DYSFUNCTIONAL UTERINE BLEEDING

Diagnosis of exclusion
Excessive bleeding heavy, prolonged or frequent
Uterine origin
Not associated with recognisable pelvic disease, complications of
pregnancy or systemic illness
Blood loss >80 mL
Peak incidence of ovulatory DUB: 35-45 yo
Peak incidence of anovulatory DUB: 12-16 yo or 45-55 yo irreg bleeding,
spotting, menorrhagia
More commonly associated with ovulatory cycles rather than anovulatory
cycles
Anovulatory cycle = estrogen stimulation I the absence of progesterone
proliferation of endometrium bleeds erratically
o Menarche
o Perimenopause
o PCOS
Ask about:
o Age
o Parity
o Smoking status
o Pregnancy
o LMP, likelihood of pregnancy
o Frequency, volume, pattern of bleeding
o Contraceptive use
o Cycle length, blood flow
o Trauma to genital tract
o Medical disorders
o Endocrine disorders
o Cancer of genital tracts
o Complications of pills
o Quality of life
o Symptoms, signs or past history of comorbidities (diabetes, obesity,
thyroid disease, PCOS, bleeding disorder)
o Experience of pelvic pain or pressure
o Family history of endometriosis, endometrial cancer, bowel cancer
Examination:
o Pelvic examination usually normal
Speculum
Smear
o Bimanual
If uterus enlarged, consider fibroid
DDx:
o Submucous fibroid
o Adenomyosis
o Endometrial polyps, hyperplasia, cancer
o Hypothyroidism, coagulation defects
Etiology:
o Unknown

Abnormal PG (high) ratio vasodilatation, platelet non-aggregation

Excessive fibrinolysis
Defects in expressions/function of MMP, vascular growth factors and
endothelins
o Aberrant steroid receptor function
o Defects in the endomyometrial junctional zone
Symptoms and signs:
o Heavy bleeding
o Saturated pads, tampons
o Frequent changing
o Clots
o Flooding, accidents
o Prolonged bleeding
Menstruation > 8 days
Heavy flow > 4 days
Frequent bleeding >once/month
If painful consider endometriosis/PID
o Anaemia
Ix:
o Beta HCG always exclude pregnancy
o FBC Hb, MCV anaemia?
o FSH, LH
o Day 21 progesterone ovulation?
o Ferritin anaemia?
o TFTs - hypothyroidism
o Coagulation profile vWD disease
o Serum androgen free testosterone
o Cervical smear
o STI screen including Chlamydia
o TVS USS fibroids, polyps, measure endometrial thickness (postmenopausal)
o Endometrial biopsy hyperplasia, cancer (especially if postmenopausal)
o Hysteroscopy D&C and biopsy
Mx:
o Exclude other pathology
o Menstruation calendar
o Medical Mx:
Regular DUB
Mirena IUD
Anti-fibrinolytics tranexamic acid (caution in cardiac
disease)
NSAIDs mefenamic acid
COCP
Oral progestogens short term continuous treatment
to stop bleeding
Irregular DUB
Mirena IUD
Anti-fibrinolytics tranexamic acid (caution in cardiac
disease)
NSAIDs mefenamic acid
o
o
o

COCP
Norethisterone or medroxyprogesterone acetate
regulate cycle but do not loss
Anaemic women
GnRH analogue causes amenorrhea
High dose progestogens medroxyprogesterone
acetate causes amenorrhea
Ferrous sulphate replace lost iron store
Surgical Mx:
For women who failed to respond to medical Mx
Have completed their families
Endometrial ablation destruction down to basalis layer (less
effective if endometrium > 10 cm)
Microwave
Thermal balloon
Novasure
Hysterectomy
Complications: haemorrhage, infection,
bladder/ureteric/bowel injury
Route of choice: vaginal hysterectomy