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Introduction
Dysfunctional uterine bleeding (DUB) is defined as ABNORMAL uterine bleeding with no demonstrable organic cause, genital or extragenital. Diagnosis of EXCLUSION Patients present with abnormal uterine bleeding DUB occurs most often shortly after menarche and at the end of the reproductive years.
20% of cases are adolescents 50% of cases in 40-50 year olds
Introduction
DUB is most frequently associated with chronic anovulation. Heavy menses, prolonged menses, or frequent irregular bleeding are the most common complaints. Up to 20% of women will experience irregular cycles in their lifetimes.
Goals
Define common terms Briefly review normal menstruation Discuss etiologies of DUB Review the differential diagnosis for abnormal bleeding Discuss the evaluation of abnormal uterine bleeding Discuss the treatment of DUB
Definitions
Menorrhagia (hypermenorrhea): prolonged (>7 days) and/or excessive (>80cc) uterine bleeding occurring at REGULAR intervals. Metorrhagia: uterine bleeding occurring at completely irregular but frequent intervals, the amount being variable. Menometorrhagia: uterine bleeding that is prolonged AND occurs at completely irregular intervals. Polymenorrhea: uterine bleeding at regular intervals of less than 21 days. Intermenstrual bleeding: bleeding of variable amounts occurring between regular menstrual periods.
Definitions
Oligomenorrhea: uterine bleeding at regular intervals from 35 days to 6 months. Amenorrhea: absence of uterine bleeding for > 6 months. Postmenopausal bleeding: uterine bleeding that occurs more than 1 year after the last menses in a woman with ovarian failure.
Normal Menstruation
Life Cycle
Menarche 5-7 years of relatively long cycles Increasing regularity of cycles In the 40s cycles begin to increase in length with increasing episodes of anovulation (2-8 years perimenopause) Menopause (average age = 52)
Characteristics
By age 25, 40% of women have cycles between 25-28 days Age 25-35, 60% of women have 25-28 day cycles. Overall 15% have 28 day cycles .5% have cycles < 21days .9% have cycles >35 days
Normal Menstruation
Results from fluctuations in the circulating levels of estrogen and progesterone. Estrogen causes increased blood flow to the endometrium A significant correlation exists between plasma Estradiol and endometrial blood flow, with both increasing in the days preceding ovulation. These vasodilatory and vasoconstrictive effects are mediated by substances like:
acetylcholine vasopressin endothelin histamine
Normal Menstruation
Estradiol and progesterone levels decrease several days prior to the onset of menses.
Endometrial blood flow decreases Endometrial height decreases and vascular stasis occurs. Tissue ischemia occurs. Arterial relaxation Sloughing of the endometrium. Uterine bleeding occurs
In women with DUB secondary to anovulation, endometrial blood flow is variable and follows no orderly pattern
Cessation of Menses
Two main mechanisms:
Formation of the platelet plug
important in the functional endometrium
Pathophysiology
Two types: anovulatory and ovulatory
Most women with DUB do not ovulate.
In theses women, there is continuous E2 production without corpus luteum formation and progesterone production.
Ovulatory DUB occurs most commonly after the adolescent years and before the perimenopausal years.
Incidence in these patients may be as high as 10%
Causes of DUB
The main cause of DUB is anovulation resulting from altered neuroendocrine and/or ovarian hormonal events.
In premenarchal girls, FSH > LH and hormonal patterns are anovulatory.
Causes of DUB
The pathophysiology of DUB may also represent exaggerated FSH release in response to normal levels of GnRH.
Causes of DUB
After menarche, normal adult FSH and LH patterns eventually develop with mid-cycle surges and E2 peaks.
Causes of DUB
In perimenopausal women, the mean length of the cycle is shorter compared to younger women.
