Dysfunctional Uterine Bleeding

Ding Ding M.D., Ph.D.

Department of Obstetrics & Gynecology
Ob/Gyn Hospital
Fudan Unoversity
 Introduction
DUB is defined as ABNORMAL uterine bleeding
absence of demonstrable structural or
organic pathology.
It is usually with hormonal disturbances due to
hypothalamic-pituitary-ovarian axis (HPOA) dysregulation.
Diagnosis must be made by exclusion.
DUB occurs most often shortly after menarche and
at the end of the reproductive years.
•20% of cases are adolescents
•50% of cases in perimenopausal years
Introduction

 Heavy menses, prolonged menses, or

frequent irregular bleeding are the most
common complaints.
 Up to 20% of women will experience
irregular cycles in their lifetimes.
 Normal Menstrual Cycle
 Follicular phase
14 days (varies)
• Dominant follicle develop with greatest number of
granulosa cells and FSH receptors
 Ovulation
• 30-36 hours after LH surge
 Luteal phase
• LH surge to menses
• Persists 14 days (constant)
 Menses
Involution of corpus luteum
Decrease progesterone and estrogen
20-60 cc of dark blood containing endometrial tissue
Normal Menstrual Cycle
Pathophysiology
 Two types: anovulatory and ovulatory

 Most women with DUB do not ovulate (70-80%).

• In theses women, there is continuous E2 production
without corpus luteum formation and progesterone
production.
• Adolescent: 20%
• Perimenopausal years: 50%

 Ovulatory DUB occurs most commonly at the reproductive

age.
• 20-30% of DUB
• Incidence in these patients may be as high as 10%
 Anovulatory DUB
Etiology
 Psychological stress
 Body weight (obesity, anorexia, or a rapid change)
 Endocrine:
In perimenopausal women, the mean length of the cycle is
shorter compared to younger women.
 Shortened follicular phase

 Diminished capacity of follicles to secrete Estradiol 

 Neoplasm,
 Drugs
 It may be otherwise idiopathic.
 Endometrial Hyperplasia
 Chronic anovulatory, persistently elevated
estrogen levels, uninterrupted by progesterone
 Proliferative Disorder: earliest pathology
 Simple Hyperplasia: 1% will develop EM cancer
 Complex Hyperplasia: 3%
 Atypical Hyperplasia: precarcinoma
15% will develop EM cancer
In fact, 17-51% cases are associated with EM cancer
Ovulatory DUB

Luteal phase insufficiency

• Shortened menstrual interval(24-26d)
• Not easy to conceive baby
• Recurrent first-trimester abortion
Irregular shedding of endometrium
• Prolonged involution of corpus luteum
• 5-6th day during menses of the
menstrual cycle, the secretory phase
endometrium was still seen
 Organic
Differential Diagnosis
• Reproductive tract cancer
• Endometrial cancer
• Cervical cancer
• Less frequently:
 vaginal, vulvar, fallopian tube cancers
 estrogen secreting ovarian tumors
• granulosa-theca cell tumors
• Systemic Disease: Coagulation disorders, liver
• Ectopic pregnancy, abortion or trophoblastic disease
• Pelvic infections
“You must exclude all organic causes first!”
 Evaluation
 History
• Onset, frequency, duration, cyclic vs.acyclic, severity
• Pain, change from menstrual pattern (calendar)
• Age, parity, marital status, sexual hx, contraception
• medications, pregnancies
• symptoms of pregnancy and reproductive tract
disease
 Physical Exam
• pelvic exam
• pap smear
 E
Diagnosis E+P

 History
 BBT
 Cervical mucus:
no typical fernlike crystal
 Sexual hormones evaluation
 Ultrasound
 D&C: endometrium biopsy
 Hysteroscopy
Treatment Goals of DUB

Adolescent
• Control bleeding
• Regulate menstrual cycle
• Induce ovulation
Reproductive age
• Stimulate follicle development
• Promote corpus luteum function
• Induce ovulation
Perimenopausal
• Control bleeding, reduce volume
• Regulate menstrual cycle
• Prevent endometrial cancer
 Treatment of DUB

