Dysfunctional Uterine Bleeding

Prof: Ahmed Nagati

MD, FRCOG

Prof Obs/Gyn

Alexandria University

DUB: Definition

Abnormal uterine bleeding

• Not due to organic disease of genital tract

• Not associated with tumor, inflamation or

• Pregnancy.

It is not a disease but a category of diseases

Normal Menses

• Flow lasts 2-7 days

• Cycle 21-35 days in length

• Total menstrual blood loss 20-60 mL

Common TerminologyDescriptive Term Bleeding pattern

Menorrhagia Regular cycles, prolonged duration, excessive flow

Metrorrhagia Irregular cycles

Menometorrhagia Irregular, prolonged, excessive

Hypermenorrhea Regular, normal duration, excessive flow

Polymenorrhea Frequent cycles

Oligomenorrhea Infrequent cycles

Other Causes of Vaginal Bleeding

• Pregnancy related causes• Medications• Anatomic causes• Infectious disease• Endocrine abnormalities: Thyroid, DM• Bleeding disorders • Endometrial hyperplasia• Neoplasms

Contraceptive Bleeding

• OCP’s– Lower dose contraceptives– Skipped pills– Altered absorption / metabolism

• Depo Provera– 50% irregular bleeding after first dose– 25% after a year

Hormone Replacement Therapy

• Greatly decreased use secondary to the WHI study findings

• Lower dose formulations promoted for shorter term use to relieve menopausal vasomotor sx

• Continuous therapy– 40% of women will bleed in first 4-6 months

• Sequential therapy– Bleeding near progesterone therapy– Bleed monthly– Can experience abnormal bleeding patterns

Medications

• Prescription: anticoagulants,antipsychotics, corticosteroids, tamoxifen

• OTC:soy supplements, gingkgo– Ginseng: known to have estrogenic properties– Other drugs can interact with oral

contraceptives causing breakthrough bleeding

Fibroids

• Often asymptomatic

• Risk factors: nulliparity, obesity, family history, hypertension, African-American

• Usually cause heavier or prolonged periods when large, multiple, or close to the cavity.

• Tx options: expectant management, surgery, embolization, ablation, medical management

Adenomyosis

• Endometrial glands within the myometrium

• Usually asymptomatic• Can present with heavy or prolonged

bleeding• Often accompanied by dysmenorrhea up to

one week before menstruation• Mostly constitute a problem after age 40

Polyps

• Endometrial– Intermenstrual

bleeding

– Irregular bleeding

– Menorrhagia

• Cervical– Intermenstual spotting

– Postcoital spotting

Infectious causes

• PID– Usually have fever, pelvic discomfort,

adnexal tenderness but can present atypically– Can cause menorrhagia or metrorrhagia– More common during menstruation and with

PV

• Trichomonas• Endocervicitis

Endocrine abnormalities

• Hyperthyroidism – Amenorrhea

– Oligomenorrhea• most common

– Hypermenorrhea

– Polymenorrhea

• Hypothyroidism – Amenorrhea

– Oligomenorrhea

– Polymenorrhea

– Menorrhagia

– Occurs more frequently with severe hypothyroidism

Bleeding disorders

• Formation of a platelet plug is first step of homeostasis during menstruation

• Two most common disorders are von Willebrand’s disease and thrombocytopenia

• May be particularly severe at menarche, due to the dominant estrogen stimulation causing increased vascularity

Endometrial hyperplasia

• Overgrowth of the glandular epithelium of the endometrial lining

• Usually occurs when a patient is exposed to unopposed estrogen, either iatrogenically or because of anovulation

• Rates of neoplasm– simple hyperplasia: <1%. – complex hyperplasia with atypia:14%

Endometrial Hyperplasia

• Complex hyperplasia with atypia– One study found incidence of concomitant

endometrial cancer in 40% of cases– Hysterectomy or high dose progestin tx

• Simple– Often regress spontaneously– Progestin treatment used for treating bleeding

may help in treating hyperplasia as well

Uterine cancer

• Fourth most common cancer in women• Risk factors

– nulliparity, late menopause (after age 52), obesity, diabetes, unopposed estrogen therapy, tamoxifen, history of atypical endometrial hyperplasia

• Most often presents as postmenopausal bleeding in the sixth and seventh decade– only 10% of patients with postmenopausal bleeding

when investigated will have endometrial cancer

• Perimenopausally can present as menometrorrhagia

Aetiology of DUB

1.Hypothalamic/Pituitary/Ovarian Dysfunction 2.Thyroid disease : increase or decrease.

3.Haematologic disorder : blood or coagulation disorder (failure of systemic haemostasis)

4.Iron deficiency anaemia

5.Local endometrial causes

4

DUB due to Hypo/pit/ovarian dysfunction

1. Ovulatory: .long or short proliferative or secretory phases.

2. Corpus Luteum abnormality insufficiency or prolonged.

3. Anovulatory: either cyclic or acyclic.

Anovulatory Bleeding

• First year after menarche• Perimenopause• Polycystic Ovarian Syndrome• Adult-onset Congenital Adrenal

Hyperplasia• Other: androgen producing tumors,

hypothalmic dysfunction, hyperprolactinemia, pituitary disease

Taking the History

• Age

• Cyclic or anovulatory pattern

• Ob history

• Gyn and sexual history

• Medications

• Family history

Physical Exam

• Vital signs

• Weight

• Neck exam

• Skin exam

• Breast exam

• Pelvic exam

Laboratory studies• CBC• Urine or serum pregnancy test• TSH

– symptoms consistent with hypo/hyperthyroidism– women presenting with a change from a normal menstrual

pattern

• PT, PTT, and bleeding time. – adolescents presenting with menorrhagia at menarche  

