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Dysfunctional

Uterine
Bleeding
Nadya Al-Faraidy
98240015
21 October 2003
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Definition
 DUB is abnormal uterine
bleeding with no pathological or
congenital cause.
 diagnosis of exclusion
 Can be:
 w/in the period: menorrhagia
 intermenstrual bleeding

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Terminology
 Primary Amenorrhea:
 no menstruation by age of 14 in
absence of secondary sexual
characteristics OR before 16 yrs in
presence of secondary sexual
characteristics

 Secondary Amenorrhea:
 cessation of menstruation or 6
months or more in a patient who was
menstruating regularly or 12 months
in a patient who had a history of
oligomenorrheaWWW.SMSO.NET
 Menorrhagia:
excessive &/or prolonged regular
menstruation

 Polymenorrhea:
frequent regular menses at intervals <21
days

 Polymenorrhagia:
frequent but w/ prolonged &/or excessive
bleeding

 Metrorrhagia:
irregular periods of uterine bleeding

 Oligomenorrhea: WWW.SMSO.NET
Pathophysiology
 DUB is most common near the beginning and end of a
woman's reproductive life, but may occur at any time.
 first 18 months after menarche: immature
hypothalamin-pituitary axis obese women: non-ovarian
endogenous estrogen production may upset the normal
menstrual cycle.
 Menopause: anovulatory DUB.
 anovulatory cycles resulting in menometrorrhagia
 luteal phase deficiency cause the loss of LH surge, may
be especially prominent in amenorrheic athletes.
 >40 years: number and quality of ovarian follicles.
 (OCPs),
 Endocrine disorders . Hyperprolactinemia Polycystic
ovary disease Hypothyroidism, hyperthyroidism, and
Cushing's disease, premature ovarian failure

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Causes
Pregnancy complications
 Abortion
 Ectopic pregnancy.

 Molar disease.

 Infection e.g. endometritis in post


partum.

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Causes
Vulvar lesions:
 Trauma.
 Infection.

 Ulcer.

 Inflammatory lesion.

 Condylomata.

 Vulvar tumors (very rare).

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Causes
Vaginal lesions:
 Vaginitis.
 Atrophic vaginitis (common in post
menopausal women).
 Foreign bodies e.g. forgotten
tampons.
 Traumas and lacerations.

 Vaginal tumors (very rare).

 Disorders of pelvic support (pelvic


relaxation).

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Causes
Cervical lesions:
 Polyps.
 Cervicitis.

 Cervical condyloma.

 Cervical tumors.

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Causes
Uterine lesions:
 Fibroid.
 Adenomyosis and endometriosis.
 Endometrial Polyps.
 Endometrial hyperplasia
 Endometritis.
 Uterine malformation: if severe,
menorrhagia
 Precocious puberty.
 IUCD.
 Endometrial ca.

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Causes
Ovarian lesions:
 Salpingo-oopheritis (PID).
 Endometriosis.

 Ovarian cyst.

 Ovarian tumors.

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Causes
GU and GI lesions:
 Hematuria.
 Hemorrhoids.

 Fissures.

 Rectal cancer.

 Colon cancer.

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Causes
General disease:
 Coagulation disorders.
 Liver disease.

 Renal disease

 Thyroid disease.

 Adrenal disease.

 Pituitary disease.

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Causes
Blood Dyscariasis:
 ITP
 Von-Willibrand disease

 Leukemia

 Anemias

 SCA

 Thalassemia

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Causes
Medications:
 Exogenous hormones eg Hormone
Replacement Therapy
 Oral contraceptives.

 Aspirin.

 Anticoagulant therapy.

 Digitalis.

 Corticosteroids.

 Others.

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Incidence
 . One of the most common symptoms
in gynecology.
 . Most frequently at the extremes of
age:
 an-ovulation or Imbalance.
 6months – 1 year after menarche and
post menopause.
 Menorrhagia affects approximately
22% of healthy women.
 In the United States, approximately
7.6 million pre-menopausal women
aged between 30 and 55 perceive
their menstrual bleeding to be
excessive. WWW.SMSO.NET
Evaluation
Age
HistoryMost common cause of bleeding
 age New born Maternal estrogen
 Menstrual history.
Childhood Foreign body, cancer
 Amount of
bleeding.
Adolescence due to hormonal imbalance
 Duration of the Due to weaning of ovarian function
Perimenopausal
loss.
reproductive -Pregnancy and its complications.
 Interval between -Anovulation due to:
episodes. 3.polycystic ovarian disease
 Associated 4.idiopathic
symptoms. 5.stress
 Drugs ingested 6.hypothyroidism
esp use of 7.hyperprolactinemia b/c of:

hormones or a.pituitary adenoma

contraceptives. b.pituitary microadenoma

 Variation in galactorrhea
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weather,
Postdiet andHormone replacement cancer
Evaluation
Physical Examination
 Examination of all symptoms.
Basal temperature charting
 Pelvic examination & speculum
examination
 Recto-vaginal examination in
young children or single women
in which you can’t do pelvic
examination.

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Evaluation
Lab Investigations
 CBC: Hb and Hct + WBCs
for infection
 ESR Test Indication
 Serum HCG
urine to rule outpregnancy
pregnancy
pregnancy.
test anemia 
 Urinalysis
CBC  coagulpathy (especially in adolescents 
 Pelvic U.S.
PT/PTT  cervical cancer 
 Hysterosalpingography
Pap smear*  > 40IU/L suggests ovarian failure 
(HSG).FSH  liver disease 
 Endometrial biopsy.
liver function tests  thyroid disease 
 Hysteroscopy.
TSH  pituitary adenoma (with breast
 prolactin
Dilatation level 
and discharge) 
curettage
(D & Serum
C)  Diagnostic Ovulation luteal phase
and therapeutic.
progesterone
 # Most of the time we
don’t need all these
investigation, Hb and
HCG will be enough.

