helped me directly or indirectly throughout the duty period.
 BACKGROUND
This report is prepared as per the curriculum of B Sc. Nursing
3rd year. During our posting we were posted at different
obstetric ward to gain comprehensive knowledge about the
various cases of antenatal, postnatal and gynecology and its
management. During our posting to gynecology ward, we
had to take one case and have to present it. So for this I
selected “Metrorrhagia”. This case study presentation is
designed to gain more knowledge about the case and to
provide holistic nursing care to the patient according to
their need.
 OBJECTIVES
 GENERAL OBJECTIVES:
 The general objective of my case study is to gain
comprehensive knowledge about the disease condition .
 SPECIFIC OBJECTIVES:
• To gain knowledge about the disease condition and its
management.
• To provide holistic nursing care to the patient according to
her need.
• To co-relate the condition of disease in the theory and
practical basis.
• To keep effective therapeutic relationship with the
client in different situation.
• To minimize the patient’s illness, stress and
hospitalization by various nursing interventions.
• To provide health education to the patient and family
regarding health promotion and prevention from its
complications.
 Reason for case selection
 The main reason for me to choose “Metrorrhagia” as my
case study are as follows :-

• For the fulfillment of criteria of curriculum.

• A case of ‘’Metrorrhagia’’ is a common gynecological problem.
I was really curious to gain knowledge in detail about it
• To provide holistic care to the patient .
• To maintain feasibility of care .
• To apply nursing theory during care of the patient .
• To evaluate the progress of the patient.
 Content
PART 1
PATIENT PROFILE :
1. Assumption of the case
2. Biodemographic data
3. Physical examination summary
4. Developmental task
 PART 2 : DISEASE PORTION

• Introduction
• Definition
• Incidence
• Risk factors
• Causes
• Pathophysiology
• Signs and symptoms
• Diagnostic investigations
• Management : medical, surgical, nursing
• Prognosis
• Complications
• Drugs list and explained in detail
 PART 3

1. Nursing theory
2. Nursing care plan
3. Discharge and health teaching
4. Learning from experience
5. Summary
6. references
PART 1
 Case scenario
• 39 year old Mrs Yasoda Dhungana was admitted to
Gynaecologyy ward on 2076/03/13with the chief complains
of bleeding with excessive flow at irregular interval,
presyncope and abdominal pain with bleeding. Also she
has history of post-coital bleeding since past 8 months.
 Biographical Data:

•Name of client: Yasoda Dhungana

•Age : 39
• Sex : female
•Diagnosis : Metrorrhagia
•Ward : General ward
•Bed no. :207
•Attendant Dr.: Dr. jageshsor gautam
•Address: chabil ,kathmandu
•Religion: Hindu
•Name of husband: Jiwan Dhungana
•Date of admission :2076/03/13 , at 11 am
•Date of interview: 2076/3/13, at 12:00 pm
 Chief complains:
• bleeding with excessive flow at irregular interval ,
presyncope * 18 month
• Bleeding after sexual intercourse * 1 year
• Abdominal pain with bleeding.
 Menstrual history:
• Menarche: 12 years
• Flow: 5-7 days
• Cycle: 30+-2 days
• Irregular menstrual cycle
 Obstetrical history:
• Married for 3.5 years
• Gravid: 2
• Para: 1
• Live birth: 1
 Physical examination
• While performing the physical examination of yasoda
Dhungana the following finding are obtained;-
Temperature:- 36.3C Pulse rate:- 91bpm
Respiratory rate: 18cpm BP:-100/70
Anthropometric Measurement
H eight:-5ft Weight :-41.5
BMI:-17.87kg/m2 (underwight)
 Abnormalities in physical examination
• Patient is underweight with BMI of 17.87kg/m2.
• Pallor- of skin, lips nail beds and conjunctival mucosa
• Nails –flattened ,fragile, brittle
• Weakness ,sleepiness ,irritability ,cyanosis
• Bleeding is present during per vaginal examination. ( 1 pad
is soaked in every two hours )
 Developmental task:
• As my patient Mrs yosoda Dhungana is 39years old female
she comes under young adulthood.
• As developmental task is listed below;-
 Developmental task
• establishing personal and economic independence.
• Identity exploration, especially in love and work .
• Instability; Self-focused
• Felling in- between
• Establishing a residence and learning how to
manage a household
• Becoming a parent and rearing children
• Making marital relationship.
 Devlopmental task
• During early adulthood, individuals enter Erikson's intimacy
versus isolation stage (developmental task of forming
intimate relationships with others or becoming socially
isolated)
• As my patient has fulfilled her developmental task as she
has good marital relationship with her husband and task of
being parent and raring children is also fulfilled.
Part II
DISEASE PORTION
 Normal Uterine Bleeding

