Dysfunctional Uterine BleedingDysfunctional Uterine Bleeding

Semyatov S., M.D., Ph.dSemyatov S., M.D., Ph.d

Department of Obstetrics and Gynecology Department of Obstetrics and Gynecology

PFURPFUR

Dysfunctional Uterine Bleeding (DUB)Dysfunctional Uterine Bleeding (DUB) - - abnormal bleeding caused by hormonal abnormal bleeding caused by hormonal abnormalities in the absence of pregnancy, abnormalities in the absence of pregnancy, tumor, infection, coagulopathy.tumor, infection, coagulopathy.It is often associated with anovulation, It is often associated with anovulation, continuos ovarian estrogen production and a continuos ovarian estrogen production and a nonsecretory endometrium.nonsecretory endometrium.

Definition:

Aetiology:

DUB may result from disorders of:

•The central nervous system;•Pituitary;•Ovary;

•From the effects of exogenous or endogenous steroids;

•Systemic metabolic disorders (hyper,-hypotheroidism, hepatic dysfunction and various chronic diseases).

•AmenorrhAmenorrhooea.ea.

Signs and Symptoms:

•Continuous uterine bleeding (may last for many weeks).

•Secondary anaemia.

•Infertility.

Diagnosis Diagnosis

HistoryHistory A full general examinationA full general examination Pelvic ExamPelvic Exam Papanicolaou smear testPapanicolaou smear test US exam (endometrium, ovaries)US exam (endometrium, ovaries) A diagnostic curettageA diagnostic curettage Hystero-salpingographyHystero-salpingography HysteroscopyHysteroscopy Hematologic studiesHematologic studies

Differential Diagnosis:

1. Complications of pregnancy (abortion, ectopic gestation, bleeding corpus luteum, hydatidiform mole, choriocarcinoma)

2. Organic lesions of:

- the corpus: myoma, carcinoma, polyps, hyperplasia of endometrium;

- cervix: chronic cervicitis, carcinoma, polyps;

- ovary: functional ovarian cysts and functioning neoplasms;

- oviducts: carcinoma;

- vagina: carcinoma.

Differential Diagnosis:

• blood dyscrasias;

• thrombocytopenia;

•deficient clotting factors;

•endocrinopathies;

•hypertension;

•bleeding from urinary tract and rectum.

Extragenital causes:

Treatment: Overall ApproachTreatment: Overall Approach

Recognize Goals: Recognize Goals:

–– HaemostasisHaemostasis

–– Restoration of Menstrual Cycle and Restoration of Menstrual Cycle and FertilityFertility

–– Regularize and control menstrual bleedingRegularize and control menstrual bleeding

–– Prevention of DUB Prevention of DUB

Treatment:

Depends on:

1. The age of the patient, her fertility and her desire for children.

2. The degree of anaemia.

3. The response to curettage, which is performed primarily as an aid to diagnosis, may be therapeutically beneficial.

Continuous OCPsContinuous OCPs

““Pseudopregnancy” (Kistner)Pseudopregnancy” (Kistner) ? Minimizes Retrograde Menstruation? Minimizes Retrograde Menstruation Lower Fertility Rates than Other Medical Lower Fertility Rates than Other Medical

TreatmentsTreatments Choose OCPs with Least Estrogenic Choose OCPs with Least Estrogenic

Effects, Maximal Androgenic / Progestin Effects, Maximal Androgenic / Progestin EffectsEffects

ProgestinsProgestins

May be as Effective as GnRH-a for Pain ControlMay be as Effective as GnRH-a for Pain Control MPA 10 mg/day, DP 150 mg Semi-MonthlyMPA 10 mg/day, DP 150 mg Semi-Monthly May be Taken Long-TermMay be Taken Long-Term Relatively InexpensiveRelatively Inexpensive Side-Effects: AUB, Mood Swings, Weight Gain, Side-Effects: AUB, Mood Swings, Weight Gain,

AmenorrhoeaAmenorrhoea

DanazolDanazol

Weak AndrogenWeak Androgen Suppresses LH / FSHSuppresses LH / FSH 200 mg daily for 4-6 months200 mg daily for 4-6 months Causes Endometrial Regression, AtrophyCauses Endometrial Regression, Atrophy ExpensiveExpensive Not recommended in young womenNot recommended in young women Side-Effects: Weight Gain, Masculinization, Side-Effects: Weight Gain, Masculinization,

Occ. Permanent Vocal Changes….Occ. Permanent Vocal Changes….