 Medical management before Surgical

• effective methods include:
 estrogens, progestins, or both
 antifibrinolytic agents
 danazol
 GnRH agonists
 Treatment of DUB
 Acute bleeding
• Estrogen therapy
 High dose estrogens: adolescent
 Oral conjugated estrogens
• 10mg a day in four divided doses
• treat for 21 to 25 days
• medroxyprogesterone acetate, 10 mg per day for the
last 7 days of the treatment
• if bleeding not controlled, consider organic cause
OR
• 25 mg IV every 4 to 12 hours for 24 hours, then
switch to oral treatment as above.
• Bleeding usually diminishes within 24 hours
 Treatment of DUB
 Recurrent bleeding episodes
• Sequential therapy: Estrodial+Progesterone
estrodial 1.25mg/d*21d , last 10d add MPA 10mg/d
• combination OCP’s
 one tablet per day for 21 days
• intermittent progesterone therapy
 medroxyprogesterone acetate, 10mg per day, for the first
10 days of each month
 higher doses and longer therapy my be tried if no initial
response
 prolonged use of high doses is associated with fatigue,
mood swings, weight gain, lipid changes
 Treatment of DUB
 Recurrent bleeding episodes
(continued)
• Progesterone releasing IUD (Mirena)
 avoids side effects
 must be reinserted annually
 Levonorgestrel IUD
• 80% reduction of blood loss at 3 months
• 100% reduction at 1 year
• found to be superior to antifibrinolytic agents and
prostaglandin synthetase inhibitors
 Treatment of DUB
 Immature hypothalamic-pituitary axis
• progestin therapy by itself for 10 days
every month or every other month until full
maturity of the axis provides effective
therapy.
 Older perimenopausal women
• cyclic progestin therapy
 prevents development of endometrial
hyperplasia
• low dose OCP’s
 healthy non-smokers, free of vascular disease
 Treatment of DUB
 Other options
• inhibitors of fibrinolysis
 EACA (epsilon-aminocaproic acid)
 AMCA (tranexamic acid)
 PABA (para-aminomethybenzoic acid)
• use limited by side effects
 nausea, dizziness
 diarrhea, headaches
 abdominal pain
 allergic manifestations
 Treatment of DUB

 Danazol: perimenopausal women

• androgenic steroid
 200mg and 400 mg daily doses for 12 weeks
studied
 200mg dose as effective as 400 mg
 androgenic side effects: weight gain, acne
• side effects minimized with 200mg dose
 100 mg not effective, expensive
 Treatment of DUB

 GnRH agonists
• treatment results in medical menopause
• blood loss returns to pretreatment levels when
discontinued
• treatment usually reserved for women with
ovulatory DUB that fail other medical therapy and
desire future fertility
• 3 months later, use add back therapy to prevent
bone loss secondary to marked hypoestrogenism
 Treatment of DUB

 Surgical Treatment
• Dilation and Curettage
 quickest way to stop bleeding in patients who
are hypovolemic
 appropriate in older women (>35)to exclude
malignancy but is inferior to hysteroscopy
 follow with medroxyprogesterone acetate or
OCP’s to prevent recurrence
 Treatment of DUB
 Surgical Treatment:
 Hysteroscopy:
Endometrial Biopsy & Ablation

• Laser ablation

• Loop electrode resection

• Roller electrode ablation

 Treatment of DUB

 Surgical Treatment
• Hysterectomy
• Indication:
elder and no demands on bearing babies
atypical hyperplasia or EM cancer
 Case presentation
1
 15 y.o. girl
 menarche
 13 y.o.
 Heavy bleeding for 10 days
 Hb 105g/L, WBC & plt normal
Following examination?
Diagnosis?
Management?
 Case presentation
2
 50 y.o. woman, 1-0-1-1
 Heavy bleeding for 8 days
 Urine HCG(-)
 Ultrasound: endometrium 12mm, ovaries(-)
 TCT: normal (two months ago)
Following examination?
Diagnosis?
Management?