DYSFUNCTIONAL UTERINE BLEEDING

1. DYSFUNCTIONAL UTERINE BLEEDING

2. Definition & Nomenclature • DUB:- Bleeding from the uterine endometrium with no demonstratable organic cause. • Abnormal uterine bleeding, Irregular uterine bleeding, Anovularoty uterine bleeding.

3. Ovulatory cycle • Proliferative Phase • Secretory Phase • Menstruation • Cyclic, predictable and relatively consistent menstrual blood loss.

4. Normal menstrual cycle Estradiol Progesterone LH 28 0 14

5. Normal Menses • Intervals of 24 to 35 days. • Duration of 4 to 6 days. • Average volume of 35 ml.

6. Normal Menses Hemostasis:- • Vasoconstriction. • Platelet plugs. • Myometrial contraction.

7. Menstrual Abnormalities Menorrhagia ( hypermenorrhea ):- • Duration > 7 days • Volume > 80 ml • Occurring at regular intervals

8. Menstrual Abnormalities Metrorrhagia:- • Bleeding occurring at irregular but frequent intervals. • Volume is variable.

9. Menstrual Abnormalities Menometrorrhagia:- • Prolonged uterine bleeding at irregular intervals.

10. Menstrual Abnormalities Polymenorrhea:- • Bleeding at regular intervals of less than 24 days.

11. Menstrual Abnormalities • Oligomenorrhea: Intervals greater than 35 days.

12. Menstrual Abnormalities Intermanstrual Bleeding:- • Bleeding of variable amounts occurring between regular menstrual periods.

13. 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.

16. DUB • Anovulatory 90% , commonest at the extremes of the reproductive age. • Ovulatory 10%

17. Anovulation LH FSH Estradiol Progesterone 28 0 14

18. Gynaecological bleeding • Estrogen withdrawal • Estrogen breakthrough • Progesteronewithdrawal • Progesteronebreakthrough

19. Pathophysiology • Anovulation. • No Corpus Luteum. • No progesterone. • Unopposed estrogen activity. • Unsustainable endometrial growth. • Irregular endometrial loss. ( non cyclic, unpredictable bleeding with inconsistent volume)

20. Causes of Anovulation Physiologic:- • Pregnancy • Adolescence • Perimenopause • Lactation

21. Causes of Anovulation Pathologic:- • Hyperandrogenic anovulation (PCO,CAH,Tumors) • Hypothalamic dysfunction (anorexia nervosa) • Hyperprolactinemia • Hypothyroidism • Primary pituitary disease • Premature ovarian failure • Iatrogenic

22. Establishing the diagnosis It is a diagnosis of exclusion • History. • Physical examination. • Investigations.

23. Age Considerations Adolescents (13-18 Years) • Anovulation is physiologic. • Blood dyscrasias.

24. Age Considerations Reproductive age (19-39 Years) • Between 6% to 10% have Hyperandrogenic chronic anovulation. • Hypothalamic dysfunction (stress, exercise,weight loss)

25. Age Considerations Later Reproductive Age (40 Years to Menopause) • Incidence of anovulatory uterine bleeding increases. • Represents a continuation of declining ovarian function.

26. 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

27. Endometrial Evaluation • 2-3 years of anovulatory bleeding, obese. • No response to medical therapy or prolonged periods of unopposed estrogen stimulation. • >40

28. 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.

29. management • No single approach is appropriate for all. Approach depends on:- • Amount of bleeding. • Age. • Medical status. • Desire to become pregnant.

30. Armamentarium • Progestin • Oral contraceptive pills • Estrogen • Nonsteroidal Anti-inflammatory Drugs • Anti-fibrinolytic Agents • Androgenic Steroids • GnRH agonists

31. Armamentarium Surgical:- • D&C • Endometrial ablation • Hysterectomy

32. Endometrial ablation • Satisfaction 80-90 % • 34% of patients in 5 years had a hysterectomy.

33. 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.

34. QUESTIONS