DYSFUNCTIONAL

UTERINE BLEEDING
DR JEREMIAH I
Department of Obstetrics and Gynaecology,
NDUTH.
Pre Test
Answer true or false
1.
a)DUB is irregular uterine bleeding that
occurs in in patients with fibroids.
b)It is usually associated with anovulatory
menstrual cycles
c)It is a diagnosis of exclusion

d)It is commoner in the black race

2. Common bleeding patterns observed with
DUB include:
a)Amenorrhoea

b)Hypermenorrhoea

c)Menorrhagia

d)Metrorrhagia
3. Treatment of DUB
a)The main stay of treatment is progestogen
administration.
b)Allcases of DUB can be treated medically
c)Hysterectomy is a firstline surgical treatment

d)Radiotherapy may be employed in those

unfit for surgery.
INTRODUCTION
 Dysfunctional uterine bleeding (DUB) is irregular
uterine bleeding that occurs in the absence of
pathology or medical illness. It is a diagnosis of
exclusion.
 It reflects a disruption in the normal cyclic pattern of
ovulatory hormonal stimulation to the endometrial
lining. The bleeding is unpredictable in many ways.
It might be excessively heavy or light, prolonged,
frequent, or random.
 This condition usually is associated with anovulatory
menstrual cycles but also can present in patients
with oligo-ovulation.
 The diagnosis of DUB should be used only when
other organic and structural causes for abnormal
vaginal bleeding have been ruled out.
EPIDEMIOLOGY
 Dysfunctional uterine bleeding (DUB) is the most
common cause of abnormal vaginal bleeding during
a woman's reproductive years.
 Makes up 5-10% of cases in the outpatient clinic
setting.
 Adolescents and perimenopausal women are
particularly vulnerable. About 20% of affected
individuals are in the adolescent age group, and
50% of affected individuals are aged 40-50 years.
 DUB has no predilection for race; however, black
women have a higher incidence of leiomyomas and
higher levels of estrogen. As a result, they are prone
to experiencing more episodes of abnormal vaginal
bleeding.
The common bleeding patterns observed with DUB
are described as follows:

 Menorrhagia - prolonged or excessive uterine bleeding

(>80ml and >7 days) occurring at regular intervals.
 Metrorrhagia - uterine bleeding occurring at irregular and
more frequent than normal intervals.
 Polymenorrhoea - uterine bleeding occurring at regular
intervals of less than 21 days.
 Hypermenorrhoea - prolonged or excessive uterine
bleeding (>80ml and >7 days) occurring at regular
intervals of 21 – 35 days.
 Amenorrhea - no uterine bleeding for 6 months or longer
 Kleine regnung (little shower) – scant bleeding for 1 – 2
seen at ovulation time.
 Pathophysiology
 Approximately 90% of DUB results from anovulation,
and 10% occurs with ovulatory cycles.
 During an anovulatory cycle, the corpus luteum fails
to form, which causes failure of normal cyclical
progesterone secretion.
 This results in continuous unopposed production of
estradiol, stimulating overgrowth of the endometrium.
 Without progesterone, the endometrium proliferates
and eventually outgrows its blood supply, leading to
necrosis.
 The end result is overproduction of uterine blood
flow. Bleeding is heavy and prolonged as there is no
vasoconstrictor effect on the spiral arteries.
 In ovulatory DUB, prolonged progesterone secretion
causes irregular shedding of the endometrium.
 This probably is related to a constant low level of
estrogen that is around the bleeding threshold.
 This causes portions of the endometrium to
degenerate and results in spotting.
 Progesterone causes the enzymatic conversion of
estradiol to estrone, a less potent estrogen.
 The changes in the endometrium remain secretory
within the glands.
 Patients who exhibit these symptoms in the
reproductive years often have ovulatory cycles or
secondary reasons for altered hypothalamic function
(e.g., polycystic ovary disease).
The major categories of DUB
include the following:

