Clinical types:

A) Pseudomenstruation: → Occurs è COCs use.

● Woman takes pills for continuous 21d' then stop it for 7d' → sudden hormonal withdrawal →
bleeding (progesterone withdrawal bleeding).
● Bleeding is cyclic [recurs every month] but anovulatory
B) Dysfunctional metrorrhagia:
1) Birth crisis: → Bleeding during 1st wk of life d2 withdrawal of placental estrogen from
neonatal blood
No Need of ttt, Only assurance (Self-limited èin hours or days)

2) Threshold bleeding: → ↓↓ estrogen level below level (threshold) w' can maintain
endometrium

3) Metropathia hemorrhagica (Shroeder's disease):

Definition: → Condition ch' by painless heavy bleeding preceded by short period of
amenorrhea (6-8wks) è absence of CL.
Incidence: → Common after puberty, before menopause & after labor or abortion.
A/E: → Chronic anovulation.
Pathogenesis:  Estrogen breakthrough bleeding.
■ Chronic anovulation + hyperestrogenemia → endometrium grows till become hyperplastic
èout shedding  period of amenorrhea.
■ Hyperplastic endometrium continue to grow till it can't be controlled by estrogen (relatively)
→ endometrial shedding  heavy bleeding.
Pathology:
Uterus Ovaries
Symmetrically enlarged & soft
Large & Multicystic
N/E -myometrial hypertrophy
(Bilateral Polycystic ovaries)
-thick polypoidal endometrium
-Myometrial hypertrophy
-No CL
M/E -Cystic? Endometrial hyperplasia
-Ovarian cysts lined by granulosa cells
(Swiss cheese appearance)
C/P:
→ Short period of amenorrhea (6-8 wks) followed by painless heavy vaginal bleeding
→ symmetrically enlarged soft uterus & Bilateral cystic ovaries.
Investigations: D by Exclusion as DUB (-ve -ve ????) Finding ???
a) Hormonal profile:  High estrogen.
b) U/S  Symmetrically enlarged uterus + thick polypoidal endometrium + cystic ovaries
???No Gross Pelvic Lesions?
c) Endometrial biopsy:  Hyperplastic endometrium.
d) Hysteroscopy:  Hyperplastic polypoidal endometrium.
DDx:
a) Causes of bleeding in early pregnancy.
b) Causes of symmetrically enlarged uterus.
ttt
See Later ttt of DUB
don't write in Hormonal COCs or Estrogen
& Just concentrate on Progesterone in addition to Take Care of Progesterone Dose
 C) Dysfunctional menorrhagia:
1) Irregular ripening of
endometrium
CL insufficiency (LPD)
A/E
"Poor formation & function of CL"
CL insufficiency  ↓↓ progesterone
release from CL → poor hormonal
support to endometrium in 2nd half
Pathogenesis of cycle → parts of endometrium
become uncontrolled by progest. →
early shedding of these parts before
menstrual flow
C/P Irregular spotting Before menstruation
Endometrial biopsy
Timing  Premenstrual [PMEB]
Diagnosis Finding  show mixed pattern of
proliferative & secretory
(Secretory is the dominant)
Giving Progesterone during 2nd half of
ttt
the cycle
2) Irregular shedding of
endometrium
Persistent CL function (Halban dse)
"Irregular degenetation of CL"
Persistent CL function  persistent
progesterone release from CL →
parts of secretory endometrium will
continue to be under persistent
control of progesterone → these
parts become late shedded after
menstrual flow
Irregular spotting After menstruation
Endometrial biopsy
Timing  Postmenstrual
Finding  show mixed pattern of
proliferative & secretory
(Proliferative is the dominant)
Hormonal regulation of the cycle

D) Dysfunctional Polymenorrhea:
a) Short follicular phase  In perimenopause.
b) Short luteal phase  Following abortion or delivery LPD???
E) Ovulatory spotting
 Def.: → spotting occurring in midcycle (around date of ovulation)
 Pathogenesis: → Type of estrogen withdrawal bleeding
deprivation of endometrium from estrogen during changing from follicular to luteal phase
 ttt: → No treatment needed

Diagnosis:
→ Diagnosis of DUB is by exclusion (see above)
Treatment Depends on age, severity of bleeding & desire of fertility

❶ General measures
1) 1st aid measures (during bleeding episode)
2) Reassurance.
3) Rest & sedation
4) Correction of anemia  By hematinics* (Iron supplementation, ….) & even blood
transfusion if needed
Hematinics (iron, B12 & folate,…)  a nutrient required for the formation of RBCs in process of hematopoiesis

❷ Medical non hormonal therapy Ecbolics have no place in DUB

Actions Efficacy
1) Anti-PGs (--) of PGs synthesis & alteration of Most effective in ovulatory
(PG synthetase inhibitors) balance () TXA2 [VC] & PGI2 [VD] DUB (↓↓ blood loss by
→ As Mefenamic acid 50%) & è IUD
500 mg tds TXA2=Thromboxane
→ Ibuprofen PGI2= prostacyclin
2) Antifibrinolytics ↓↓ fibrinolytic activity
→ Tranexamic acid (kapron ®)
● C/I  Patients è ↓↓ blood loss by 50%.
Epsilon amino-caproic
acid [EACA] thromboembolism.
3) Ethamsylate  Stabilization of capillary wall & ↑↑
(Dicynone ®) platelet adhesiveness ↓↓ blood loss by 50%.

