DYSFUNCTIONAL UTERINE BLEEDING

Basim Abu-Rafea, MD, FRCSC, FACOGAssistant Professor & Consultant

Obstetrics & GynecologyReproductive Endocrinology & Infertility

Advanced Minimally Invasive Gynecologic SurgeryDepartment of Obstetrics & Gynecology

College of MedicineKing Saud University

Definition & Nomenclature

• DUB:- Bleeding from the uterine endometrium with no demonstratable organic cause.

• Abnormal uterine bleeding, Irregular uterine bleeding, Anovularoty uterine bleeding.

Ovulatory cycle

• Proliferative Phase

• Secretory Phase

• Menstruation

• Cyclic, predictable and relatively consistent menstrual blood loss.

Normal menstrual cycle

0 14 28

Estradiol

Progesterone

LH

Normal Menses

• Intervals of 24 to 35 days.

• Duration of 4 to 6 days.

• Average volume of 35 ml.

Normal Menses

Hemostasis:-

• Vasoconstriction.

• Platelet plugs.

• Myometrial contraction.

Menstrual Abnormalities

Menorrhagia ( hypermenorrhea ):-

• Duration > 7 days

• Volume > 80 ml

• Occurring at regular intervals

Menstrual Abnormalities

Metrorrhagia:-

• Bleeding occurring at irregular but frequent intervals.

• Volume is variable.

Menstrual Abnormalities

Menometrorrhagia:-

• Prolonged uterine bleeding at irregular intervals.

Menstrual Abnormalities

Polymenorrhea:-

• Bleeding at regular intervals of less than 24 days.

Menstrual Abnormalities

• Oligomenorrhea: Intervals greater than 35 days.

Menstrual Abnormalities

Intermanstrual Bleeding:-

• Bleeding of variable amounts occurring between regular menstrual periods.

Causes of abnormal vaginal bleeding

• Bleeding associated with pregnancy.• Anovulation.• Uterine leiomyoma.• Endometrial polyp.• Endometrial hyperplasia or carcinoma.• Cervical or vaginal neoplasia.• Infection.• Adenomyosis.• Coagulopathies.• Iatrogenic & medications.• Systemic diseases.

DUB

• Anovulatory 90% , commonest at the extremes of the reproductive age.

• Ovulatory 10%

Anovulation

0 14 28

Estradiol

Progesterone

LH

FSH

Gynaecological bleeding

• Estrogen withdrawal

• Estrogen breakthrough

• Progesterone withdrawal

• Progesterone breakthrough

Pathophysiology

• Anovulation.• No Corpus Luteum.• No progesterone.• Unopposed estrogen activity.• Unsustainable endometrial growth.• Irregular endometrial loss.

( non cyclic, unpredictable bleeding with inconsistent volume)

Causes of Anovulation

Physiologic:-

• Pregnancy• Adolescence• Perimenopause• Lactation

Causes of Anovulation

Pathologic:-• Hyperandrogenic anovulation

(PCO,CAH,Tumors)• Hypothalamic dysfunction (anorexia

nervosa)• Hyperprolactinemia• Hypothyroidism• Primary pituitary disease• Premature ovarian failure• Iatrogenic

Establishing the diagnosis

It is a diagnosis of exclusion

• History.

• Physical examination.

• Investigations.

Age Considerations

Adolescents (13-18 Years)

• Anovulation is physiologic.

• Blood dyscrasias.

Age Considerations

Reproductive age (19-39 Years)

• Between 6% to 10% have Hyperandrogenic chronic anovulation.

• Hypothalamic dysfunction (stress, exercise,weight loss)

Age Considerations

Later Reproductive Age (40 Years to Menopause)

• Incidence of anovulatory uterine bleeding increases.

• Represents a continuation of declining ovarian function.

Endometrial Evaluation

Incidence:-

• Age 15-19 is 0.1 per 100,000

• Age 19-39 is 9.5 per 100,000

(however Age 35-39 is 6.1/100,000)

• Age 40 to Menopause is 36.2/100,000

Endometrial Evaluation

• 2-3 years of anovulatory bleeding, obese.

• No response to medical therapy or prolonged periods of unopposed estrogen stimulation.

• >40

management

Goals:-

• Alleviate acute bleeding.

• Prevent future episodes of non-cyclic bleeding.

• Decrease the risk of long term complications of anovulation.

• Improve the quality of life.

management

• No single approach is appropriate for all.

Approach depends on:-

• Amount of bleeding.

• Age.

• Medical status.

• Desire to become pregnant.

Armamentarium

• Progestin• Oral contraceptive pills• Estrogen• Nonsteroidal Anti-inflammatory Drugs• Anti-fibrinolytic Agents• Androgenic Steroids• GnRH agonists

Armamentarium

Surgical:-

• D&C

• Endometrial ablation

• Hysterectomy

Endometrial ablation

• Satisfaction 80-90 %

• 34% of patients in 5 years had a hysterectomy.

Recommendations

• Treatment of choice for anovulatory uterine bleeding is medical thearapy, OCP or Progestins.

• Women who have failed medical therapy and no longer desire future childbearing are candidates for endometrial ablation or hysterectomy.

QUESTIONS