Dr.

Kusuma Andriana, SpOG

G A N G G U A N M EN S TR U A S I

O verview ofPresentation
1.

Abnormal uterine bleeding (DUB) and

dysfunctional uterine bleeding (DUB)

2.

Normal menstrual cycle

3.

Pathophysiology of DUB

4.

Algorithms for the evaluation of DUB

5.

Diagnostic evaluation techniques in DUB

6.

Medical treatments for DUB

7.

Surgical treatments for DUB

Abnormal uterine bleeding (AUB)

Abnormal uterine bleeding may involve any
disturbance of regularity, frequency, duration or
volume menstrual flow, and the cause maybe
physiological, pathological, or pharmacological
Fraser and Sungertekin, 2000

Causes of abnormal uterine bleeding

Excessive m enstrualbleeding (Causa)

Uterine

Fibroids
Endometrial polyps
Endometriosis
Pelvic inflammatory
disease

Systemic
Coagulation disorders
Von Willebrands disease
Idiopathic
thrombocytopenic purpura
FactorV,VII, X, and XI
deficiency
Hypothyroidism

Iatrogenic
Progestogen-only

contraceptives
Intrauterine devices
Anticoagulants

Dysfunctional uterine
bleeding ( DUB )

Abnormal uterine bleeding without an organic

cause
Megan S Walden
JAAPA, vol 19 February 2006

Epidemiology

DUB affects approximately 5% of menstruating

women

Comprising about 80% of cases of menorrhagia

20% affected individuals are in the adolescent

age group

50% affected individuals are aged 40-50 years

JAAPA, vol 19, February 2006

Perdarahan Uterus D isfungsional(PUD )

Definisi
Perdarahan uterus abnormal yang terjadi

tanpa kelainan pada saluran reproduksi,

penyakit medis tertentu atau kehamilan.

Diagnosis perdarahan uterus

disfungsional (PUD) ditegakkan per

ekslusionam.
Manifestasi klinis dapat berupa
perdarahan akut dan banyak, perdarahan
ireguler, menoragia dan perdarahan
akibat penggunaan kontrasepsi

Pola perdarahan uterus

disfungsional
A. Perdarahan uterus abnormal yang
terjadi tanpa kelainan pada saluran
reproduksi,penyakit medis tertentu
atau kehamilan. Diagnosis PUD
ditegakkan perekslusionam.
B. Perdarahan akut dan banyak
merupakan perdarahan menstruasi
dengan jumlah darah haid > 1
tampon per jam dan atau disertai
dengan gangguan hipovolemik.

Pola perdarahan uterus

disfungsionalcont..
C. Perdarahan ireguler meliputi :
metroragia, menometroragia,

oligomenore,
perdarahan haid yang lama (> 12 hari),
perdarahan antara 2 siklus haid
Pola perdarahan lain yang ireguler.
Pasien usia perimenars yang mengalami
gangguanhaid tidak dimasukkan dalam
kelompok ini karena kelainan ini terjadi
akibat belum matangnya poros
hipothalamus hipofisis ovarium.

Pola perdarahan uterus

disfungsional
D. Menoragia merupakan perdarahan
menstruasi
dengan jumlah darah haid > 80 cc atau
lamanya > 7 hari pada siklus yang teratur.
Bila perdarahannya terjadi > 12 hari harus

dipertimbangkan termasuk dalam

perdarahan ireguler

E. Perdarahan karena efek samping

kontrasepsi
Pengguna PKK, suntikan depo medroksi

progesteron asetat (DMPA) proses

perdarahan sela, Infeksi chlamydia atau

Initiation of menstrual bleeding

Corpus luteum demise
Decrease estrogen and
progesterone
Vasoconstriction
Leukocyte infiltration

Follicular phase: day

1-14, menses: day 1-5
Ovulatory phase: day
14-16
Luteal phase: day 1628

Endometrial lysosome

Progesterone withdrawal
Phospolipase A2

Endothelin-1

MMP-1,MMP-3,MMP-9

PGF2

Arachidonic acid
PGI2

PGE2

Reduced blood flow

COX

TXA2

TNF-, IL-8
macrophages, PMN, lymphocytes

MMPs

Endometrial ischemia
Vascular permeability

Destruction of ECM
TXA2

PGE2 + PGI2

coagulation

fibrinolytic

VEGF + Fibroblast growth factor + Estradiol

Epithelial repair

Vasodilatation

Heparin
like activity

Gynaecological bleeding

Estrogen withdrawal

Estrogen breakthrough

Progesterone withdrawal

Progesterone breakthrough

Estrogen withdrawal

Sudden decreaase in E
level

After oophorectomy

After withdrawal of
exogenous estrogens

Midcycle (just before

ovulation

Estrogen breakthrough bleeding

E >> prolif endomet >>

P tak cukup endomet luruh

Constant low dosesprolonged, intermittent

spotting

Sustained high levels of Eprolonged periods of

amenorrhoea followed by
profuse bleeding

Progesterone breakthrough bleeding

P >> rasio P : E me ok KB mini
pil (only P)

Atrofi endometrium
Ulserasi ok E <<

Irregular bleeding

Bleeding Patterns
No
1

Definition
Normal

Description
The normal interval is 21 to 35 days.
The normal duration of bleeding is 1 to
7 days. The amount should be less
than 1 pad or tampon per 3-hour
period

