Dysfunctional Uterine Bleeding (DUB) 15-9-2013

Dr. Mohamed El Sherbiny MD Ob&Gyn

Definition: DUB is defined as abnormal uterine bleeding without a demonstrable

organic cause. So the diagnosis is by exclusion. DUB is 2 types :
Anovulatory Bleeding: 80% Usually in peripubertal & perimenopausal
Ovulatory Bleeding : 20% Usually in reproductive period. It includes:
1-Menorrhagia (The commonest ) 2-Polymenorrhoea 3-Polymenorrhagia .

Pathophysiology Of DUB:
Anovulatory DUB: No progesterone: Peresistent proliferative endometrium with
stromal breakdown, decreased spiral arteriole density, and increased dilated and
unstable venous capillaries i e; alterations in vascular architecture and tone
Ovulatory DUB: Predominantly it results from the vascular dilatation alone with no
prominent alterations in vascular architecture (no of spiral arteriole)
Differential Diagnosis: 1-General Causes 2- Reproductive Tract Disorders
1-General Causes:a- Coagulation defects :Thrombocytopenic &Von-Willebrand D.
b-Endocrine disorders: Hypo or hyperthyroidism, systemic diseases c- Liver failure,
d-Hypertension(late postmenp) & ?Renal failure e-Obesity,Emotional
f-Drugs ; Sex hormones, Anticoagulants& Psychotropic medications
2-Reproductive tract disorders
a-Complications of pregnancy: Miscarriage, Ectopic pregnancy & G T diseases.
b-Tumours : Ovarian, Uterine(mainly fibroids) , cervical& vaginal,
c-Other Pelvic Pathology : Endometrial &Cervical polyps, Endometriosis, Infections
(salpingo-oophoritis ) ,Vaginal atrophy , Vulvar lesion and Displacements
dTrauma or foreign body ( e.g.IUCD)
Diagnosis: In the majority of women with true anovulatory bleeding, menstrual
history alone can establish the diagnosis with sufficient confidence .
1-Laboratory tests :a-Pregnancy test can exclude complication of pregnancy.
b-CBC to exclude anemia and thrombocytopenia c-Free T4 or TSH if there is linical
evidence of thyroid dysfunction. d-von Willebrand for adolescent bleeding
2-U/S. It is the first-line diagnostic tool .
Trans vaginal U/S can accurately measure the endometrial thickness and can detect
polyps & leiomyomata with sensitivity 80% and specificity of 70% or associated
functional ovarian cyst &PCO.
Postmenopausal Endometrial thickness : =/< 4 mm has a Sensitivities of 95 %
exclusion of endometrial cancer. Postmenopausal endometrial thickness of >5 mm or
premenopausal endometrial thickness>12 mm and those with risk factors for
endometrial carcinoma warrant additional evaluation with SIS, hysteroscopy, or
endometrial biopsy.
3-Saline Infusion Sonography (SIS). It is particularly useful for :a-Finding
focal endometrial abnormalities. b-Confirming that a focal abnormality diagnosed by
transabdominal or TV Sonography is present .c-Better defining the nature of the
abnormality. It is best performed in the proliferative phase of the cycle to minimize
false-negative and false-positive results. SIS has Sensitivity 93% &Specificity 94%
with meno-metrorrhagia for detection of Polyp Versus Sensitivity 75% & Specificity
76% for TVS. Hysteroscopy for diagnosis or therapy of suspected uterine abnormality
on TVS could be avoided in 84 % if preceded by SIS .
4-Color Doppler can differentiate endometrial pathology (as PolypVs fibroid)

5-Endometrial biopsy. It is required for histological diagnosis if :a- At cut-off

