1. 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

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 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 14

18. Gynaecological bleeding
Estrogen withdrawal
Estrogen breakthrough
Progesterone withdrawal
Progesterone breakthrough

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 is 0.1 per 100,000
Age is 9.5 per 100,000
(however Age 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