Dysfunctional Uterine Bleeding
Hammad Tahir GM01
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.
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.
Intermenstrual bleeding: bleeding of variable amounts
occurring between regular menstrual periods.
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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.
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
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 •
Reproductive tract disease –
Systemic Disease –
Iatrogenic causes –
Non-organic •
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) –
Treatment of DUB
Goals •
control bleeding –
prevent recurrence –
preserve fertility –
correct associated conditions –
induce ovulation in patients who want to –
conceive
Treatment of DUB
Medical management before Surgical •
effective methods include: –
estrogens, progestins, or both
NSAID’s
antifibrinolytic agents
danazol
GnRH agonists
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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
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
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 –