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.
DUB is 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

11. 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.

13. 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.

14. 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

15. 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 .

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

17. PCB: postcoital bleeding; PMB: postmenopausal bleeding; IMB: intermenstrual bleeding; 2ww : urgent appointment within 2-week wait rule for suspected cancer; uterus>10w: clinical measurements suggests uterus greater 10 weeks size (or uterine cavity >10 cm length); FBC: full blood count (anaemia tends to indicate severe HMB).
Red flag features: six features are numbered in the figure that, if present, warrant referral to secondary care.
Adapted from: National Institute for Health and Clinical Excellence. Heavy menstrual bleeding. NICE clinical guideline 44. London: NICE; 2007.

18. Red Flag features of AUB indicating 2ry care referral
Pathology suspected before treatment
Suspected Gynaecology cancer
Requires endometrial biopsy (to rule out endometrial hyperplasia or endometrial cancer).
PCB, IMB, Pelvic mass or Cervical lesion
Persistent IMB
>45years with treatment failure
Irregular bleeding while on HRT or tamoxifen
Pathology suspected before\ after treatment
3. Enlarged uterus (clinically measures >10 weeks size or >10 cm uterine cavity length).
4. Moderate/severe anaemia on FBC.
.Uterine/ovarian pathology identified on ultrasound scan.
. Identification of coagulation/haemostatic disorder on clinical screening and testing
Fibroids, adenomyosis
Fibroid
e.g. von Willebrand disease
Pathology suspected after treatment
5. Medical treatment has failed
6. Patient wishes for surgery
At least 3 months of drug treatment (at least 6 months of Mirena) and failure is based on woman’s own assessment.
Endometrial ablation, hysterectomy

20. 2ndry options COCpills Primary options Progestogens
Northiosterone:5mg TDS D5-D26 OR
medroxyprogesterone: 5-10 mg orally once daily for 5-10 days of each month, start on days of cycle
progesterone micronised: 200 mg orally once daily for 12 days of each month
*levonorgestrel intrauterine device:
etonogestrel subdermal implant/injection
Non-Steroidal anti-inflammatory drug (NSAID)
CI: Peptic ulcer and bronchial asthma
Antifibrinolytic agents [C Evidence]
useful when the use of oestrogens and progestogens are contraindicated. [B Evidence]
mefenamic acid: 500 mg orally as a single dose initially, followed by 250 mg every 6 hours when required
ibuprofen: mg orally every 6-8 hours when required, maximum 2400 mg/day
naproxen: 250 mg orally every 6-8 hours when required, maximum 1250 mg/day
tranexamic acid: 1 g orally three times daily for up to 4 days during menstruation
2ndry options
COCpills

21. 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.

22. Complications
Endometrial hyperplasia/cancer
Anemia

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

24. 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