• Age of patient: reproductive-aged women (from menarche

to menopause)
• Frequency: 21 days to 35 days interval
• Duration: 2 days to 8 days; usually 4-6 days
• Flow: 35 ml although 10ml – 80ml is considered normal.
• (1 normally soaked regular pad/tampon holds +/- 5mls of
blood. However, depending on the brand, a pad can hold
between 5 and 15 ml of blood)
 Normal Uterine Bleeding
Menarche:
• 9-16 years usually 2,3 years after 1st sign of breast
development.
Reproductive years:
• Cycle length 23-39 days (mean 30).
• Duration of menstrual bleeding 2-8 days (mean 5).
• Normal blood loss 10-55ml(=/< 80mls)
Menopause:
• 48-55 years ,40 – 48 = early menopause
 Abnormal uterine bleeding
•  (AUB) is bleeding from the uterus that is longer than usual or that
occurs at an irregular time. Bleeding may be heavier or lighter than
usual and occur often or randomly. AUB can occur: As spotting
or bleeding between your periods.

• Bleeding from the uterine corpus that is abnormal in regularity,

volume, frequency or duration, and occurs in absence of pregnancy
• The bleeding is unpredictable in many ways.

• It may be excessively heavy or light and may be prolonged,

frequent, or random.
 Types of AUB

1. Dysfunctional Uterine Bleeding

2. Menorrhagia
3. Polymenorrhea
4. Metrorrhagia
5. Oligomenorrhea
6. Hypomenorrhea
 Metrorrhagia

Metrorrhagia: Uterine bleeding at irregular intervals,

particularly between the expected menstrual periods.
Metrorrhagia may be a sign of an underlying disorder, such as
hormone imbalance, endometriosis, uterine fibroids or, less
commonly, cancer of the uterus. Metrorrhagia may cause
significant anemia.
 Definition
• Metrorrhagia is defined as irregular, acyclic bleeding
from the uterus.
• Amount of bleeding is variable.
• Non-cyclical, patternless vaginal bleeding is often
described as metrorrhagia. A useful classification is as:
Postcoital bleeding
Intermenstrual bleeding
Postmenopausal bleeding
• Menometrorrhagia is the term applied when the
bleeding is so irregular and excessive that the
periods can’t be idenfied at all.
 Incidence
• Abnormal uterine bleeding is a common morbid condition of
woman seeking medical advice.
• This is a retrospective study carried out in the department of
gynecology and obstetrics at chitwan medical college and
teaching hospital for 1 yr period from 2067 Baisakh 1st to 2067
Chaitra last.
• Data were analyzed from O.P.D., operation notes, maternity
ward and pathology records. A total of 634 patients (4.7%) with
abnormal uterine bleeding were found among 13,243 patients
attended in Gynae OPD. Maximum number 50.9% of cases of
abnormal uterine bleeding. The prevalence of metorrhagia was
9.2% in general among age below 30 years.
 Risk factor
• Obesity
Hormones in fat tissues can turn into estrogen. This can lead
to heavier bleeding.
• Health Problems:- the certain health problem like can
cause heavy bleeding:-
Fibroids
Uterine polyps
Cancer of the uterus , cervix , or vagina
Endometriosis
Bleeding disorders
Pelvic infections
Thyroid problems (in my patient)
Systemic lupus erythematosus
Bleeding disorders
 Risk factor
• Eating Disorders:- (In my patient)
Eating disorders can cause low body fat, rapid weight loss, and
hormonal problems. They can all cause period changes.
• Stress
Stress can cause hormone changes that may slow or stop
signals to start periods. When stress is eased, periods often
return.
• Lack of Periods
Too Much Exercise Regular intense exercise may stop periods. It
can happen in athletes or those with compulsive exercising.
 Risk factor
• Older Women
Periods may change leading up to menopause. The risk of heavy bleeding
may also be higher in older women who still have regular periods.
• Birth Control Copper
 IUDs may cause heavy periods in some women. IUDs with progestin may
ease bleeding.

