DYSFUNCTIONAL UTERINE BLEEDING

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

Estradiol Progesterone LH

0 14 28

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%

0 Anovulation

LH FSH Estradiol Progesterone

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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