Shortened follicular phase Diminished capacity of follicles to secrete Estradiol
Non-organic
DUB
Systemic Disease
Coagulation disorders
platelet deficiency platelet function defect prothrombin deficiency
Iatrogenic Causes
Medications
Steroids Anticoagulants Tranquilizers Antidepressants Digitalis Dilantin
Intrauterine Devices
Evaluation
History
Onset, frequency, duration, cyclic vs.acyclic, severity Pain, change from menstrual pattern (calendar) Age, parity, marital status, sexual hx, contraception medications, dates of pregnancies symptoms of pregnancy and reproductive tract disease
Physical Exam
pelvic exam pap smear
Evaluation
Tests
Choices are extensive Not practical or cost effective to do every test They are not used as general screening tests for all women with DUB. Selection should be tailored to suspected causes from the history and physical Stepwise process should be considered
Step One:
Rapid assessment of vital signs
Hemodynamically stable Hemodynamically unstable
Step Two:
If screen is normal, a diagnosis of anovulatory DUB is assumed and appropriate therapy begun
No lesion
High risk for neoplasia endometrial biopsy Low risk for neoplasia can assume DUB and treat
Treatment of DUB
Goals
control bleeding prevent recurrence preserve fertility correct associated conditions induce ovulation in patients who want to conceive
Treatment of DUB
Medical management before Surgical
effective methods include: estrogens, progestins, or both NSAIDs antifibrinolytic agents danazol GnRH agonists
Treatment of DUB
Acute bleeding
Estrogen therapy
Oral conjugated equine estrogens
10mg a day in four divided doses treat for 21 to 25 days medroxyprogesterone acetate, 10 mg per day for the last 7 days of the treatment if bleeding not controlled, consider organic cause
OR
25 mg IV every 4 to 12 hours for 24 hours, then switch to oral treatment as above.
Treatment of DUB
Acute bleeding (continued)
High dose estrogen-progestin therapy
use combination OCPs containing 35 micrograms or less of ethinylestradiol four tablets per day treat for one week after bleeding stops may not be as successful as high dose estrogen treatment
Treatment of DUB
Recurrent bleeding episodes
combination OCPs
one tablet per day for 21 days
Treatment of DUB
Recurrent bleeding episodes (continued)
Progesterone releasing IUD
avoids side effects must be reinserted annually Levonorgestrel IUD
80% reduction of blood loss at 3 months 100% reduction at 1 year found to be superior to antifibrinolytic agents and prostaglandin synthetase inhibitors
Treatment of DUB
Immature hypothalamic-pituitary axis
progestin therapy by itself for 10 days every month or every other month until full maturity of the axis provides effective therapy.
Treatment of DUB
Other options
NSAIDs
cyclooxygenase inhibitors inhibits prostacyclin formation administered throughout the duration of bleeding or for the first 3 days of menses. treatment results in a sustained reduction in blood loss so side effects tend to be mild most effective in ovulatory DUB
Treatment of DUB
Other options
inhibitors of fibrinolysis
EACA (epsilon-aminocaproic acid) AMCA (tranexamic acid) PABA (para-aminomethybenzoic acid)
Treatment of DUB
Danazol
androgenic steroid
200mg and 400 mg daily doses for 12 weeks studied 200mg dose as effective as 400 mg androgenic side effects: weight gain, acne
side effects minimized with 200mg dose
Treatment of DUB
GnRH agonists
treatment results in medical menopause blood loss returns to pretreatment levels when discontinued treatment usually reserved for women with ovulatory DUB that fail other medical therapy and desire future fertility use add back therapy to prevent bone loss secondary to marked hypoestrogenism
Treatment of DUB
Surgical Treatment
Dilation and Curettage
quickest way to stop bleeding in patients who are hypovolemic appropriate in older women (>35)to exclude malignancy but is inferior to hysteroscopy follow with medroxyprogesterone acetate, OCPs, or NSAIDs to prevent recurrence
Treatment of DUB
Surgical Treatment: (Ablation)
Laser ablation
Treatment of DUB
Surgical Treatment: (Ablation)
Thermal balloon ablation Microwave ablation Electromagnetic ablation
poor follow up
Treatment of DUB
Surgical Treatment
Hysterectomy