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Management
Medical
 Combined contraceptive pill: transforms uterus into
pseudo-secretory state “short secretory & short
proliferative & then shedding occurs
 Progesterone: for 21 days if uterus hyperplastic
 PGSI- PG Synthase Inhibitor:
 Rationale: during DUB, there is excessive PG esp PGE2
which cause excessive bleeding
 Eg indomethacin, mefenamic acid (Ponstan)
 Rx 50-70% of DUB
 Side effect: diarrhea
 ECA:
 Fibrinolytic
 Causes thrombosis of spiral uterine blood vessels
causes decreased bleeding
 > side effects

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How successful is HRT at
preventing menstrual
bleeding?
 Continuous combined hormone
replacement usually results in amenorrhea
after about 3 months of use
 intermittent bleeding during the first 3
months is common.
 By 6 months, about 2/3's of women will
not have bleeding
 at 1 year 80-85% will be without bleeding.
 Increasing the estrogen dose as well as
the progestin dose may help stop some of
the bleeding. WWW.SMSO.NET
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Management
Surgical
 Removal of the endometrium
If hormone therapy is not effective,
the endometrium may be removed.
 Endometrial ablation is usually the
method of choice, although some
patients choose a hysterectomy or
D & C.

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Endometrial ablation
 YAG LASER
 Thermal balloon
 Hydrothermablator
 Resectoscope

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YAG LASER
Advantages
 15 and 30 minutes.
 discharged two or three
hours.
 The patient should be
reassured that discharge is
normal
 80% successful in reducing
heavy periods and may
eliminate menstruation
altogether.
 Advantages of the
procedure over
hysterectomy
 it is safer, less invasive,
and does not require a
surgical incision
 it is less expensive
 it requires a shorter
hospital stay WWW.SMSO.NET
YAG
Disadvantages
o fluid overload
o hyponatremia,
o perforation of the uterus or adjacent
organs,
o uterine rupture,
o infection or haemorrhage. Overall,
endometrial ablation has a
o morbidity rate of 3%.
o sterility
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The Novasure System

 Another new
device, the
Novasure System™
, is now available,
and has a number
of advantages over
other systems.  It
only takes a few
minutes and has an
excellent safety
record
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Thermal balloon
 two components - a balloon catheter for heating and a
controller
 local anaesthesia
 87 degrees Celsius, for eight minutes.

 outpatient procedure equal it to inserting an intrauterine


device (IUD).
 SE: pressure or cramping sensation (NSAID) suppository
administered 45 minutes prior to the procedure.
 might experience vaginal discharge or spotting, which
normally changes to a watery discharge, between 10 and
30 days. it is normal.
 intended for use by women who have already completed
their families.

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HTA Hydrothermablator
 hot water, but allows it to circulate
freely in the endometrial cavity.  It is
done under direct vision through a
hysteroscope
 10 minutes

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Who should consider
endometrial ablation?
 menstrual bleeding that is impacting
life, with no other problems that
require a hysterectomy >80ml per
cycle, >8 days

 Activity is limited b/c of periods


 anemic and tired
 Bleeding limits intimate time with
partner
 Failure of drug therapy
 Exclusion of other causes
 NO desire to retain fertility
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Who shouldn't have an
endometrial ablation?
 endometrial ablation is not for
anyone who desires to keep her
fertility. 
 malignancy or pre-malignant condition of
the uterus  
 severe pelvic pain, unless the pain is
coming from an intracavitary myoma 
 Although pregnancy is unlikely after
ablation, serious complications could
arise.  It is essential for to use reliable
contraception after an endometrial
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Who can help me decide if
an endometrial ablation is
for me?
 gynecologist
 A physician who does not do
endometrial ablation on a regular
basis is unlikely to have the
experience to help you make the best
decision. 
 The physician should be expert at vaginal-
probe ultrasound and at diagnostic
hysteroscopy, and should consider non-
surgical treatments, as well as discussing
the advantages and disadvantages of all
the options available.  While the physician
can provide you with information, the
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How successful is endometrial
ablation at stopping uterine
bleeding problems?
 The various techniques used for
endometrial ablation may have slightly
different outcomes

 in general about 1/3 to 1/2 of women are


completely without any bleeding afterwards
(amenorrheic)

 about 15-20% still have bleeding problems


severe enough to warrant further surgery .
 The overall satisfaction rate of endometrial
ablation is about 65%

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Other Surgical Options
 Hysteroscopy

 Resectoscopy

 Hysterectomy

 D&C

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Is hysterectomy a better treatment
than endometrial ablation for bleeding
problems?
 The two procedures are somewhat difficult
to compare.
 outpatient vs. inpatient
 1 week vs. 6 weeks
 4 year study:
 36% of the women having endometrial
ablation and 24% of the women having
hysterectomy required more sx
 Satisfaction rates 80% in the ablation
group and 89% in the hysterectomy group.
(retreatment, PMS)
 Endometrial ablation allows about 75% of
women to avoid hysterectomy
 Hysterectomy was more successful in the
long run in treating the bleeding problems
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as well as premenstrual symptoms