 Estrogen breakthrough bleeding

 Estrogen withdrawal bleeding

 Progestin breakthrough bleeding

 Problems
 There is an increased fibrinolytic activity in the uterus
of patients with DUB.
 There is also an abnormal metabolism of
prostaglandins in the endometrium and myometrium.
 PGF2α is the most important PG for controlling
bleeding at the time of menstruation. The following are
functions of the PGs manufactured by the
endometrium and myometrium

PGF2α- vasoconstriction and myometrial contraction

PGE2 -vasodilatation and myometrial contraction

Prostacycline (PGI2) – vasodilatation, myometrial
relaxation and inhibition of platelet activity.
 In the normal menstrum PGF2α to PGE2 ratio
is 2:1
 In DUB there is an increase in both PGE2 and
PGI2 with a fall in PGF2α with the following
result that favour increased menstrual loss
 Vasodilatation

 Myometrial relaxation

 Reduced platelet aggregation

Differential Diagnosis of
DUB.
Endocrine
Cushing's disease
Infections
chlamydia


immature hypothalamo- gonorrhea

pituitary PID
axis  Medications (Iatrogenic)
hyperprolactinemia hormonal agents
hypothyroidism low-dose oral contraceptive pills
menopause (OCPs)
obesity nonprogestin-containing IUDs
polycystic ovary disease nonsteroidal anti-inflammatory
premature ovarian failure drugs
 Stuctural lesions (NSAIDS)
adenomyosis Norplant System
coagulopathies progestin-only contraceptive (the
condyloma acuminata "mini pill")
dysplastic or malignant lesion tamoxifen
of the cervix or vagina warfarin
endometiosis  Pregnancy
endometrial cancer ectopic pregnancy
uterine or cervical polyps incomplete abortion
uterine leiomyomata pregnancy complications
trauma
Clinical Features
History:
 Patients often present with complaints of amenorrhea,
oligomenorrhea, menorrhagia, or metrorrhagia.
 Occasionally, bleeding is profuse with associated signs and
symptoms of hypovolemia, including hypotension,
tachycardia, diaphoresis, and pallor. These patients usually
do not have pain associated with bleeding episodes, and
other systemic symptoms rarely are noted unless vaginal
bleeding has an organic cause.
 A reproductive history should always be obtained, including
the following:
 Menstrual regularity

 Last menstrual period (LMP), including flow and duration

 Gravidity and parity

 Previous abortion or recent termination of pregnancy

 Contraceptive use
 Questions about medical history should include
the following:
 Diabetes mellitus

 Hypertension

 Hypothyroidism, hyperthyroidism

 Liver disease

 Medication usage, including anticoagulants,

aspirin, anticonvulsants, and antibiotics

Physical examination
 Initial evaluation should be directed at assessing
patient's volume status and degree of anemia.
Examine for pallor.
 Galactorrhea
 Visual field deficits
 Patients who are hemodynamically stable require
a pelvic speculum and bimanual examination to
define the etiology of vaginal bleeding. The exam
should look for the following:
 Trauma

