Dysfunctional Uterine Bleeding
Dr. Nasira Sabiha Dawood
Definition
• Abnormal bleeding from the uterus in the
absence of organic disease of the genital tract
• Disturbance of menstrual cycle ,regular
irregular or alteration in amount and duration
of bleeding
• Group of disorders characterized by
dysfunction of uterus ,ovary ,pituitary,
hypothalamus
• Incidence:40/1000
Classification
• Primary: primary dysfunction of uterus ,ovary,
pituitary, hypothalamus, or higher centres
• Secondary: to IUCD ,hormones for
contraception or other use,
Normal menstrual cycle
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Mean cycle length
At age 40
Duration
Excessive
MBL
Menorrhagia
28 days
20-27 days
2-7 days
8days or longer
40 ml
>80 ml
Mechanism of normal menstrual cycle
• Proliferative phase: intence vasoconstriction
,ischemia of endometrium and shedding,reepithelisation by estrogen from ovarian follicle
• Secretary phase
Endometrial pathology
• Irregular ripening and irregular shedding :1525% cases deficient corpus luteum
• Endometrial hyperplasia : endomerial stroma
and glands with abnormal vascularization
Atrophy of endometrium : large dilated
venules under thin epithilium venules rupture
causing post menopausal bleeding pv
Eetiolgy of Primary DUB
• Disturbance in eicosanoids fibrinolytic and
lysosomal enzyme system
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Ischemia and cell death
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Arachidonic acid
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PGF2@(vasoconstrictor and weak
platelet aggregator)
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PGE2 (vasodilator and platelet ant
aggregator)
• TxA2(potent vasoconstrictor and platelet
aggregator)
Secondary DUB
• Hormones or IUCD: low dose progesterone
underdevelopment of spiral arterioles
degeneration of large venules
• large doses of progesterone produce superficial
dilated venules with atrophy of endometrium
• IUCD: ulceration of endometrium and increased
vascularity
• Bleeding disorder, thrombocytopenia, von Wille
brand disease, factor 2,5,7,10 def
• Hypothyroidism: direct effect of thyroxine on
spiral arterioles
Clinical presentation
• Adolescent and teen age : anovulatory
immaturity of hypothalamus
• Adults: Ovulatory, rule out PID fibroids
complications of pregnancy
• Perimenopausal: Anovulatory ,rule out
fibroids ca cervix and endometrium
Clinical presentation
• Regular cyclical : ovulatory for short duration
,rule out fibroids and PID
• Irregular or acyclic: anovulatory, rule out ca
cervix or endometrium
• Intermenstrual : ovulatory fall in estrogen
secretion following ovulation ,rule out cx
polyp sub mucous fibroid and cervical
carcinoma
Diagnosis
• History : Age, parity, fertility , occupation
• Amount duration and pattern of bleeding
associated gynecological problem
dysmenorrheal infertility or menopausal
symptoms bleeding disorders or thyroid
dysfunction contraception future pregnancies
possible hysterectomy social and personal
background
Examination
• Abdominal and pelvic examination
• Investigations: blood CP Hb platelets
coagulation screen day 21 progesterone
thyroid function tests laparoscopy ultrasound
scan, endometrial biopsy by dx D and C,
aspirate, brush, levage or hysteroscopy
Management
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Menstrual calendar
Oral iron therapy
Treatment of sec disease
Medical therapy : NSAID
antifibrinolytics
Prostaglandin inhibitors
Hormone therapy COC
progesterone estrogens androgens and danazol
Management
• Endometrial ablation
• Laser
• Rafea
• Cryo
• TUMR
• Hystrectomy
• Radiotherapy