Transcript Dysfunctional Uterine Bleeding

Dysfunctional Uterine Bleeding
Dr. ELHAM GHANBARI JOLFAEI
MD
OB & Gynecologiest
Introduction
Dysfunctional uterine bleeding (DUB) is •
as ABNORMAL uterine bleeding
defined
demonstrable organic cause,
with no
extragenital. genital or
Diagnosis of EXCLUSION•
Patients present with “abnormal uterine •
bleeding”
DUB occurs most often shortly after •
at the end of the
menarche and
reproductive years.
20% of cases are adolescents–
50% of cases in 40-50 year olds–
Introduction
DUB is most frequently associated with 
chronic anovulation.
Heavy menses, prolonged menses, or 
frequent irregular bleeding are the most
common complaints.
Up to 20% of women will experience 
irregular cycles in their lifetimes.
Goals
Define common terms
Briefly review normal menstruation
Discuss etiologies of DUB
Review the differential diagnosis for abnormal
bleeding
Discuss the evaluation of abnormal uterine bleeding
Discuss the treatment of DUB
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Definitions
Menorrhagia (hypermenorrhea): prolonged
(>7 days) and/or excessive (>80cc) uterine
bleeding occurring at REGULAR intervals.
Metorrhagia: uterine bleeding occurring at
completely irregular but frequent intervals,
the amount being variable.
Menometorrhagia: uterine bleeding that is
prolonged AND occurs at completely
irregular intervals.
Polymenorrhea: uterine bleeding at regular
intervals of less than 21 days.
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Definitions
Oligomenorrhea: uterine bleeding at 
regular intervals from 35 days to 6
months.
Amenorrhea: absence of uterine bleeding 
for > 6 months.
Postmenopausal bleeding: uterine 
bleeding that occurs more than 1 year
after the last menses in a woman with
ovarian failure.
Normal Menstruation
Life Cycle 
Menarche
5-7 years of relatively long cycles
Increasing regularity of cycles
In the 40’s cycles begin to increase in length with increasing
episodes of anovulation (2-8 years “perimenopause”)
Menopause (average age = 52)
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Characteristics 
By age 25, 40% of women have cycles between 25-28 days
Age 25-35, 60% of women have 25-28 day cycles.
Overall 15% have 28 day cycles
.5% have cycles < 21days
.9% have cycles >35 days
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Normal Menstruation
Results from fluctuations in the circulating 
levels of estrogen and progesterone.
Estrogen causes increased blood flow to 
the endometrium
A significant correlation exists between 
plasma Estradiol and endometrial blood
flow, with both increasing in the days
preceding ovulation.
These vasodilatory and vasoconstrictive 
effects are mediated by substances like:
acetylcholine ◦
Normal Menstruation
Estradiol and progesterone levels decrease 
several days prior to the onset of menses.
Endometrial blood flow decreases
Endometrial height decreases and vascular stasis occurs.
Tissue ischemia occurs.
Arterial relaxation
Sloughing of the endometrium.
Uterine bleeding occurs
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In women with DUB secondary to 
anovulation, endometrial blood flow is
variable and follows no orderly pattern
Cessation of Menses
Two main mechanisms: 
Formation of the platelet plug ◦
important in the functional endometrium 
Prostaglandin dependent vasoconstriction ◦
important in the basalis layer 
Menstrual Period Characteristics
Abnormal
<2d, >7d
Normal
4-6 days
Duration
>80cc
30-35cc
Volume
<21d, >35
21-35d
Cycle length
Average Iron loss: 16mg
Pathophysiology
Two types: anovulatory and ovulatory 
Most women with DUB do not ovulate. 
In theses women, there is continuous E2 production without ◦
corpus luteum formation and progesterone production.
Ovulatory DUB occurs most commonly 
after the adolescent years and before the
perimenopausal years.
Incidence in these patients may be as high as 10% ◦
Causes of DUB
The main cause of DUB is anovulation 
resulting from altered neuroendocrine
and/or ovarian hormonal events.
In premenarchal girls, FSH > LH and hormonal patterns are ◦
anovulatory.