• MEDICINE
Medicines that may raise the risk of heavy bleeding are:
Blood thinners
Anti-inflammatory medicine
Cancer drugs
 CAUSES

Causes of acyclic bleeding

• DUB — usually during adolescence, following

childbirth and abortion and preceding
menopause
• Submucous fibroid
• Uterine polyp
• Carcinoma cervix and endometrial carcinoma
Causes of intermenstrual bleeding
• Urethral caruncle
• Ovular bleeding
• Breakthrough bleeding in pills use (in my
patient)
• IUCD in utero
• Decubitus ulcer
Causes Contact Bleeding
• CA cervix
• Mucus polyp of cervix
• Vascular atopy of cervix
• Infection –chalamydia
• Cervical endometrosis
 Others causes
• Infection
Sexually transmitted infection is a probable cause of
metrorrhagia .syphilis is known to cause vaginal
bleeding.
• Hormonal imbalance (In my patient)
There are underlying conditions such as
hyperthyroidism /hypothyroidism that cause hormonal
imbalance as thyroid hormone helps in maturation of
ovum. the thyroid disorder causes immature
hypothalamic pituitary ovarian axis.
• Coagulation problems
Women who have an underlying coagulation problem
such as those prone to bleeding are highly susceptible to
metrorrhagia .
• Use of contraception
The use of devices that can traumatize the vaginal or uterine
lining can cause bleeding.
 Pathophysiology
Due to alteration in hypothalamic-pituitary axis

Corpus luteum not formed

Failure of the cyclical secretion of progesterone

Continuous unopposed production of estrogen

Stimuates overgrowth of the endometrium

Endometrium grows thick, outgrowth its blood supply

Neecrosis and irregular bleeding

 Clinical feature
The cardinal symptoms of metrorrhagia is a light to heavy
bleeding between regular menstrual period
Others clinical feature are :-
• Post-coital bleeding (In my patient )
• Dyspareunia
• Dysmenorrhoea
• Intermenstrual bleeding (In my patient)
• Pelvic pain
.
• Vaginal discharge
• Hirsutism
• Bruises (coagulation disorder)
• Passing large blood clots. (In my patient)
• May cause fatigue, tiredness , anemia. ( In my patient)
 Diagnostic investigation

History
• Medical history ;bleeding disorder ,other disease
• Obstetric history ;pregnancy ,abortion
• Contraceptive history ; oral pills IUD
• Confirmed that the bleeding is through the vagina and
not from the urethra or rectum.
• Statement of excessive bleeding is assessed by
number of pads used, passage of clots (size and
number) and duration of bleeding
• Nature of menstrual abnormality is then to be enquired —
cyclic or acyclic, its relation to puberty, pregnancy events
and last normal cycle.
• Use of steroidal contraceptives or IUCD insertion should be
enquired.
 Blood values
• Haemoglobin estimation is done in every case.
• In suspected cases of thyroid dysfunction, serum TSH, T3,
T4 estimation is to be done. ( In my patient)
• Blood tests ; CBC ,blood grouping, clotting factors.(In my
patients)
• Speculum examination of cervix for polyp, vascular erosion
endocervicitis, cancer cervix, genital tract ulcers and growth, and IUCD.
• Pap smear examination
• Diagnostic hysteroscopy and endocervical curettage for histological
examination of endometrial tissue
• Pelvic sonography
• Transvaginalsonography (TVS) is also very sensitive to detect any
anatomical abnormality (fibroid, adenomyosis) of the uterus,
endometrium md adnexae.
• Saline Infusion Sonography (SIS) is found very helpful to diagnose
endometrial polyps, submucous fibroids and uterine abnormality
(septate/subseptate uterus).
• Ultrasound and Colour Doppler findings of endometrial
hyperplasia are :
i. Endometrial thickness >12 mm
ii. Hyperechoic and regular outline,
 Management
management protocols have been grouped
accordingly.
• Pubertal and adolescent < 20 years .
• Reproductive period (20-40 years).
• Premenopausal (> 40 years).
• Postmenopausal
 Reproductive period
♦ General
♦ Medical
♦ Surgery
 GENERAL
Rest
Assurance on handling diet, and blood transfusion. Clinically
systemic or endocrinal abnormalities should be investigated
and treated accordingly.
 MEDICAL MANAGEMENT
1. Hormonal treatment
2. Non-hormonal treatment
Levonorgestrel-releasing intrauterine system

