dysfunctional uterine bleeding

1. Dysfunctional Uterine Bleeding
Semyatov S., M.D., Ph.d
Department of Obstetrics and Gynecology
PFUR

2. DysfunctionalUterineBleeding(DUB)-
abnormalbleedingcausedbyhormonal
abnormalitiesintheabsenceofpregnancy,
tumor, infection, coagulopathy.
Itisoftenassociatedwithanovulation,
continuosovarianestrogenproductionanda
nonsecretoryendometrium.
Definition:

3. Aetiology:
DUB may result from disorders of:
•The central nervous system;
•Pituitary;
•Ovary;
•From the effects of exogenous or endogenous
steroids;
•Systemic metabolic disorders (hyper,-
hypotheroidism, hepatic dysfunction and
various chronic diseases).

4. •Amenorrhoea.
Signs and Symptoms:
•Continuousuterinebleeding(maylastfor
manyweeks).
•Secondaryanaemia.
•Infertility.

5. Diagnosis
History
A full general examination
Pelvic Exam
Papanicolaou smear test
US exam (endometrium, ovaries)
A diagnostic curettage
Hystero-salpingography
Hysteroscopy
Hematologic studies

6. Differential Diagnosis:
1.Complicationsofpregnancy(abortion,ectopicgestation,
bleedingcorpusluteum,hydatidiformmole,
choriocarcinoma)
2.Organiclesionsof:
-thecorpus:myoma,carcinoma,polyps,hyperplasiaof
endometrium;
-cervix:chroniccervicitis,carcinoma,polyps;
-ovary:functionalovariancystsandfunctioningneoplasms;
-oviducts:carcinoma;
-vagina:carcinoma.

7. Differential Diagnosis:
•blood dyscrasias;
•thrombocytopenia;
•deficient clotting factors;
•endocrinopathies;
•hypertension;
•bleeding from urinary tract and rectum.
Extragenital causes:

8. Treatment: Overall Approach
Recognize Goals:
–Haemostasis
–Restoration of Menstrual Cycle and Fertility
–Regularize and control menstrual bleeding
–Prevention of DUB

9. Treatment:
Depends on:
1. The age of the patient, her fertility and her desire for
children.
2. The degree of anaemia.
3. The response to curettage, which is performed
primarily as an aid to diagnosis, may be
therapeutically beneficial.

10. Continuous OCPs
“Pseudopregnancy” (Kistner)
? Minimizes Retrograde Menstruation
Lower Fertility Rates than Other Medical
Treatments
Choose OCPs with Least Estrogenic
Effects, Maximal Androgenic / Progestin
Effects

11. Progestins
May be as Effective as GnRH-a for Pain Control
MPA 10 mg/day, DP 150 mg Semi-Monthly
May be Taken Long-Term
Relatively Inexpensive
Side-Effects: AUB, Mood Swings, Weight Gain,
Amenorrhoea

12. Danazol
Weak Androgen
Suppresses LH / FSH
200 mg daily for 4-6 months
Causes Endometrial Regression, Atrophy
Expensive
Not recommended in young women
Side-Effects: Weight Gain, Masculinization,
Occ. Permanent Vocal Changes….

13. Oestrogen
Suppresses LH / FSH
Causes Endometrial Regression, Atrophy

14. Clomiphen
Induce ovulation.
50-150 mg daily from 5 to 9 day of
menstrual cycle.
Complications: multiple pregnancy,
hyperstimulation of ovaries.

15. Ethamsylate
Reduces the capillary fragility.
Reduces menorragia by 50%.
500 mg 4 times a day started from 5 day
prior to the anticipated start of the period to
10 days after.

16. Nonsteroidal anti-inflammatory drugs
(NSAID)
Mefenamic acid 500 mg for 5-6 days
controls menorrhagia in 70% cases of
ovulatory cycles.
Side effects: nausea, vomiting, dyspepsia,
diarrhoea, headache, auto-haemolytic
anaemia.

17. Combined oral contraceptive pills
More effective than oestrogen and progesteron
alone.
Reduces blood loss by 50% and eliminates
dysmenorrhoea.
Not expensive

18. Antifibrinolytic agents
Tranexamic acid, epsilon-amino-caproic acid,
1-2 g 4 times a day for 6-7 days during
menstruation -with 50% success.
Side effects: nausea, vomiting, diarrhoea,
headache, visual disturbances, intracranial
thrombosis
Not expensive

19. GnRH
is used as a last drug when others fail.
Depot injection 3.6 mg monthly for 4-6 month
-nearly 100% successful.
Expensive.
Side effects: anti-oestrogenic effect for more
than 6 monhts can cause menopausal
symptoms and osteoporosis.

20. Surgical Treatment
1.D&C-removal of endometrium’s hyperplasia
D&C will be required in young women, if
hormonal therapy failed.
30-40% may be cured by curettage alone.
2. Hysterectomy-in older women with severe
menorrhagia; recurrent irregular uterine
bleeding that is unresponsive to progestin
therapy.
The ovaries should be conserved in women
below the age of 50 yrs.

21. Surgical Treatment
3. Hysteroscopic endometrial ablationby
Nd:YAG laser
electro-cautery
resection (TCRE)
roller-ball electrocoagulation
radio-frequency induced ablation (RITEA) -
thermal destruction of endometrium at 66°C.
85% get cured.
balloon therapy -hot fluid is used which
causes superficial burn.