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Dysfunctional Uterine Bleeding

Janice Bernal-Lacuna, MD, FPOGS, FPSREI

Abnormal uterine bleeding

Abnormal uterine bleeding encompasses any


significant deviation from normal frequency,
regularity, heaviness and duration of menstrual
bleeding. It is used to describe all abnormal menstrual
signs and symptoms arising from the uterine corpus

Level of Evidence III


Grade of Recommendation: C

The normal limits for the 4 main clinical


dimensions of menstruation and the menstrual
cycle are regularity, frequency, duration and flow.
AUB may include short or long (but regular)
menstrual cycles, irregular menstrual cycles, heavy
or light menstrual periods, intermenstrual bleeding,
premenarcheal or postmenopausal bleeding, with
or without any recognizable pathology

Abnormal Uterine Bleeding

Normal - 28 +/- 7 days, mean of 4 days duration, not


more than 7 days
Intermenstrual bleeding bleeding of variable
amounts in between regular menses
Menorrhagia or hypermenorrhea prolonged (>7 days
or excessive (>80 ml) bleeding at regular intervals
Metrorrhagia irregular but frequent intervals,
variable amount
Menometrorrhagia prolonged bleeding at irregular
intervals
Polymenorrhea regular intervals < 21 days
Oligomenorrhea regular intervals > 35 days

It is recommended that the term menorrhagia be


discarded and replaced by the term heavy
menstrual bleeding

Level of Evidence: III


Grade of Recommendation: C

Menstrual blood loss (MBL) - < 80 ml

Difficult to measure
Sanitary pad count
Radioisotope labeling of rbcs
Photometric measurement of hematin in sanitary
pads
Estimate, reports of change in duration of blood
flow

Abnormal Uterine Bleeding

Etiology

Organic
Systemic
reproductive

Dysfunctional or endocrinologic

Organic: Systemic

Blood coagulatoion defects von Willebrands,


prothrombin deficiency
Platelet deficiency: leukemia, DIC, sepsis, ITP,
hypersplenism
Hypothyroidism menorrhagia or intermenstrual
bleeding
Cirrhosis of the liver reduced capacity to
metabolize estrogen

Organic: Reproductive
Accidents of pregnancy
Malignancies
Infection endometritis
Uterine abnormalities myoma, polyp,
adenomyosis
Cervical lesions erosions, polyps,
cervicitis
Vagina - Traumatic lesions, foreign
body
IUD
OCPs HRT, TRANQUILIZERS,
PSYCHOTROPIC DRUGS

Dysfunctional Uterine Bleeding

After other causes have been ruled out


Excessive uterine bleeding with no
demonstrable organic cause.
most frequently due to endocrine problem,
particularly anovulation
Types

Ovulatory
anovulatory

DUB

Prostaglandins regulation of
vasoconstiction and vasodilation

PGE2 vasodilatation
PGF2 vasoconstriction
Thromboxane platelet
aggregation
Prostacycline inhibits platelet
aggregation
Increasing PGF2 to PGE2 ratio
from midcycle to menses in normal
ovulatory women with normal
MBL

Dysfunctional Uterine Bleeding

Ovulatory

After adolescent years


Before perimenopausal years
10% of ovulatory women
Reduced uterine synthesis of PGF2 and increase in
synthesis of prostacycline and PGE2
Due to relative deficiency in thromboxane

DUB

Anovulatory

Postmenarcheal
Premenopausal
Continuous estrogen production without corpus
luteum formation and progesterone production
Estrogen proliferation of endometrium
necrosis non-uniform slough off of functionalis
layer excessive bleeding
Not secondary to excessive number of arteries and
abnormal distribution of endometrial glands

DUB

Anovulatory DUB

Progesterone is needed to increase arachidonic acid which


is the precursor of PGF2 Lower PGF2
Estrogen stimulates synthesis of prostaglandins from
arachidonic acid by cyclic peroxidase Normal PGE2
PGF2 binds to receptors in the spiral arteries in the late
secretory phase vasoconstriction control menstrual
flow

Anovulation - low PGF2 excessive bleeding

DUB

Diagnosis

History of bleeding: frequency, duration and


amount of bleeding, change in menstrual pattern
Bleeding calendar
Determine menstrual blood loss
Estimate not reliable
Indirect assessment: hemoglobin, serum iron
Serum ferritin valid indirect measurement of iron in
the bone marrow

Diagnosis

hcG determination
TSH
Tests for coagulation
Test for ovulation: BBT,
luteal phase serum
progesterone, premenstrual
sampling of endometrium

Diagnosis

If ovulatory: rule out


uterine lesions like
submucous myoma,
endometrial polyp and
CA

Transvaginal ultrasound
D and C
Endometrial biopsy
HSG
Hysteroscopy
sonohysterography

Diagnosis

Endometrial biopsy is
recommended to rule
out hyperplasia or
carcinoma

Age 40

Arbitrary cut off


Age specific cancer
registry showed that
endometrial cancer rises
exponentially above 40