4) Diosmin (Daflon ®)  Improvement of venous tone &

protection of capillary  Effective in 70-90 % of
microcirculation from damaging cases
processes

❸ Hormonal therapy Main line of ttt

1) Gestagens (Progestins)  MPA (Provera)
Norethisterone [NET] (Cidolut Nor ®)  "Commonly Used"

Indications ttt of Choice As Most Cases of DUB "90%" are anovulatory

Mechanism of action [Antiestrogenic action]

❶ ↓↓ estrogen Rc on endometrium
❷ ↑↑ conversion of E2 to E1 (weak & easily displaced from cells).
❸ Antimitotic & antigrowth effects
❹ Convert endometrium from hyperplastic to secretory followed by shedding
(Medical curettage)

Regimen
a) To arrest acute bleeding: → 10-30 mg/d orally for 10d'
(bleeding is usually controlled èin 48h').
b) Cyclic regimen: Short for CL insufficiency & Long  for Metropathia Hemorrhagica
1- Short (10d') regimen: → 5-10 mg/d from day 15 to day 25 in each cycle for 3-6m'
2- Long (21d') regimen: → 5-10 mg/d from day 5 to day 25 in each cycle for 3-6m'
c) Continuous regimen: → Depot MPA / 2m' IM for 3 doses.
d) Progesterone medicated IUD [Mirena] : → Can be used in ovulatory DUB
disadvantages may cause irregular bleeding for many weeks after insertion
S/E → Headache, depression, wt gain, breast discomfort, Vagina dryness & ↓↓ libido
2) COCs (Combined Estrogen & Progesterone)  The best preparations are low dose COCs.

 Indications

a) Acute bleeding in young women only

b) Regulation of cycle in Metropathia hemorrhagica & dysfunctional polymenorrhea

 Mechanism of action Regulation of the Cycle by control of Endometrium

Conversion of fragile overgrown endometrium to stable pseudodecidualized endometrium

Regimen
a) To arrest acute bleeding: → 3 tablets / day for 7d' (bleeding is usually controlled èin 24h')
b) Cyclic regimen: → 1 tablet / day for 21d' & stop for 7d' for 3m'

3) Estrogen
 Action: → Rapid proliferation of endometrium → covers denuded & raw areas of
endometrium →Stop bleeding
 Indications: Has limited use now d2 high S/E
a) Prolonged heavy bleeding (high estrogen doses can arrest bleeding èin 24h').
b) Threshold bleeding.
c) Progesterone breakthrough bleeding
d) Atrophic endometrium

 Disadvantage: → Prolonged excessive withdrawal bleeding after stopping treatment

4) GnRH analogue (agonists)?

 Action: → Pituitary suppression & downregulation of HPO axis leading to amenorrhea.
 Indications:
a) Used after control of acute bleeding  To induce amenorrhea in chronically ill patients
b) Used as Preoperative preparation to  Endometrial thickness
 Disadvantage: → Expensive & have hypoestrogenic S/E
5) Danazol (Testosterone derivative)
 Indications:
Used as Preoperative preparation to  Endometrial thickness
 Disadvantage: → Expensive & has androgenic (Virilizing) S/E
6) Induction of ovulation: → For anovulatory cases desiring fertility
❹ Surgical ttt
1) Endometrial curettage: (+ Hysteroscopy)
 Indications Not the 1st choice in ttt of DUB but indicated in:
a) Severe uncontrolled bleeding (arrests bleeding in 60% of cases).
b) Bleeding refractory to medical ttt.
c) Women not candidate for hormonal therapy.
2) Hysterectomy:
 Indications Indicated in patient completed her family è:
a) Failed or untolerated medical ttt.
b) Resistant or recurrent DUB.
c) Presence of high risk for endometrial Mg (atypical hyperplasia,…..)
3)Alternative to Hysterectomy:
a) Endometrial ablation
 Indications
a) medical C/I to surgery
b) patients refusing surgery
 Best results when
1) DUB in patient age is >35y'
2) Prettt è gestagens or danazol for 6wks
3) Uterus isn't felt abdominally (<10wks). & Uterine sound is <10cm
4) No endometriosis or adenomyosis.

 Methods
a) Hysteroscopic ablation: → Laser ablation, Endometrial electrocautery & resection or
Rollerball ablation.
b) Thermal balloon ablation
c) Radiofrequency induced thermal ablation.
d) Microwave ablation.
 Results:
a) Amenorrhea: → In 50% of cases.
b) ↓↓ bleeding: → In 20-40% of cases.
c) No improvement: → In 20% of cases.
b) Bilateral uterine artery embolization:
C) Laparoscopic Myolysis
 Def. A/E ttt
PMB ttt of the Cause
Atrophic  Estrogen
See Table Hyperplastic  See Later
Mg  See Later
Menorrhagia Organic
-Simple pelvic congestion
(
-Pathological pelvic congestion
Dysfunctional
-General causes
-CL insufficiency Irreg ripening
-Persistent CL function Irreg shedding
Metrorrhagia Organic
-Obstetric Causes
-Gynecological cause  C T I N
Dysfunctional
See Before

-General causes
Polymenorrhea Organic
-Ovarian congestion
-Pathological pelvic congestion Regulation of Cycle by Cyclic
Dysfunctional E&P
-Short
-Short
Oligomenorrhea 1) Constitutional:
Present since puberty & is ovulatory.
2) During 1st or 2nd y' after
menarche.
3) Before natural menopause.
4) PCOS: → MC cause (88%)
Hypomenorrhea 1) Constitutional:
Present since puberty & is ovulatory.
2) Uterine causes: → Uterine
hypoplasia or intrauterine synechiae.
3) Other pathological causes of 2ry
amenorrhea: → Hypomenorrhea is
commonly seen as a forerunner to
amenorrhea

If ask about Diagnosis of PMB

as AUB but exclude what related to DUB & Concentrate on possibilities of endometrial
sampling (atrophic, hyperplastic & Mg)