OestrogenOestrogen

Suppresses LH / FSHSuppresses LH / FSH Causes Endometrial Regression, Atrophy Causes Endometrial Regression, Atrophy

ClomiphenClomiphen

Induce ovulation. Induce ovulation. 50-150 mg daily from 5 to 9 day of 50-150 mg daily from 5 to 9 day of

menstrual cycle.menstrual cycle. Complications: multiple pregnancy, Complications: multiple pregnancy,

hyperstimulation of ovaries. hyperstimulation of ovaries.

EthamsylateEthamsylate

Reduces the capillary fragility. Reduces the capillary fragility. Reduces menorragia by 50%. Reduces menorragia by 50%. 500 mg 4 times a day started from 5 day 500 mg 4 times a day started from 5 day

prior to the anticipated start of the period to prior to the anticipated start of the period to 10 days after. 10 days after.

Nonsteroidal anti-inflammatory drugs Nonsteroidal anti-inflammatory drugs (NSAID)(NSAID)

Mefenamic acid 500 mg for 5-6 days Mefenamic acid 500 mg for 5-6 days controls menorrhagia in 70% cases of controls menorrhagia in 70% cases of ovulatory cycles.ovulatory cycles.

Side effects: nausea, vomiting, dyspepsia, Side effects: nausea, vomiting, dyspepsia, diarrhoea, headache, auto-haemolytic diarrhoea, headache, auto-haemolytic anaemia.anaemia.

Combined oral contraceptive pillsCombined oral contraceptive pills

More effective than oestrogen and progesteron More effective than oestrogen and progesteron alone. alone.

Reduces blood loss by 50% and eliminates Reduces blood loss by 50% and eliminates dysmenorrhoea. dysmenorrhoea.

Not expensiveNot expensive

Antifibrinolytic agentsAntifibrinolytic agents

Tranexamic acid, epsilon-amino-caproic acid, Tranexamic acid, epsilon-amino-caproic acid, 1-2 g 4 times a day for 6-7 days during 1-2 g 4 times a day for 6-7 days during menstruation - with 50% success. menstruation - with 50% success.

Side effects: nausea, vomiting, diarrhoea, Side effects: nausea, vomiting, diarrhoea, headache, visual disturbances, intracranial headache, visual disturbances, intracranial thrombosisthrombosis

Not expensive Not expensive

GnRHGnRH

is used as a last drug when others fail.is used as a last drug when others fail. Depot injection 3.6 mg monthly for 4-6 month Depot injection 3.6 mg monthly for 4-6 month

- nearly 100% successful.- nearly 100% successful. Expensive.Expensive. Side effects: anti-oestrogenic effect for more Side effects: anti-oestrogenic effect for more

than 6 monhts can cause menopausal than 6 monhts can cause menopausal symptoms and osteoporosis.symptoms and osteoporosis.

Surgical Treatment Surgical Treatment

1.1. D&CD&C - removal of endometrium’s hyperplasia - removal of endometrium’s hyperplasia D&C will be required in young women, if hormonal D&C will be required in young women, if hormonal

therapy failed.therapy failed. 30-40% may be cured by curettage alone. 30-40% may be cured by curettage alone.

2. Hysterectomy2. Hysterectomy - in older women with severe - in older women with severe menorrhagia; recurrent irregular uterine bleeding that menorrhagia; recurrent irregular uterine bleeding that is unresponsive to progestin therapy.is unresponsive to progestin therapy.

The ovaries should be conserved in women below the The ovaries should be conserved in women below the age of 50 yrs.age of 50 yrs.

Surgical Treatment Surgical Treatment

3. Hysteroscopic endometrial ablation3. Hysteroscopic endometrial ablation by by Nd:YAG laser Nd:YAG laser electro-cautery electro-cautery resection (TCRE) resection (TCRE) roller-ball electrocoagulation roller-ball electrocoagulation radio-frequency induced ablation (RITEA) - thermal radio-frequency induced ablation (RITEA) - thermal

destruction of endometrium at 66°C. 85% get cured.destruction of endometrium at 66°C. 85% get cured. balloon therapy - hot fluid is used which causes balloon therapy - hot fluid is used which causes

superficial burn.superficial burn.