Causes of DUB
The pathophysiology of DUB may also represent ◦
exaggerated FSH release in response to normal levels of
GnRH.
Causes of DUB
After menarche, ◦
normal adult FSH
and LH patterns
eventually develop
with mid-cycle
surges and E2
peaks.
Causes of DUB
In perimenopausal women, the mean length of the cycle ◦
is shorter compared to younger women.
Shortened follicular phase 
Diminished capacity of follicles to secrete Estradiol 
Other disorders commonly causing DUB ◦
Alterations in the life span of the corpus luteum. 
Prolonged (Halbans syndrome) 
Variable function or premature senescence in patients WITH 
ovulatory cycles
Luteal phase insufficiency 
Differential Diagnosis of
Abnormal Uterine Bleeding
Organic
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Reproductive tract disease ◦
Systemic Disease ◦
Iatrogenic causes ◦
Non-organic
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DUB ◦
“You must exclude all organic causes first!”
Reproductive Tract Disease
Complications of pregnancy 
Abortion
Ectopic gestation
Retained products
Placental polyp
Trophoblastic disease
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Reproductive Tract Disease
Benign pelvic lesions 
Leiomyomata
Endometrial or endocervical polyps
Adenomyosis and endometriosis
Pelvic infections
Trauma
Foreign bodies (IUD, sanitary products)
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Reproductive Tract Disease
Malignant pelvic lesions 
Endometrial hyperplasia
Endometrial cancer
Cervical cancer
Less frequently:
vaginal,vulvar, fallopian tube cancers 
estrogen secreting ovarian tumors 
granulosa-theca cell tumors 
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Systemic Disease
Coagulation disorders 
platelet deficiency ◦
platelet function defect ◦
prothrombin deficiency ◦
Hypothyroidism 
Liver disease 
Cirrhosis ◦
Iatrogenic Causes
Medications 
Steroids
Anticoagulants
Tranquilizers
Antidepressants
Digitalis
Dilantin
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Intrauterine Devices 
Evaluation
History
Onset, frequency, duration, cyclic vs.acyclic, severity
Pain, change from menstrual pattern (calendar)
Age, parity, marital status, sexual hx, contraception
medications, dates of pregnancies
symptoms of pregnancy and reproductive tract disease
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Physical Exam 
pelvic exam ◦
pap smear ◦
Evaluation
Tests 
Choices are extensive
Not practical or cost effective to do every test
They are not used as general screening tests for
all women with DUB.
Selection should be tailored to suspected
causes from the history and physical
Stepwise process should be considered
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Step One: 
Rapid assessment of vital signs ◦
Hemodynamically stable 
Hemodynamically unstable 
Step Two: (simultaneous with step 1) 
Baseline CBC, quantitative beta hCG ◦
Step Three (adolescents): 
Low risk for intracavitary or cancerous lesion ◦
High coagulopathy risk ◦
coagulation profile 
if abnormal, further testing and consultation is 
warranted
If screen is normal, a diagnosis of anovulatory ◦
DUB is assumed and appropriate therapy begun
Step Four (Adults): 
Transvaginal ultrasound ◦
Lesion present 
biopsy 
hysteroscopy 
No lesion 
High risk for neoplasia 
endometrial biopsy 
Low risk for neoplasia 
can assume DUB and treat 
Step Five (Adults): 
Secretory endometrium ◦
>50% have polyp or submucosal fibroid 
next step is dx hysteroscopy 
lesion present 
biopsy/excision 
lesion absent 
consider systemic disease 
assume DUB and treat if disease absent 
Step Six (Adults): 
Proliferative endometrium or hyperplasia ◦
without atypia
assume DUB 
manage according to desired fertility 
Hyperplasia with atypia or CA ◦
treat accordingly 
Treatment of DUB
Goals 
control bleeding
prevent recurrence
preserve fertility
correct associated conditions
induce ovulation in patients who want to
conceive
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Treatment of DUB
Medical management before Surgical 
effective methods include: ◦
estrogens, progestins, or both 
NSAID’s 
antifibrinolytic agents 
danazol 
GnRH agonists 
Treatment of DUB
Acute bleeding 
Estrogen therapy ◦
Oral conjugated equine estrogens 
10mg a day in four divided doses
treat for 21 to 25 days
medroxyprogesterone acetate, 10 mg per day for the last 7
days of the treatment
if bleeding not controlled, consider organic cause
OR
25 mg IV every 4 to 12 hours for 24 hours, then switch to oral
treatment as above.
