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Dysfunctional Uterine Bleeding
Dysfunctional Uterine Bleeding
NORMAL PHYSIOLOGY
UTERUS. The uterus is a hollow, thick-walled, pear-shaped muscular organ in the female reproductive system. During pregnancy the uterus
expands to accommodate a developing embryo.
LAYERS OF THE UTERUS:
o Endometrium. This is the lining of the uterine cavity which consists of the functional endometrium and the basal endometrium from which
the former arises.
o Myometrium. This is the muscular layer of the uterus and is used in labor to deliver a baby.
o Perimetrium. This is the loose surrounding tissue that forms ligaments in order to hold the uterus to the pelvic walls.
During menstruation: thickening of endometrium in preparation for pregnancy→ shedding of the epithelium
After menstruation (menopausal stage) : endometrium stops growing and shedding
Less than 5 tablespoons or up to 80 ml of blood is shed every menstruation.
DIAGNOSTIC TESTS
Human chorionic gonadotropin
o The most common cause of abnormal uterine bleeding during the reproductive years is abnormal pregnancy.
o Rule out threatened abortion, incomplete abortion, and ectopic pregnancy.
Complete blood count
o Document blood loss. Charting the number of menstrual pads used per day or keeping a menstrual calendar is helpful.
o When in doubt, obtain a baseline CBC count for hemoglobin and hematocrit.
o Rule out anemia.
o Obtain a differential with platelet count if hematologic disease is suspected.
Pap smear
o Should be up to date. Cervical cancer still is the most common gynecologic cancer affecting women of reproductive age in the
world population.
Endometrial sampling
o Perform a biopsy to rule out endometrial hyperplasia or cancer in high-risk women >35 years and in younger women at extreme
risk for endometrial hyperplasia/carcinoma. Women with chronic eugonadal anovulation, obesity, hirsutism, diabetes, or chronic
hypertension are at particular risk.
o Most biopsies will confirm the absence of secretory endometrium.
Perform thyroid function tests and prolactin because hyperthyroidism, hypothyroidism, and hyperprolactinemia are associated with
ovulatory dysfunction. Identify and treat these conditions.
MANAGEMENT
1. PHARMACOLOGIC
a. Oral contraceptives
Oral contraceptive pills (OCPs) suppress endometrial development, reestablish predictable bleeding patterns, decrease
menstrual flow, and lower the risk of iron deficiency anemia.
Acute episodes of heavy bleeding suggest an environment of prolonged estrogenic exposure and buildup of the lining.
c. Progestins
Chronic management of DUB requires episodic or continuous exposure to a progestin. In patients without contraindications, this
is best accomplished with an oral contraceptive given the many additional benefits, including decreased dysmenorrhea,
decreased blood loss, ovarian cancer prophylaxis, and decreased androgens.
In patients with a pill contraindication, cyclic progestin for 12 days per month using medroxyprogesterone acetate (10 mg/d) or
norethindrone acetate (2.5-5 mg/d) provides predictable uterine withdrawal bleeding, but not contraception. Cyclic natural
progesterone (200 mg/d) may be used in women susceptible to pregnancy, but may cause more drowsiness and does not
decrease blood loss as much as a progestin.
In some women, including those who are unable to tolerate systemic progestins/progesterone, a progestin secreting IUD may be
considered that controls the endometrium via a local release of levonorgestrel, avoiding systemic levels.
2. SURGICAL
HEALTH EDUCATION
1. The goals of therapy for dysfunctional uterine bleeding (DUB) are to control and prevent recurrent bleeding, correct or treat any
pathology present, and induce ovulation in patients who desire pregnancy. Age, past history, and bleeding amount influence
management.
References:
1. Casablanca Y. Management of dysfunctional uterine bleeding. Obstet Gynecol Clin North Am. Jun 2008
2. Demers C, Derzko C, David M, et al. Gynaecological and obstetric management of women with inherited bleeding disorders. Int J
Gynaecol Obstet. Oct 2006
3. James AH, Kouides PA, Abdul-Kadir R, Edlund M, Federici AB, Halimeh S, et al. Von Willebrand disease and other bleeding disorders in
women: Consensus on diagnosis and management from an international expert panel. Am J Obstet Gynecol. May 28 2009
4. Mohan, S, Page, LM, Higham, JM. Diagnosis of abnormal uterine bleeding. Best Pract Res Clin Obstet Gynaecol 2007