values for Endometrial Neoplasia:Premenopausal :12mm in the follicular phase
&Postmenopausal : > 4 mm b- The endometrium is not adequately visualized cPersistent bleeding . Endometrial sampling my be recommended in women aged >
40 years and those with increased risk of endometrial carcinoma (obesity, diabetes
mellitus, hypertension, nulliparity with infertility, family history of endometrial and
colonic cancer ,or tamoxifen therapy). Diagnostic endometrial sampling (Pipelle
aspiration device ) is preferable to D&C -and almost replacing it- because it
is,more convenient, ,less expensive, safer, equally reliable , not need dilation,
hospitalization, or general/regional anesthesia.
6-Hysteroscopy: Blind biopsy is most accurate in women with a globally thickened
endometriumand hysteroscopy is preferable for women with focal abnormalities.
The main indications are a-After a nondiagnostic office biopsy in cases at high risk
of endometrial carcinoma b-After benign histology on office biopsy with persistent
abnormal uterine bleeding c- After a nondiagnostic office biopsy in cases at high
risk of endometrial carcinoma d-After benign histology on office biopsy with
persistent abnormal uterine bleeding e-When there is insufficient tissue for analysis
on office biopsy f-When cervical stenosis prevents the completion of an office
biopsy g- When a concomitant hysteroscopy or laparoscopy, is deemed necessary
h-Endometrial hyperplasia with atypia to exclude a coexistent endometrial
adenocarcinoma(25%).
Summary of Diagnostic Procedures : TVS for several reasons is a logical first
step. It is well-tolerated,simple, cost-effective, and can determine whether a lesion
is diffuse or focal. Once anatomic lesions have been identified, subsequent
evaluation requires individualization. If endometrial hyperplasia or cancer is
suspected, then endometrial biopsy may offer advantages. Alternatively, possible
focal lesions may be best investigated with either hysteroscopy or SIS.
Treatment of Abnormal Uterine Bleeding:
I-Treatment Of Acute Profuse Bleeding: IV lactated Ringer & Blood transfusion
, Foley catheter balloon inflated tamponade if needed.Then either D&C and
Curettage or medical hemostasis . Medical hemostasis: Premarin 25 mg IV/6h for
up to 24 hours Or Estradiol benzoate ( Folone) 5 mgIM/8h for24 h Then COC
tapering: 4 tablet /d for 4d then 3 tablet/d for 3 d then 2 tablet /d for 2 weeks
.Tranexamic acid (Cyklokapron/Kapron) 100 mg IV/8 h or 1g oral/6h
II- Treatment Of DUB: The treatment is mainly hormonal therapy with:
Estrogen,Progestogens,Combination Estrogen/Progestogens. The choice of therapy
is based on the: Endometrial thickness, duration of bleeding&age of the patient
1.Anovulatory (DUB) a- Anovulatory (DUB) with U/S Thin endometrium
(Insufficient follicles: inadequate proliferative or atrophic endometrium: Initial
combination Estrogen/Progestogen for 5-10D to arrest bleeding with compact
secretory endometrium.(IM.E2:Folone5 mg+ Progesterone:Lutone 25 mg for 5-7
days) or low dose COC 2 tablet /d for 7-10days. After withdrawal bleeding: 3-6
cycles COC or Sequential regimen CycloProgynova from D5
b-Thick endometrium (Persistent follicles: Proliferative or hyperplastic
endometrium,common with functional cyst or PCOS. Initial Progestogen for 7-10
days to arrest bleeding and to have compact secretory endometrium. Oral:15-20
mg :Cidolut-Nor or Provera or Duphaston or IM. Progestrone :Luton 25 mg/6h Or
Prontogest 100 mg/d. After withdrawal bleeding: 3-6 cycles COC or Progestogen
(10 mg Cidolot-Nor or Provera or Duphaston) from D5-25 for 3-6 cycles.
2- I.Ovulatory (DUB) mainly Menorrhagia : I Drug therapy& II Surgery

I-Drug therapy (Non-hormonal or Hormonal)

A- Non- hormonal-1-Non-steroidal anti-inflammatory drugs: 20-40% reduction
of blood loss :Cox I :Mefenamic acid ,Naproxen,Ibuprofen, &Diclofenac COX-2
inhibitors: Celebrex 2-Antifibrinolytics: 35-60% reduction Tranexamic
acid(Cyklokaprone& Kapron): Oral 1-1.5 g /6h , IV 500mg/6-8h for 4 to 7 days 3Etamsylate: ?? effect.
HORMONAL TREATMENTS: : Effectiveness 40% but has higher side effect
1- Progestogens: effectiveness 30-40% a-Norethisterone(cidolut Nor, Provera or
duphaston: 5 mg 3 times/d day 526
b-Levonorgestrel Intrauterine system (Device) (Mirena) effectiveness 90%
2- COC any type of low dose pills: effectiveness >40%
3- Gonadotropin-Releasing Hormone (GNRH)Agonists:For short-term use to
induce amenorrhea to rebuild red blood cell mass prior to surgery.
II-Surgery: When?: Unsuccessful medical management or high side effect.
1-D&C: To arrest severe bleeding refractory to high dose estrogen &tranximic acid.
2- Endometrial Ablation: Effectiveness 80% Less invasive procedures either
destroy or resect the endometrium and lead to amenorrhea similar to Asherman
syndrome .First generation : Hysteroscopic :Thermal loop resection or rollrball
coagulationor Laser .Second Generation :Need less skill 1-Hot liquid balloons as
ThermaChoice, Cavaterm , 2-Cryoablation 3- Microwave endometrial ablation
3-Hysterectomy :The most effective treatment for bleeding Disadvantages :more
frequent and severe intraoperative and postoperative complications compared with
either conservative medical or ablation procedures. Operating time, hospitalization,
recovery times, and costs are greater.
III Treatment of Organic Causes: They are treated by specific measures.
Management of General Causes:1-Hypothyroidism :Thyroid hormone 2-Liver
Failure :Vitamin K1& Desmopressin3-Coagulation defects : Idiopathic
thrombocytopenic purpura may undergo a remission after corticosteroid. Platelet
transfusion may be needed.Von Willebrand's : Desmopressin; severe cases need
transfusion with blood products.4-Emotional &Psychotropic support.5-Iatrogenic
Drugs as sex hormones, anticoagulants: stopping or proper dosing.
Management of Local Causes1-Endocervical polyps are removed by grasping the
polyp with a ring or polyp forceps. The polyp is twisted repeatedly about the base of
its stalk to strangulate its feeding vessels. With repeated twisting the base will avulse.
2-Endometrial polyps : Hysteroscopy and polypectomy is recommended for
symptomatic women or for those with risk factors for malignant transformation.
A asymptomatic premenopausal women with polyps <1.5 cm can be observed
Surgery For Uterine Fibroid 1- Hysteroscopic resection of submucous F. <4cm
2-Myomectomy :when there is a need for children
3-HYSTERECTOMY:The 3 choices are abdominal (TAH) , vaginal (VH) or
laparoscopically (LAVH) assisted with the first being the most common .
4- Embolization for selected cases( e.g.contraindication for surgery, refusing surgery).