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Bleeding usually diminishes within 24 hours ◦
Treatment of DUB
Acute bleeding (continued) 
High dose estrogen-progestin therapy ◦
use combination OCP’s containing 35 micrograms or
less of ethinylestradiol
four tablets per day
treat for one week after bleeding stops
may not be as successful as high dose estrogen
treatment
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Treatment of DUB
Recurrent bleeding episodes 
combination OCP’s ◦
one tablet per day for 21 days 
intermittent progestin therapy ◦
medroxyprogesterone acetate, 10mg per day, for the 
first 10 days of each month
higher doses and longer therapy my be tried if no 
initial response
prolonged use of high doses is associated with fatigue, 
mood swings, weight gain, lipid changes
Treatment of DUB
Recurrent bleeding episodes (continued) 
Progesterone releasing IUD ◦
avoids side effects 
must be reinserted annually 
Levonorgestrel IUD 
80% reduction of blood loss at 3 months 
100% reduction at 1 year 
found to be superior to antifibrinolytic agents and 
prostaglandin synthetase inhibitors
Treatment of DUB
Immature hypothalamic-pituitary axis 
progestin therapy by itself for 10 days every ◦
month or every other month until full maturity
of the axis provides effective therapy.
Older perimenopausal women 
cyclic progestin therapy ◦
prevents development of endometrial hyperplasia 
low dose OCP’s ◦
healthy non-smokers, free of vascular disease 
Treatment of DUB
Other options 
NSAID’s ◦
cyclooxygenase inhibitors
inhibits prostacyclin formation
administered throughout the duration of bleeding or
for the first 3 days of menses.
treatment results in a sustained reduction in blood
loss so side effects tend to be mild
most effective in ovulatory DUB
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Treatment of DUB
Other options 
inhibitors of fibrinolysis ◦
EACA (epsilon-aminocaproic acid) 
AMCA (tranexamic acid) 
PABA (para-aminomethybenzoic acid) 
use limited by side effects ◦
nausea, dizziness
diarrhea, headaches
abdominal pain
allergic manifestations
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Treatment of DUB
Danazol 
androgenic steroid ◦
200mg and 400 mg daily doses for 12 weeks studied 
200mg dose as effective as 400 mg 
androgenic side effects: weight gain, acne 
side effects minimized with 200mg dose 
100 mg not effective, expensive 
Treatment of DUB
GnRH agonists 
treatment results in medical menopause
blood loss returns to pretreatment levels when
discontinued
treatment usually reserved for women with ovulatory
DUB that fail other medical therapy and desire future
fertility
use add back therapy to prevent bone loss secondary to
marked hypoestrogenism
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Treatment of DUB
Surgical Treatment 
Dilation and Curettage ◦
quickest way to stop bleeding in patients who are 
hypovolemic
appropriate in older women (>35)to exclude 
malignancy but is inferior to hysteroscopy
follow with medroxyprogesterone acetate, OCP’s, or 
NSAID’s to prevent recurrence
Treatment of DUB
Surgical Treatment: (Ablation) 
Laser ablation ◦
Loop electrode resection
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Roller electrode ablation ◦
Treatment of DUB
Surgical Treatment: (Ablation) 
Thermal balloon ablation ◦
Microwave ablation ◦
Electromagnetic ablation ◦
poor follow up 
Intracavitary radiotherapy (case report) ◦
was common treatment in past 
used in a patient who failed medical treatment with multiple 
contraindications for surgery
chose radiation secondary to complications with a previous 
D&C and the cost of long term GnRH agonist therapy
Treatment of DUB
Surgical Treatment 
Hysterectomy ◦