Management

Medical preferred treatment especially for


those desirous of future child-bearing
Surgical

Acute bleeding or reduce MBL in subsequent


menstrual cycle

Medical Management

Estrogens

Causes rapid growth of endometrium over the


denuded and raw areas
Conjugated equine estrogen 10 mg/ day in 4
divided doses highest dose at 20 mg/ day
IV CEE
Continue with progestin therapy once bleeding
stops for 7 -10 days to induce withdrawal bleeding
Combination oral contraceptive: 4 tabs 50g of
estrogen with progestin every 24 hours. Continue
tx until 1 week after bleeding stopped

Progestins

Stop endometrial growth


Support and organize the endometrium for organized
slough to the basalis layer after withdrawal
Stimulate arachidonic acid formation increasing
PGF2/PGE2 ratio
Not for acute bleeding
Treatment of choice for anovulation for long-term
treatment after acute episode
May also be tried for women who ovulate

Progestins

Anti-estrogen
Medroxyprogesterone acetate
10mg daily for 10 days each
month
19-nortestosterone affects lipid
levels
Levonorgestrel-releasing IUD

OCP

Can be used to reduce MBL in ovulatory


women with heavy menstrual bleeding
(regardless of association with other pathology)

In women with unexplained menorrhagia,


OCP can decrease bleeding by 40%
May regulate menstruation in anovulatory
DUB

Low-dose Combined Oral


Contraceptives

Amenorrhea and delayed fertility

Rather than causing oligomenorrhea or


amenorrhea, OCs merely mask it by inducing
cyclic withdrawal bleeding
The risk of amenorrhea after OC pill
discontinuation is less than 1% and appears to be
more common in women who had irregular
menses before using OCs

Low-dose Combined Oral


Contraceptives

Effect on height

fear that OC use by adolescents will stunt physical growth.


Oral contraceptives do not cause premature closure of the
epiphyses or inhibit skeletal growth.
By the time menarche occurs, endogenous estrogen
production has already initiated epiphyseal closure, and
this process cannot be altered by exogenous steroids
Therefore, use of OCs after menarche is appropriate.
Bolton GC. Adolescent contraception. Clin Obstet Gynecol 1981

Adolescent anovulation

Progestin treatment is ideal


Immaturity of HPO axis
OCPs may delay maturity (no evidence)

Medical Management

NSAIDs

Prostaglandin synthetase inhibitor


Inhibits cyclic peroxidase which converts arachidonic
acid to prostaglandin
Block synthesis of both prostacyclin and thromboxane
Effective in ovulatory women
May be used in conjunction with other treatment in
anovulatory DUB
Mefenamic Acid, Ibuprofen, Naproxen

Antifibrinolytic agent

Inhibitors of fibrinolysis
Tranexamic Acid may be given as high as 6g/day
in divided doses
Effective for ovulatory DUB
Combined with hormonal tx
Side effects: nausea, dizziness, diarrhea, headache,
abdominal pain, allergy

Medical Management

Androgenic steroid (Danazol)

200mg to 400mg daily for 12 weeks


Side effects: acne, weight gain

Medical Management

GnRH Agonists

Inhibit ovarian steroid production


Use in women with severe MBL and wish to retain
childbearing capacity
Return to pretreatment blood loss when tx is
discontinued

Surgical Management

Dilatation and Curettage

DUB with hypovolemia


Stop acute bleeding in women above 35yo when
incidence of pathologic findings increases
Temporary treatment in anovulation
Not useful in ovulatory menorrhagia

Surgical Management

Endometrial ablation

Laser photovaporization
Transcervical resection of endometrium with electrocautery
(ball-end or loop electrode or thermal balloon)
Failed medical treatment
Severe menorrhagia with medical contraindications against
hysterectomy
Ovulatory DUB not amenable to medical management
Not for those who want to retain childbearing capacity

LASER

ROLLERBALL

LOOP

Microwave Endometrial Ablation

Surgical Management

Hysterectomy

Reserved for women with


other pathologies like
myoma or uterine prolapse
Medical treatment failure
Severe MBL

Long term therapy

After confirming diagnosis of DUB


Progestin for adolescents initially for 3 months
For reproductive age women

Perimenopause

For contraception: OCPs


For infertility: clomiphene citrate
Just DUB: MPA
Low dose OCPs

Chronic ovulatory DUB

Other medical treatment, combination

Dysmenorrhea

Painful cramping sensation in the lower


abdomen just before or during menses
May be associated with sweating, tachycardia,
headaches, nausea, vomiting, diarrhea and
tremulousness

Primary Dysmenorrhea

No obvious
pathology
Effects of
endogenous
prostaglandins
Almost always
occurs in women
younger than 20
Usually as soon as
ovulatory cycles
are established

Secondary
dysmenorrhea

Associated with
pelvic conditions or
pathology in
conjunction with
menses
May occur in women
under 20 but most
often seen in women
over 20

Primary Dysmenorrhea

Reduced

women who had vaginal delivery


OCP use
Smokers

IUD no effect

Pathogenesis

Unknown
Close association with elevated prostaglandin
F2 in the secretory endometrium
Hypercontractility, cramping
Prostaglandin synthetase inhibitor - NSAIDS

treatments

OCPs modulating effect on hypothalamus or


direct reduction of endometrium
Analgesics
TENS transcutaneous electrical nerve
stimulation mode of action is through the
CNS