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Dysfunctional Uterine Bleeding

Comprehensive discussion on the definition, epidemiology, classification, etiology, diagnosis, investigation, treatment, follow-up, and complications of Dysfunctional Uterine Bleeding (DUB) by Dr. Mona El-Talatini ST7 at Queen Medical Centre, Nottingham.

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Dysfunctional Uterine Bleeding

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  1. Dysfunctional Uterine Bleeding Dr. Mona El-Talatini ST7, Queen Medical Centre, Nottingham

  2. Discussion Points • Definition • Epidemiology • Classification of abnormal uterine bleeding (AUB) • Etiology • Diagnosis • Investigation • Treatment • Follow up • Complication • Summary

  3. Definition of DUB • Excessive uterine bleeding affecting pre-menopausal women that is not due to pregnancy or any recognizable uterine or systemic diseases. • The underlying pathophysiology is believed to be due to ovarian hormonal dysfunction.

  4. Epidemiology • 25% of Women-One episode. • 5% of women aged 30-49years in UK. • Only Quarter of women with excessive bleeding seek medical treatment. • DUB affects women at extremes of their reproductive age and women suffering from chronic anovulation(PCOS).

  5. Classification of Abnormal uterine Bleeding • International Federation of Gynecology and Obstetrics (FIGO) Menstrual Disorders Group(2011): • 1. structural causes for AUB: polyp; adenomyosis; leiomyoma; malignancy and hyperplasia. • 2. non-structural causes for AUB: coagulopathy; ovulatory dysfunction; endometrial; iatrogenic; and not yet classified. • DUBis not included in classification. • generally fit ovulatory dysfunction and endometrial hemostatic disorders if coagulopathy has been excluded.

  6. PALM-COEIN classification system for abnormal uterine bleeding in non gravida reproductive-age women, 2011

  7. DUB (AUB-O) • Dysfunctional uterine bleeding (DUB) : • ovulatory or anovulatory HMB but mainly due lack pf ovulation. • This is diagnosed after the exclusion of pregnancy, medications, iatrogenic causes, genital tract pathology and systemic conditions.

  8. Etiology • Disorders that interfere with ovarian follicular development resulting in ovulatory dysfunction (either anovulation or defective ovulation with abnormal corpus luteum formation) are known to be associated with DUB. • These include polycystic ovary syndrome, hyperprolactinaemia, hypothalamic anovulation , and hypothyroidism.

  9. Clinical Assessment : History: • Age • Menstrual history: Cycle (22d-35d), Duration, Volume, frequency • IMB, PCB • Associating symptoms Pelvic pain, Anemia, impact on quality of life. Fertility wishes • CX smear • Contraception • Medical history: Endocrine disorders such as thyroid, hyperprolactinemia, PCOS problems • PH/ FH of inherited hemophilia ,thrombocytopenia Gynae cancer, thromboembolism, Liver disease. • Drug history: Tricyclic antidepressant, warfarin/tamoxifen/Implant

  10. Physical examination • BMI ,PCOS signs • Signs of anemia. • Abdominal and pelvic examination: • Speculum: • cervical cytology if appropriate • genital tract infection screening: • cervicitis/endometritis is suspected on history or examination. • Bimanual examination of uterus : fibroids .

  11. Investigations • 1.Pregnancy test • 2. FBC, • coagulation profile • 3. Hormonal investigations; PRL, Thyroid , Testosterone , FSH, LH • 4. Pelvic scan

  12. Red Flag features of AUB indicating 2ry care referral

  13. Follow up • Monitoring • longstanding DUB, those associated with anovulation, to be monitored due to the increased risk of endometrial hyperplasia and endometrial cancer. • To identify failed medical treatment. • Patient instructions • Menstrual diary. This gives valuable information on the amount and extent of bleeding and is useful in monitoring response to treatment.

  14. Complications • Endometrial hyperplasia/cancer • Anemia

  15. Summery • AUB Classification • Clinical assessment: history, clinical examination, investigations • Management • Referral to the hospital • Follow up • Complications

  16. References • National Institute for health and Clinical Excellence (NICE). Heavy menstrual bleeding.2007 updated August 2016. • Munro MG, Critchley HO, Broder MS, Fraser IS and the FIGO Working Group on Menstrual Disorders. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet 2011;113:3–13 • Dysfunctional uterine bleeding. Best practice; BMJ 2015

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