 Foreign body

 Cervical or vaginal laceration

 Bleeding from the os

 Uterine or ovarian structural abnormalities may be noted on
bimanual exam.
 Patients with hematologic pathology also may have cutaneous
evidence of bleeding diathesis. Physical findings include petechiae,
purpura, and mucosal bleeding (eg, gums) in addition to vaginal
bleeding.
 Patients with liver disease may manifest additional symptomatology
because of abnormal hepatic function. Evaluate patients for spider
angioma, palmar erythema, splenomegaly, ascites, jaundice, and
asterixis.
 Women with polycystic ovary disease present with signs of
hyperandrogenism, including hirsutism, obesity, and palpable
enlarged ovaries.
 Hyperactive and hypoactive thyroid can cause menstrual
irregularities. Patients may have characteristic eye findings, tremors,
changes in skin texture, and weight loss or gain. Goiter may be
present.
Investigations
 HCG
 FBC count + Platelets
 Pap smear
 Thyroid functions
 Prolactin
 Liver functions
 Coagulation factors (PT, aPTT)
 Other hormone assays as indicated-FSH, DHEAS.
 TVUS
 Endometrial sampling
 All patients older than 35 years
 Obese patients
 Patients with diabetes mellitus
 Patients with hypertension
 Patients with suspected polycystic ovarian disease
 Histologic Findings: Most endometrial biopsy specimens will
show proliferative or dyssynchronous endometrium.
 Treatment
 The main stay of treatment is progestogen
administration.
 The progestogens have the following effects
 Suppression of DNA synthesis and hence cell
proliferation
 Depletion of oestrogen receptors
 Activation of enzymes necessary for the conversion of
oestradiol to the less potent oestrone
 Endometrial maturation with healing of superficial
breaks
 Improved endometrial stromal stability
 Cessation of bleeding
 After adequate exposure (10-12 days)
withdrawal of the progestogen results in
orderly and uniform shedding of the
endometrium with a finite and self limiting
bleeding.
 After prolonged treatment with progestogens
(or OCPs) there is progressive reduction in
the endometrial height with reduction in
menstrual flow.
 Progestogens or OCPs may not control
bleeding fast enough in the face of profuse
life threatening bleeding
 Oestrogens cause rapid regeneration of
the endometrium with rapid healing of the
disrupted superficial layers and hence
controlling blood loss
 Oestrogens are particularly effective when
the bleeding has been prolonged and the
endometrium grossly reduced. It is then
necessary to build up the endometrium
before administering the progestogen.
Adolescence
Profuse life threatening bleeding
 Admit

 Resuscitate with IV fluids and blood Tx

 Start oestrogen therapy

 IV conjugated equine oestrogen (Premarin)
 25mg 4-6hrly for up to 24hrs
 Bleeding is usually controlled within 24hrs
 Oral Premarin – 1.25 – 2.5mg dly
 If bleeding continues after instituting IV estrogen,
insert a pediatric Foley catheter into the cervical os
and inflate to tamponade the bleeding.
 Dilatation and curettage is not indicated unless a
pregnancy related problem is found.
 When bleeding is controlled follow with
progestogens or COCP
 COCP -1tab dly for 3-6 cycles
 MPA 10md dly for 10-12 days
 Norethisterone 5mg tds for 10-12 days
 This is followed by a withdrawal bleed 2-7days later
 Less effective treatments:
 MPA 10md dly for 10-12 days (bleeding takes 24hrs to
stop)
 COCP 4 tabs dly for 5 days (in divided doses)
 When bleeding stops continue dly COCPs for 3-6 cycles.
 Administer oral haematinics.
MILD TO MODERATE BLEEDING
 MPA as above

 Norethisterone acetate
Other forms of chronic DUB
 Progestogens
 Norethisterone – 5mg tds from days 15-25 of each menstrual

