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DYSFUNCTIONAL UTERINE BLEEDING
Basim Abu-Rafea, MD, FRCSC, FACOGAssistant Professor & Consultant
Obstetrics & GynecologyReproductive Endocrinology & Infertility
Advanced Minimally Invasive Gynecologic SurgeryDepartment of Obstetrics & Gynecology
College of MedicineKing Saud University
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Definition & Nomenclature
• DUB:- Bleeding from the uterine endometrium with no demonstratable organic cause.
• Abnormal uterine bleeding, Irregular uterine bleeding, Anovularoty uterine bleeding.
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Ovulatory cycle
• Proliferative Phase
• Secretory Phase
• Menstruation
• Cyclic, predictable and relatively consistent menstrual blood loss.
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Normal menstrual cycle
0 14 28
Estradiol
Progesterone
LH
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Normal Menses
• Intervals of 24 to 35 days.
• Duration of 4 to 6 days.
• Average volume of 35 ml.
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Normal Menses
Hemostasis:-
• Vasoconstriction.
• Platelet plugs.
• Myometrial contraction.
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Menstrual Abnormalities
Menorrhagia ( hypermenorrhea ):-
• Duration > 7 days
• Volume > 80 ml
• Occurring at regular intervals
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Menstrual Abnormalities
Metrorrhagia:-
• Bleeding occurring at irregular but frequent intervals.
• Volume is variable.
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Menstrual Abnormalities
Menometrorrhagia:-
• Prolonged uterine bleeding at irregular intervals.
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Menstrual Abnormalities
Polymenorrhea:-
• Bleeding at regular intervals of less than 24 days.
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Menstrual Abnormalities
• Oligomenorrhea: Intervals greater than 35 days.
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Menstrual Abnormalities
Intermanstrual Bleeding:-
• Bleeding of variable amounts occurring between regular menstrual periods.
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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.
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DUB
• Anovulatory 90% , commonest at the extremes of the reproductive age.
• Ovulatory 10%
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Anovulation
0 14 28
Estradiol
Progesterone
LH
FSH
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Gynaecological bleeding
• Estrogen withdrawal
• Estrogen breakthrough
• Progesterone withdrawal
• Progesterone breakthrough
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Pathophysiology
• Anovulation.• No Corpus Luteum.• No progesterone.• Unopposed estrogen activity.• Unsustainable endometrial growth.• Irregular endometrial loss.
( non cyclic, unpredictable bleeding with inconsistent volume)
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Causes of Anovulation
Physiologic:-
• Pregnancy• Adolescence• Perimenopause• Lactation
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Causes of Anovulation
Pathologic:-• Hyperandrogenic anovulation
(PCO,CAH,Tumors)• Hypothalamic dysfunction (anorexia
nervosa)• Hyperprolactinemia• Hypothyroidism• Primary pituitary disease• Premature ovarian failure• Iatrogenic
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Establishing the diagnosis
It is a diagnosis of exclusion
• History.
• Physical examination.
• Investigations.
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Age Considerations
Adolescents (13-18 Years)
• Anovulation is physiologic.
• Blood dyscrasias.
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Age Considerations
Reproductive age (19-39 Years)
• Between 6% to 10% have Hyperandrogenic chronic anovulation.
• Hypothalamic dysfunction (stress, exercise,weight loss)
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Age Considerations
Later Reproductive Age (40 Years to Menopause)
• Incidence of anovulatory uterine bleeding increases.
• Represents a continuation of declining ovarian function.
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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
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Endometrial Evaluation
• 2-3 years of anovulatory bleeding, obese.
• No response to medical therapy or prolonged periods of unopposed estrogen stimulation.
• >40
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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.
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management
• No single approach is appropriate for all.
Approach depends on:-
• Amount of bleeding.
• Age.
• Medical status.
• Desire to become pregnant.
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Armamentarium
• Progestin• Oral contraceptive pills• Estrogen• Nonsteroidal Anti-inflammatory Drugs• Anti-fibrinolytic Agents• Androgenic Steroids• GnRH agonists
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Armamentarium
Surgical:-
• D&C
• Endometrial ablation
• Hysterectomy
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Endometrial ablation
• Satisfaction 80-90 %
• 34% of patients in 5 years had a hysterectomy.
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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.