• PCOS/Adult-onset CAH – LH, FSH, testosterone, androstenedione, basal 17-

hydroxyprogesterone (17-HP)

Ultrasound

• Evaluate ovaries for PCOS

• Evaluate for fibroids• Evaluate endometrial

stripe

Sonohysterography

• transvaginal ultrasound following installation of saline into the uterus

• most useful for differentiating focal from diffuse endometrial abnormalities

• can help guide the decision of doing a hysteroscopy to evaluate a focal abnormality versus performing an endometrial biopsy or dilatation and curettage

Magnetic Resonance Imaging

• better than ultrasound in distinguishing adenomyosis from fibroids

• sometimes used to evaluate fibroids prior to uterine artery embolization or myomectomy for the treatment of fibroids

• endometrium can be evaluated with a MRI

Endometrial sampling Dilation and curretage

• generally will provide sampling of less than half of the uterine cavity

• not effective as the sole treatment for menorrhagia

• useful in patients with cervical stenosis or other anatomic factors preventing an adequate endometrial biopsy

Endometrial sampling Endometrial biopsy

• In the office use a clear, flexible endometrial curette with an inner plunger or piston that generates suction during the procedure

• rates of obtaining an adequate endometrial sample depends on the age of the patient

• If inadequate sample is obtained, must use additional diagnostic studies to fully evaluate the cause of the vaginal bleeding

Diagnostic Hysteroscopy

• direct exploration of the uterus is useful in identifying structural abnormalities like fibroids and endometrial polyps

• Larger diameter hysterocopes allow specific biopsy of lesions

• In general, the diagnostic hysteroscopy is combined with a D&C or endometrial biopsy

Management

• Principles:• exclusion of organic disease:

proper clinical evaluation

special investigations• diagnosis of possible endocrinopathy.• individualization of treatment according

to: age, parity, emotional and social background,severity, pattern and duration of bleeding and nature of defect.

Treatment Goals

• alleviation of any acute bleeding and correction of general condition.

• Immediate investigation and treatment of anaemia.

• Assurance and alleviation of emotional upset or psychiatric disturbance.

• Menstrual chart if mild or moderate.

Anti Haemorhagic measures

1.Diosmin: reinforces tonicity of veins and

treats fragility of microvessels by restoring biological integrity of

capillary endothelium.

e.g daflon, dafrax, diosed, dioven

2.Etamsylate: normalizes capillary resistance and permiability.

e.g dicynone, haemostop, haemostat

3- Vitamins

Vitamin K: Essential cofactor in hepatic synthsis of prothrombin and other clotting factors (7, 9,10 )

Vitamin C: Integrity of blood vessels and capillaries.

e.g C & K, Konakion, Haemokion

4- Tranexamic acid: Inhibit activation of plasminogin to plasmin (antifibrinolytic)

e.g Cyclokapron, Kapron, Styptobion, Trasylol.

5- Rutin + Vitamin : Similar to Diosmin

e.g Ruta C, Rutin C

6-Calcium dobesilate: Regulates physiological function of capillary wall resistance and permiabilty

e.g Dilasal, Doxium.

7- Proanthocyanidin (grape- seed extract)

Anti oxidant and venotonic

e.g gervital, oxyplex

8- PG synthetase inhibitors

e.g flufenamic & mefinamic acid

ponstan, farostan, pinox

9- others: difrarel, pinbark, venoruton, venotek

• Hormonal therapy:

estrogen

progestins

combined

androgens

Estrogen

• will temporarily stop most uterine bleeding, no matter what the cause

• dose commonly used is 25 mg IV of conjugated estrogen every four hours, or 2.5 mg p.o. QID

• Nausea limits using high doses of estrogen orally, but lower doses can be used in a patient who is hemodynamically stable

Progestins

• induce withdrawal bleeding • decrease the risk of future hyperplasia and/or

endometrial cancer • continued for 7-12 days each cycle • Medroxyprogesterone 10 mg x 10 days monthly

common regimen• norethindrone acetate (Aygestin), norethindrone

(Micronor), norgestrel (Ovrette), and micronized progesterone (Prometrium, Crinone)

Oral Contraceptives

• option for treatment of both the acute episode of bleeding and future episodes of bleeding as well as prevention of long term health problems from anovulation

• triphasil norgestimate/ethinyl estradiol combination is what has been studied in a double-blind, placebo-controlled study

• various oral contraceptives have been used for decades

• Acute bleeding: 50mcg tab QID for one week after bleeding stops

Intrauterine Contraception (IUC)

• Levonorgestrel intrauterine system (Mirena)

• Off label use in U.S., approved in over 102 countries

• Will result in amenorrhea or oligomenorrhea

Endometrial Ablation

• electrocautery, laser, cryoablation, or thermoablation

• all result in destruction of the endometrial lining • outcomes are not well studied for women with

anovulation• most women will not experience long term

amenorrhea after treatment • risk of endometrial cancer is not eliminated

• Surgery: minor

minimally invasive

hysterectomy

• Radiotherapy

Summary

• Differential diagnosis depends on patients age

• Consider risks for endometrial cancer– nulliparity, late menopause (after age 52),

obesity, diabetes, unopposed estrogen therapy, tamoxifen, and a history of atypical endometrial hyperplasia

• For DUB treatment plan includes addressing acute symptoms and preventive needs,hormonal status and follow up.

• THANK YOU