Dysfunctional Uterine Bleeding-Sumate

8/6/2019 Dysfunctional Uterine Bleeding-Sumate

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DD

YSFUNCTIONYSFUNCTION

ALAL UUTERINETERINE

BBLEEDINGLEEDING

S. Pattanasuttinont M.D.S. Pattanasuttinont M.D.

Department of OB & GYNDepartment of OB & GYN

Faculty of MedicineFaculty of Medicine

Srinakharinwirot UniversitySrinakharinwirot University


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DEFINITION

Excessive uterine bleeding with no organic cause

Most commonly caused by anovulationA diagnosis of exclusion


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CAUSE OF ABNORMAL UTERINE

BLEEDING


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NORMAL WITHDRAWAL

BLEEDING

Withdrawal of E/P

-Vasomotor events ( PGF2 , Endothelin-1)-Apoptosis (Lysosomal enzymes, Metallo-proteinases)

-Tissue loss and menstruation

Shrinkage of tissue height Spiral arteriole vasomotor response


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NORMAL WITHDRAWAL

BLEEDING

Early control of blood loss

-Formation of thrombin plugs Late control of blood loss

-Generalized vasoconstrictive hemostasis

-Healing effects of estrogen


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NORMAL MENSTRUAL BLEEDING

Tissue and vascular breakdown (upper 2/3)

Focal

breakthrough bleeding Diffuse withdrawal bleeding

Endometrium (balance)

Paracrine

Angiogenesis

Vasoactive

Hemostatic substances


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NORMAL VAGINAL BLEEDING :

MENSES

Interval 28 + 7 days

Duration 3 - 5 days Amount < 80 ml

Color dark- red

Clot no or small amount


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PATHOPHYSIOLOGY

Hormonal disturbances

Anovulation Ovulatory bleeding

Abnormal folliculogenesis

Corpus luteum insufficiency

Abnormal PGs production

Abnormal fibrinolytic activity


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MECHANISM

Hyperestrogenic or progestogenic state

Abnormal neovascularization Increased enzymatic tissue/ vascular breakdown

Impaired hemostatic mechanism

Uterine bleeding


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MECHANISM OF BLEEDING IN DUB

PatternPattern MechanismMechanismMenorrhagia abn.PG production, abn.fibrinolysis

Metrorrhagia E or P breakthrough bleeding

Polymenorrhea short FP or short LP

Oligomenorrhea anovulation

Midcycle bleeding E withdrawal bleeding

Premenstrual spotting corpus luteal dysfunction

Postmenstrual spotting abn. folliculogenesis


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Characteristic anovulatoryDUB

ovulatoryDUB

Bleeding pattern

Age

Dysmenorrhea

PMS

metrorrhagia

short period ofamenorrhea followed

by excessive bleeding

teenage, climacteric

no

no

menorrhagia

pre or post menstrualspotting

reproductive year

yes

yes


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Diagnostic approach

Pt. with vaginal bleeding

uterineextrauterine

urethra

rectum

genital:

vaginacervix

preg.related:

- abortion- ectopic- molar

non-preg:-uterine pathology-systemic dz.-drug/hormone-Infection

-DUB

false vg bleedingtrue vg bleeding


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APPROACHDifferential

Dx.pregnancy

relatedpelvic

pathologyinfection systemic

dz.contraception drug DUB

Hx

PE

PV & PR

Obtain Hx taking according to differential Dx and complete PE

Initial Dx could be made in most cases


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History :

- age- present abnormal bleeding- menstrual pattern, OB Hx

- previous abnormal bleeding- method of contraception- physical-psychological stress

- systemic review

Physical exam:

- vital signs- general appearance- abdominal exam- PV (indicated cases)


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APPROACHDifferential

Dx.pregnancy

relatedpelvic

pathologyinfection systemic

dz.Contra

ception

drug DUB

Hx

PE

PV & PR

Investigation pregnancytest

U/S

Pap smearbiopsy

D&C

U/Shysteroscopylaparoscopy

culture

laparoscopy

CBC

TFT

LFT

renal fncoag.

- - investigatecause ofanovulation

Obtain Hx taking according to differential Dx and complete PE

Initial Dx could be made in most cases


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Goal of managementGoal of management

Control the immediate bleedingDetermine the cause

Prevent similar episodes


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MEDICAL TREATMENTAnti PGs agents

Mefenamic acid

NaproxenHormone

Estrogen

Progesterone

Combine OCs

Danazol

GnRH agonist

GestrinoneFibrinolytic inhibitor

Tranxenamic acid

Epsilon amino caproic acid


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ESTROGEN RXAtrophic or thin endometrium

On progestin medication

POP

DMPA

Progesterone IUD

Long term use of COCs

CEE 1.25 mg/d for 7-10 daysCEE 1.25 mg/d for 7-10 days


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PROGESTERONE RXAnovulatory bleeding

Stop bleeding Maintenance for cyclic withdrawal bleeding

Ovulatory bleeding

(cyclic P is less effective for ovulatory bleeding,Continuous P D5-D25)

MPA or NETA10 mg/d for 12-14 days per cycle

MPA or NETA10 mg/d for 12-14 days per cycle


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COMBINED E-P RXAnovulatory bleeding

Stop bleeding Maintenance in women with androgenic symptom

Need contraception

Ovulatory bleeding


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bleeding Mechanism Treatment

Menorrhagia

Metrorrhagia

Polymenorrhea

Oligomenorrhea

Midcycle bleeding

Premenstrualspotting

Postmenstrual

spotting

Treatment of Bleeding in DUB

abn.PGS production,abn.fibrinolysis

E or P breakthroughbleeding

short FP or short LP

anovulation

E withdrawal bleeding

corpus luteal dysfunction

abn.folliculogenesis

anti PGS, fibrinolytic inh.

cyclic P, E, COCs

cyclic P, COCs

late FP E, COCs

cyclic P, COCs

early FP E, COCs

COCs, cyclic P


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SURGICAL TREATMENT D & C

Endometrial ablation

Selective embolization

Hysterectomy


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Dysfunctional Uterine Bleeding-Sumate

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