 Release doses of 20 micrograms of LNG

Effects:-
• prevent endometrial proliferation
• thicken cervical mucus
• suppress ovulation

 Cost effective when compared with other hormonal and

non hormonal treatments
combined oral contraceptive pill (COCP)
• Contain estrogen and progestogen in combinations.
• Act on HPO axis to suppress ovulation and fertility -cause
withdrawal bleeding.
 Oral Progestogen
• Hormone produced during luteal phase .
• Cause secretory transformation of endometrium - bleeding
when levels fall.
• Requires long course regimen
 Danazol
• Estogenic and anti-progesteronic activity
• Antiproliferative to endometrium
• Anovulatory by preventing GnRH at pituitary

Significant androgenic side effects

• Weight gain
• Acne
• Hirsutism
• Voice changes
 GnRH-analogues
MOA
Synthetic peptide that act like a natural GnRH but with
longer biological half life

• Action .
1) Flare effect-
increase FSH and LH
2. Profoung hypogonadal effect –
after 10 days down regulation
 GnRH-analogues
• No follicular development, estrogen production, no
ovulation, no progeterone, no menses

Treatment
1. Hormonal sensitive cancer -breast cancer, prostate cancer
2. Estrogen dependant lesion - leiomyoma, endometriosis
Non-hormonal treatments
 Anti-fibrinolytic agents (Tranexamic acid )

MOA
• Competitive inhibitor of plasminogen activator
-antifibrinolytic agents
However,
• not reduce dysmenorrhea
• not a contraceptive
• not regulate cycles
• Cost effective when compared with other NSAIDS and no
treatment -not when compared with LNG-IUS
Dosage:
• 1g ( 2 tablets) 3-4x daily from onset of bleeding up to 4 days
 NSAIDs
MOA
Reduce prostaglandin synthesis by inhibiting COX
• Inflammatory response –
Pain pathways
Uterine cramps
Uterine bleeds
• Treatment of dysmenorrhea
• However,
Not contraceptions
Not to be used in bleeding disorders
Surgical treatments
 Endometrial Ablation
• Indications
• Severe bleeding that impact quality of life - Not want to
remain fertile
• Normal size uterus, small fibroids
How it works?
• Remove endometrial lining will stop heavy bleeding
• Recurrence occur and repeated surgery can be done
• Effective contraception after surgery

Unwanted outcomes
• Increasing dysmenorrhea
• Infection (less common)
• vaginal discharge
Hysterectomy
• Indications –
• Heavy bleeding with failed other treatment options –
• Don’t want to remain fertile
• Want period to stop
Or, large fibroids
Adverse Outcomes
infection-common
• Intraoperative hemorrhage, damage abdominal organs,
urinary dysfunction
• With oophorectomy - menopausal like syndrome
Uterine artery embolization (UAE)

• Indications
• - Heavy bleeding –
• Large fibroids
• How it works?
• Small particles introduced into artery supply to the uterus -
fibroid shrinks
 Contd

• Adverse outcomes
• - Persistent vaginal discharge
• Post-embolisation syndrome: pain, nausea,
vomiting and fever
• Need additional surgery
• Premature ovarian failure - hematoma Fert
Myomectomy
 Contd..
Indications
Heavy bleeding
Large fibroids
• How it works?
Fibroids are removed
• Adverse outcomes
Adhesion ; pain and impaired fertility
Need additional surgery
Recurrence of fibroids
Perforation (hysteroscopic route)
infection
Uterine thermal balloon for destruction of
endometrium
 Uterine thermal balloon for destruction of
endometrium

