1. Functional and symptomatic abnormal uterine bleeding
Assoc. Prof. Małgorzata Walentowicz-Sadłecka, MD, PhD

2. Dysfunctional uterine bleeding (DUB)
DUB is abnormal bleeding without specific cause.
Intensity of bleeding ranges from light to heavy or prolonged, frequent bleeding.
The diagnostic goal is to exclude other causes of bleeding (firstly, exlusion of malignancies).
Pathological mechanism of DUB is:
an absence of ovulation and the production of progesterone;
the high level of estrogen (unoppsed by progesterone), which leads to hyperplasia of endometrium.

3. Abnormal uterine bleeding – ACOG reccomendation
ACOG reccomend to use the term „abnormal uterine bleeding”
In ACOG classification of abnormal uterine bleeding, there is „ovulatory dysfunction”, which is similar to the classic term „dysfunctional uterine bleeding”. The classification contains only non-pregnancy-related causes.

4. Differnetial diagnosis – abnormal menses
Term
Interval
Duration
Amount
Menorrhagia
Regular
Prolonged
Excessive
Metrorrhagia
Irregular
+/- Prolonged
Normal
Menometrorrhagia
Hypermenorrhea
Hypomenorrhea
Normal or less
Less
Oligomenorrhea
Infrequent
Variable
Scanty
Amenorrhea
Absent
No menses (90days)

5. Differential diagnosis
Conditions assosiated with anovulation
Eating disorders
anorexia nervosa
bulimia nervosa
Excesive physical exercise
Chronic illnes
Alcohol or drug abuse
Stress
Thyroid disease
Hypothyroidism
hyperthyroidism
Diabetes mellitus
Policystic ovary syndrome

6. Differential diagnosis
Pregnancy related bleeding
Spontaneous abortion
Ectopic pregnancy
Exogenous hormones (using conraceptive hormones)
Coagulopathies
Von Willebrand’s disease
Liver disease
Infection causes
Chlamydia trachomatis
Exogenous hormones (using conraceptive hormones)- During first 1 to 3 months observation is reccomended. Long-term cases may require changing in hormonal delivery.
Pregnancy - Spontaneous abortion

7. Differential diagnosis
Anatomic causes:
Endometrial polyps
Fibroid (submucosal)
Endometrial cancer/hyperplasia

8. Physical examination Pelvic examination: Speculum examination
Bimanual examination
Identification of any trauma to the genital tract
Intensity of bleeding
Uterine enlargement and irregularity
Physical examination

9. Diagnosis Cytologic examination Endometrial biopsy
Transvaginal sonography
Hysteroscopy

10. Treatment of abnormal uterine bleeding
The first line of treatment for patients with known or suspected bleeding cause should be specific.
Ectopic pregnancy
Pharmacologic uterine evacuation
Thyroid disease
Medical treatment
Von Willebrand’s disease
Desmopressin
Bacterial Infections
Antibiotic
Surgical options, such as dialtion and curettage, myomectomy, endometrial ablation, utery artety embolization or hysterectomy, are required in structural abnormalities.

11. Treatment of ovulatory dysfunction
≤18 years
low-dose combination hormonal contraceptive ( μg ethinyl estradiol)
19-39 years
low-dose combined hormonal contraceptive therapy or to progestin therapy
high-dose estrogen therapy (cases of extremely heavy menstrual flow or hemodynamically unstablity)
≥40 years
cyclic progestin therapy, low-dose oral contraceptive pills, the levonorgestrel intrauterine device, or cyclic hormone therapy
these treatments can relieve perimenopausal symptoms such as hot flashes, night sweats, and vaginal atrophy

12. Summary Dysfunctional bleeding is a result of ovulatory dysfunction.
Every patient with bleeding requires preliminary diagnostic with exclusion of malignancies.
First step of abnormal uterine bleeding treatment should be specific for the bleeding cause.
Contraceptive therapy may be benefit in ovulatory dysfunction cases.
If childbearing is complete, women who have failed medical therapy may be considered for hysterectomy.