Severe acute
bleeding

Bleeding that requires more than one

pad / tampon per hour or vital sign
indicating hypovolemia

Irregular
bleeding

Includes metrorrhagia,
menometrorrhagia, oligomenorrhea,
prolonged bleeding, intermenstrual
bleeding or other irregular patterns

Menorrhagia

Heavy but regular cyclic bleeding plus

> 7 days of bleeding or clots.
Prolonged bleeding > 12 days should

M enstrualcycle irregularities:
1.abnorm alfrequency
Kaltenbach chart:
Normal cycle
Abnormal
frequency:
oligomenorrhea
Abnormal
frequency:
polymenorrhea

Duration: 28 d 5
Amount: 3-5 pads
or tampons
(35 mL)
Duration > 35 days

Duration < 22 days

Menstrual cycle irregularities:

2. abnormal amount of duration
Normal cycle

Duration: 28 d 5
Amount: 3-5 pads
or tampons

Hypomenorrhea

Amount < 2 per day

Hypermenorrhea

Amount > 5 per day

Menorhagia

Duration 7-14 days

M enstrualcycle irregularities:
3.others
Spotting: bleeding unrelated to

menses
Ovulatory bleeding
Metrorrhagia: > 14 days, no clear

cycle
Amenorrhea: absence of bleeding for

more than 3 months

Patofi
siologiPU D
Siklus berovulasi
Perdarahan teratur dan banyak terutama pada tiga hari

pertama siklus haid.

Penyebabnya adalah terganggunya mekanisme
hemostasis lokal di endometrium.

Siklus tidak berovulasi

Perdarahan tidak teratur dan siklus haid memanjang

disebabkan gangguan pada poros hipothalamushipofisis-ovarium.

Adanya siklus tidak berovulasi menyebabkan efek
estrogen tidak terlawan (unopposed estrogen) terhadap
endometrium Proliferasi endometrium berlebihan
tidak mendapat aliran darah yang adekuat iskemia
dilepaskan dari stratum basal.

Patofi
siologiPU D cont..
Efek samping penggunaan

kontrasepsi

Dosis estrogen yang rendah dalam

kandungan pil kontrasepsi kombinasi

(PKK) menyebabkan integritas
endometrium tidak mampu
dipertahankan.
Progestin menyebabkan endometrium
mengalami atrofi Kedua kondisi ini
dapat menyebabkan perdarahan bercak.
Sedangkan pada pengguna alat
kontrasepsi dalam rahim (AKDR)
kebanyakan perdarahan terjadi karena

Anovulatory DUB
Unopposed estrogen

Excessive endometrial proliferation

Increase vascular fragility
Reducing vascular tone

Stimulates stromal VEGF

>> PGE2

Increase endometrial NO

Estrogen breakthrough bleeding

Ovulatory DUB

AUB without any attributable anatomic,

organic, or systemic cause but associated with
regular ovulation

Regular progesterone withdrawal menses

every 24-35 days but excessive blood loss

Loss of local endometrial hemostasis

Ratio of PGE2 : PGF2

Level of PGI2

Fibrinolytic activity

History taking

Physical exam

Lab investigation

Uterine cavity assessment

Bleeding pattern
Associated symptoms
Pregnancy
Medication
Systemic diseases
PE
Pelvic examination
CBC
Coagulation tests
Thyroid function tests
Pregnancy test
USG/TVS (Recom A)
EB, D&C
Hysteroscopy (Recom B)

Diagnostic Techniques in AUB

Endometrial biopsy

Transvaginal ultrasonography
(TVS)

Saline Infusion Sonography (SIS)

Hysteroscopy

Endometrial Biopsy

Emergency

High risk

If no response with medical

(12 24 hours)
Recommendation B

- Obese
- > 35 yo
- DM
- Hypertension
- Nulliparous
- 2 years suffer from irregular bleeding

Medical Treatment of
DUB

Iron

Progestins : Estradiol estron

Estrogen memicu vasospasme kapiler dg cara

mempengaruhi kadar fibrinogen, faktor IV, faktor X ,
proses agregasi trombosit & permeabilitas pembuluh
kapiler

Estrogens + progestins (OCs)

Antifibrinolytics agen anti fibrinolitik

NSAID Cyclooxygenase inhibitors me [PG] di

endometrium

Androgens (Danazol 200 mg/hr ) menekan prod

estradiol dari ovarium

GnRH agonists down regulation recep GnRH di

M edicaltreatm ent options for

m enorrhagia

Antifibrinolytics
Non-hormonal treatment
options foracid
tranexamic
menorrhagia
Reducers of
Non-steroidal anti

inflammatory drugs
mefenamic acid
meclofenamic acid
naproxen
ibuprofen
flurbiprofen
diclofenac

capillary fragility
etamsylate
Stimulators of
endogenous
hemostasis
desmopressin
(DDAVP)

M edicaltreatm ent options for

progesteronem enorrhagia
Oral progestogens
norethisterone
medroxyprogestero

ne acetate
dydrogestrone
Intrauterine
progestogens:
levonorgestrelreleasing
intrauterine device
(Mirena)

releasing
intrauterine device
(Progestasert)
Combined
estrogen/progestog
ens
oral contraceptives
Other
danazol
gestrinone
gonadotropin
releasing hormone
analogs

Hormonal treatment options for menorrhagia

Surgical Treatment of DUB

Hysterectomy

Hysteroscopic endometrial
ablation

Non hysteroscopic endometrial

ablation

ThankYou

Wassalaamu `alaikum Wr. Wb