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Dysfunctional Uterine Bleeding

Dr Mohamad El-Said Ghanem

SUBJECT

REMARKS

Definition

Excessive MBL without organic cause Novak

Irregular or excessive MBL in absence of gross pelvic lesion Lumsden

 

& Norman

Synonymously with anovular bleeding Sperof

Epidemiology

Overall 10% of all gynecologic patient

Age common at the perimenarcheal & perimenopausal period

Contraceptive pills reduce, IUD increase risk while injection variable

Parity higher risk in multipara

Pathophysiology

1. In the absence of ovulation, estrogen stimulate endometrium without silmutaneous production of progesterone from CL

2. Unopposed estrogen stimulation excessive glandular proliferation without stromal support unstable, fragile endometrium that is susceptible to breakdown & bleeding

3. Continuation of this process endometrium sloughs off in isolated location process recyle prolonged & excessive bleeding

4. In absence of estrogen-progesterone withdrawal, the rythmic & progressive VC of spiral arteries is lost non-cyclic, self-limited shedding of endometrium

CLASSIFICATION

 

1) Estrogen

2ry to decrease of estrogen level

withdrawal

Happen in cases of:

Cessation of exogenous estrogen therapy

bleeding

Ovulation spotting

Bilateral Oophrectomy

Radiotherapy

2) Estrogen

Chronic E stimulates endometrial proliferation which outgrowth structural stromal support endometrial breakdown

breakthrough

bleeding

Happen in obese & PCOD patient

3) Progesterone

Results from decrease progesterone level in estrogen primed endometrium

withdrawal

bleeding

Happen in cases of cessation of progestin ex. contraceptive pills

4) Progesterone

In-patient with prolonged progesterone administration

breakthrough

Bleeding is minimal & intermittent

bleeding

Happen in cases of women using long-acting progestin contraceptives

Metropathia

Old term used to describe simple endometrial hyperplasia

hemmorrhagica

Used as a clinical term to describe Anovular UDB in extreme age

Characterized by endometrial & myometrial hyperplasia

Pathology: cystic type Swiss-Cheese pattern

Etiological

 

1ry DUB

classification

Most common

Due to neuroendrocrine dysfunction

Ex: anovulation

 

2ry DUB

2ry to extragenital dysfunction

Ex: thyroid disorder

Idiopathic

HRT, contraceptives, IUD, post-sterilization syndrome

PATTERNS OF DUB

 

1) Ovulatory

Dysfunctional menorrhagia:

Irregular ripening: irregular spotting before proper menstruation due to irregular secretion of progesterone

Irregular shedding: irregular spotting after proper menstruation due to irregular degeneration of CL

Dysfunctional polymenorrhea due to either:

Short follicular phase

Short luteal phase luteal phase defect

2) Anovulatory

Estrogen breakthrough bleeding:

Previously known as Metropathia Hemorrhagica

Painless heavy bleeding preceded by a period of amenorrhea(6 -8 wks) commonly after puberty, before menopause, following labor or abortion

Occur due to persistent of dominant follicle (follicular cyst)

Treshold bleeding:

Rarely occur

Due to low deficient estrogen production & poor proliferation

ETIOLOGY

 

1) Anovulation or Oligo-ovulation

(90%)

Immaturity of hypothalamic-pituitary-ovarian axis

Anovulation & DUB usually seen in post-pubertal girls shortly after menarche

 

The onset of 1 st menstrual period occurs before the hypothalamic control mechanism of ovulation are fully mature

Dysfunction of the hypothalamic-pituitary-ovarian axis

Any factor that interferes with normal pulsatile GnRH secretion ma lead to anovulation: stress, anxiety, hyperprolactinemia, rapid wght. loss, hypothyroidism, perimenopausal period

Abnormal ve feedback signal

Sustained high estradiol level prevents normal cycle

Results from:

 

Medical condition liver diseases or thyroid abnormalities

Extragonadal production of estrogen in adipose tissue

Abnormal LH surge

If estrogen level fails to reach critical peak LH level doesn’t peak anovulation

Most commonly occur in perimenopausal women

Polycystic Ovarian Syndrome(PCOS) associated with:

Chronic anovulation

Hyperandrogenism

Glucose intolerance 2ry to insulin resistance

Obesity

2) Ovulatory

Occurs 2ry to hormonal changes during ovulatory cycle

(10%)

Can occur at any age, but most cases in the years preceding the menopause

 

Due to:

Decrease estrogen production at midcycle of ovulation

CL insufficiency

Persistent CL (Halban’s disease)

CLINICAL PICTURE

By bleeding

Cyclic bleeding

pattern

Usually ovular

Good prognosis

D&C may be deferred

Acyclic bleeding

Usually anovular

Can exclude endometrial pahtology

Intermenstrual bleeding

Low dose pills

Ovulation bleeding

By age group

Adolescent DUB (10-20 yrs)

Anovular type

Metropathia-like pattern

Self-limited

Adult DUB

Usually ovular, less commonly anovular

Ovular type: good prognosis

Peri-menopausal DUB

Usually anovular

60% of cases: endometrial hyperplasia

INVESTIGATIONS

Should be based upon

History to exclude other disease & iatrogenic causes

Examination general, local & abdominal

 

Investigation depends on above 2 items

Laboratory

CBC, coagulation profile, liver fn. test, thyroid fn. test, prolactin level & if 2ry to hyperandrogenism: DHEA, testosterone level, FSH & LH level

Assessment of

Abdominal & transvaginal Sonography & Sonohysterography

endometrium

Dilatation & Curettage:

Mandatory for >40 yrs age

Better done for 20-40 yrs age

Avoid for age <20 yrs

Must be restricted to women with DUB unresponsive to HRT

TREATMENT

 

1) General measure

Rest

Hematinics or bl. Transfusion

Treat general cause: hypothyroidism etc.

Hemostatics, tranexamic acid etc.

2) Hormonal

Gestagens

therapy

Treatment of choice due to 90% of cases is anovulatory causes

The bleeding is due to estrogen breakthrough bleeding

Types:

19 norsteroids: norethisterone acetate(cidulot-nor) - tablets

17 hydroxy progesterone derivatives: medroxy progesterone (provera)

Combined Oral Contraceptives(COC)

Effective but of limited use

Indicated in acute bleeding in young women

 

Estrogens

Used in emergency cases

High dose estrogen to stop acute bleeding within 24h

 

Types:

Estradiol(E 2 )

Conjugated estrogen(premarin)

GnRH Agonists

Indicated usage in control of bleeding after acute episode

Expensive

Medical Hypophysectomy

 

Danazol

Medical Oophrectomy

Androgenic side effect

Expensive

Hormone releasing IUD(mirena): effective but expensive

3) Non-Hormonal Medical Treatment

PG Synthetase Inhibitor or NSAIDs

Mefenamic acid(ponstan)

Inhibit PG synthesis

 

Reduce blood loss by 50%, effectively use in ovulatory cases

Side effect: GIT disturbance

Antifibrinolytics

Tranexomic acid(cyklokapron) & ethamsylate

Inhibit plasminogen activators

Reduce accelerated fibrinolytic activity

Reduce blood loss by 50%

4) Surgical

Dilatation & Curettage(D&C)

Not the 1 st choice in DUB

Indicated in:

 

Refactory of medical treatment

Not a candidate of HRT

Hysterectomy

Indicated in:

Complete her family

Untolerated to medical treatment

Endometrial ablation/resection

Muhammad Fuad Jaafar 05.10.10