• Endometrium is destroyed using a thermal balloon with

hot normal saline (87°C) for 8-10 minutes.
• No dilatation of the cervical canal is needed. This
procedure is suitable for women who are not suitable for
general anaesthetic or long duration surgery.
Microwave endometrial ablation
 Microwave endometrial ablation
• is simple and carried out as an outpatient procedure.
• Microwave electromagnetic heat energy causes ablation of
the endometrium.
• Endometrial tissue upto a depth of 6 mm is ablated.
• Temperature in the region is 75-80°C.
• Treatment time (2-3 minutes)
 prognosis
• If left untreated, metrorrhagia can interfere with daily life.
In addition, it can cause anemia and leave you feeling tired
and weak. Other health problems can also arise if the
bleeding problem is not resolved. With proper treatment and
doctor assistance, metrorrhagia can be managed and not
cause a disruption to your life.
 Complication
• Anemia.
 Metrorragia can cause blood loss anemia by reducing the number of
circulating red blood cells. The number of circulating red blood cells is
measured by hemoglobin, a protein that enables red blood cells to
carry oxygen to tissues.
Iron deficiency anemia occurs as your body attempts to make up for the
lost red blood cells by using your iron stores to make more hemoglobin,
which can then carry oxygen on red blood cells. Metrorrhagia may
decrease iron levels enough to increase the risk of iron deficiency
anemia.
Signs and symptoms include pale skin, weakness and fatigue. Although
diet plays a role in iron deficiency anemia, the problem is complicated
by heavy menstrual periods.
 Contd

• Severe pain.
• Difficulty getting pregnant
• Infertility

 
Part -III
 APPLICATION OF NURSING THEORY

S.N. ACCORDING TO VIRGINIA ACCORDING TO PATIENT

1. Breathes normally Mrs. dhughana was breathing
normally in a regular way. Her
respiratory rate was 18b/m.
2. Eat and drink adequately Her diet was normal. Due to
heavy bleeding she was
felling weak and had loss of
appetite . She was anorexic .
Encouraged her to have
nutritious diet.
3 Eliminate the body waste Mrs. Dhugana had
normal bowel and
bladder habit.
4 Move and maintain desirable Due to excessive
posture blood loss she was
having difficulty to
move and maintain
desirable posture
as she has
symptoms of
presyncope . I
advised to change
position every 2
hourly
5. Sleep and rest She wouldn’t able to sleep
due to abdominal pain and
heavy bleeding. She had to
wake up frequently over
night to change her pad . I
advise her water heat
thrapy to relieve pain.
6. Select suitable clothing Since it is summer, she was
wearing the summer dress
for woman.
7. Maintain body temperature Her body temperature was
within normal range. within normal range.
8. Keep the body clean and well Mrs. Dhungana was clean
groomed and protect and well groomed.
integument.
9. Avoid danger in the The hospital was made danger free:
environment and •Keeping one visitor on her side.
avoid injuring others. •Asking attendant sister to clean
around the area.
•The sharp needles were discarded.

10. Communicate with She was able to express emotion as

others to express she was asking to how overcome her
emotions, needs fear problem .
or opinion.

11. Worship according to She follows Hinduism. So she goes to

one’s faith temple and worship accordingly.

12. Work in such a way She is a housewife. She is proud of

that there is a sense of her task till date.
accomplishment.
13. Play and participate in Prior to her health
different forms of condition, she used to
recreation. participate in recreational
work in family as well as in
her working place.
14. Learn, discover or satisfy She used to ask question
the curiosity that leads to regarding disease condition
normal development an and fulfill her curiosity.
health and use of the
available health facilities.
 Nursing management