cycle
 For ovulatory or unknown type of bleeding treat from days 5-25 of

each menstrual cycle

 Combined oral contraceptive pills
 Give for 6 cycles

 Prostaglandin synthetase inhibitors

 Inhibit PG synthesis in the endometrium causing relief of

menorrhagia and dysmenorrhoea

 For best results, combine with OCPs or Progestogens

 Contraindicated in PUD
 Mefanamic acid -500mg tds during menstruation
 Ibuprofen – 400mg tds during menstruation
 Naproxen – 750mg dly for 3 days, then 250mg dly for 5 days
 These are effective for DUB ass. with IUCD, fibroids, von
Willenbrands disease and ovulatory DUB
 Fibrinolytic inhibitors
 Reduce bleeding by reducing plasminogen activity
 Contraindicated if history of thrombosis
 ε-aminocaproic acid- 3-6mg tds or qid for 1 st 3 days of menstrual cycle (has severe GI
side effects)
 Tranexamic acid 1.5g tds during menstruation
 Ethamsylate
 500mg qid
 Diminishes capillary blood loss
 Ovulation induction
 Done for those requiring pregnancy
 Chlomiphene
 bromocriptine
 Androgens
 The fear of masculinization with androgens has made it less attractive but can be
used in the premenopausal women e.g.
 methyltestosterone is given 10mg for 7days preceding menstruation.
 Danazol
 17-alfa-ethinyl-testosterone.
 Has progestogenic action.
 Does not produce any change in blood coagulation.
 Dose:200mg dly for 3 months
 Causes masculinising effects
 GnRH agonists (medical castration)
 Given up to 3 months as it is ass with severe bone
resorption and osteoporosis
 Not effective in treating acute bleeding
 Desmopressin
 A synthetic analog of arginine vasopressin
 Useful for coagulation disorders
 Increases factor VIII with therapeutic effect lasting for 6 hrs
 May be given im or iv
 Oxytotics
 Ergometrine has no place in the treatment of DUB
 They have been shown to be effective rarely in clinical studies
and have many side effects.
Surgical Care
 Most cases of DUB can be treated medically.
 Surgical measures are reserved for situations when medical
therapy has failed or is contraindicated.
 D&C is an appropriate diagnostic step in a patient who fails to
respond to hormonal management.
 The addition of hysteroscopy will aid in the treatment of

endometrial polyps or the performance of directed uterine biopsies.

 As a rule, apply D&C rarely for therapeutic use in DUB because it

has not been shown to be very efficacious.

 D&C is indicated in the following situations:
 in patients at high risk for endometrial hyperplasia and carcinoma.

 Consider D&C rather than endometrial biopsy if suspected

diagnosis is endometritis, atypical hyperplasia, or carcinoma.

 Perform in patients having heavy, uncontrolled bleeding.

 Perform if histologic examination is required but biopsy is

contraindicated.
 Hysterectomy remains the most absolutely
curative treatment for DUB.
 Abdominal or vaginal hysterectomy might be
necessary in
 patients who have failed or declined hormonal therapy
 have symptomatic anemia
 experience a disruption in their quality of life from
persistent, unscheduled bleeding.
 Those over 40 years
 Those with endometrial hyperplasia with cellular atypia
 Endometrial ablation is an alternative for
those who wish to avoid hysterectomy or
who are not candidates for major surgery.
 Ablation techniques are varied and can employ laser,
rollerball, resectoscope, or thermal destructive
modalities.
 Pretreat the patient with an agent, such as leuprolide
acetate, medroxyprogesterone acetate, or danazol, to
thin the endometrium.
 The ablation procedure is more conservative than
hysterectomy and has a shorter recovery time.
 High rates of rebleeding following ablation have raised
concern about the possibility of an occult endometrial
cancer developing within a pocket of active
endometrium. Further studies are needed to quantify
this risk.
 Radiotherapy.
 For those who are unfit for surgery and over 40
years. Produces amenorrhea in 99% of cases.
Complications
 Iron deficiency anemia: Persistent menstrual
disturbances might lead to chronic iron loss in up to
30% of cases. Adolescents might be particularly
vulnerable. Up to 20% of patients in this age group
presenting with menorrhagia might have a disorder of
hemostasis.
 Endometrial adenocarcinoma: About 1-2% of women
with improperly managed anovulatory bleeding
eventually might develop endometrial cancer.
 Infertility associated with chronic anovulation, with or
without excess androgen production, frequently is
seen in these patients. Patients with polycystic ovarian
syndrome, obesity, chronic hypertension, and insulin-
resistant diabetes mellitus particularly are at risk.
Pre Test
Answer true or false
1.
a)DUB is irregular uterine bleeding that
occurs in in patients with fibroids. F
b)It is usually associated with anovulatory
menstrual cycles T
c)It is a diagnosis of exclusion T

d)It is commoner in the black race F

2. Common bleeding patterns observed with
DUB include:
a)Amenorrhoea T

b)Hypermenorrhoea T

c)Menorrhagia T

d)Metrorrhagia T
3. Treatment of DUB
a)The main stay of treatment is progestogen
administration. T
b)Allcases can be treated medically. F
c)Hysterectomy is a first line surgical
treatment. F
d)Radiotherapy may be employed in those
unfit for surgery. F
Conclusion