DYSFUNCTIONAL UTERINE BLEEDING Basim Abu-Rafea, MD, FRCSC, FACOG Assistant Professor & Consultant Obstetrics & Gynecology Reproductive Endocrinology & Infertility Advanced Minimally Invasive Gynecologic Surgery Department of Obstetrics & Gynecology College of Medicine King Saud University

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

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

Normal menstrual cycle Estradiol Progesterone LH 28 14

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

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

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

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

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

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

Menstrual Abnormalities Oligomenorrhea: Intervals greater than 35 days.

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

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.

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

Anovulation LH FSH Estradiol Progesterone 28 14

Gynaecological bleeding Estrogen withdrawal Estrogen breakthrough Progesterone withdrawal Progesterone breakthrough

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

Causes of Anovulation Physiologic:- Pregnancy Adolescence Perimenopause Lactation

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

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

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

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

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

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

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

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.

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

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

Armamentarium Surgical:- D&C Endometrial ablation Hysterectomy

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

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.

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