Nursing assessment:
 History : age, parity fertility occupation
 Physical assessment
 Weight, height , vitals and nutrition status.
 Site ,intensity and duration of pain
 Amount, duration and pattern of bleeding.
 Use number if sanitary pads.
 Passage of clots.
 Nursing diagnosis
• Acute pain related to abnormal uterine bleeding as evidence
by facial expression of patient.
• Sleep disturbance related to hospitlization and pain as
evidence by patient’s verbalization.
• Imbalanced nutrition less then body requirement related to
loss of appetite as evidence by underweight BMI.
• Fear related to abnormal health status as evidenced by
frequent questioning by patient’s
• Fatigue due to excessive blood loss.
• Sexual dysfunction related to altered body function
associated with post-coital bleeding.
 Nursing intervention
• Encourage the client to express her feelings.
• Explain importance of iron-rich food to supplement
iron.
• Explain method of quantifying blood loss and
reporting to health care provider.
• Encourage patient to express her feeling to
increase understanding of individual coping style.
• Nutritional counseling
• Emphasize healthy life style
• Explain to the patient the importance of sharing her
concerns with her partner.
• Explain the importance of recording dates, types of
flow and number of sanitary pads or tampons used
• Teach the client relief techniques
• Encourage the client to maintain personal hygiene
• Avoid risk of infection.
• If metrorhagia occur for more then one menstrual cycle
and the client is not on oral contraceptives, she should be
referred to her primary care provider for examination,
because vaginal bleeding is also an early sign of uterine
carcinoma or ovarian cyst.
 Discharge and health teaching
Health promotion and maintenance are important. I provided
informal health teaching to patient and her family
members so that her health condition gets improved. I
have health teaching on following topics:

Stress: Emotional stress can hamper the normal regular

menstrual cycle. Therefore, they should be managed by
assessing the areas of stress in life, developing coping
strategies and reducing the things that are causing stress.
Be moderate in all your activities. Try to balance your
work, recreation, and rest. Maintain a positive outlook.
Diet: Manage energy expenditure with energy intake. Encourage for
the intake of calorie rich food with the intake of calcium such as dairy
products and dietary fats. Avoid excessive use of alcohol and mood-
altering stimulants or sedative drugs and smoking.

•Participate in ongoing care to monitor replacement therapy or

associated conditions.
•Try to balance work, recreation, and rest.
•Maintain a positive outlook regarding the diagnosis and prognosis.
•Proper rest and sleep is necessary
•Maintenance of personal hygiene
•Follow up visits as advised by the doctor
 Learning from experience:
• Case study is one of the most important part of nursing
practice. It is the best method of learning and by choosing
this case for the study, I came to learn about the
metrorrhagia in depth including its definition, types, causes,
sign and symptoms, diagnostic investigation and
management.
• This case study helps me to widen my knowledge and views
and enhance my skills
 Summary
• This is the case study of a woman of 39 years old
named Yosodha Dhungana who was diagnosed of
metrorrhagia . This case study was taken in order to
obtain through knowledge about Metrorrhagia .
• On the basis of the assessment done along with the
physical examination, facts and figures, this case was
studied in depth that helps us to broaden our mind and
expand our horizon of knowledge regarding
Metrorrhagia.
 Reference
• Dutta DC, Textbook of gynecology, 5th edition New Central Book
Agency, Kolkata (pg- 359-360)
• Ross and Wilson, Anatomy and Physiology in health and illness, 12th
edition, Churchill living stone (pg: 760-768)
• Rai, Lalita; Nursing concepts, theories and principles, 3rd edition,
Tara books and stationary. (pg; 202-205)

• https://www.sciencedirect.com/topics/pharmacology-toxicology-and
-pharmaceutical-science/metrorrhagia

(retrieved date on September 25)

• https://www.researchgate.net/publication/286931389_Menorrhagia
_Risk_Factors_Diagnosis_and_Treatment
• retrieved date on September 25)
• https://www.jaypeedigital.com/eReader/chapt
er/9789350259627/ch8
• retrieved date on September 25)
• https://www.medicinenet.com/script/main/art
.asp?articlekey=4367
(retrieved date on September 26)
• https://www.youtube.com/watch?v=liyVwsc9-
T8&t=71s
(retrieved date on September 28)
• https://www.youtube.com/watch?v=j3lYFkEQ
• https://www.slideshare.net/KemiDDeleIjagbulu/abnor
mal-uterine-bleeding-by-dr-kemi-dele
(retrieved date on September 24)
• https://www.slideshare.net/drisyavr1/abnormal-uterin
e-bleeding-63991844
• (retrieved date on September 26)
http//www.cmc.edu.np/images/gallery/Original%20Articl
es/uVLsn9.pdf
(retrieved date on September 27)