Dysfunctional uterine Bleeding is type of Abnormal bleeding from the genital tract- Factore, Types, Diagnosis, Treatment in that one type DUB- Define, sign and Symptoms, Diagnosis, Treatment, Management, hormonal Therapy in PPT made By sonal Patel

1. Abnormal
bleeding
from the
genital tract

2. Introduction
Abnormal bleeding from the genital tract is a frequent presentation in gynecologic
outpatient clinics. It is among the common causes of hysterectomy in gynecologic
practice. Menorrhagia is one of the commonest causes for iron deficiency anemia
Characteristics of normal and abnormal menstruation:
Normal Abnormal
Duration of flow 2-7 days average 5 days < 2 or > 7 days
Amount (volume) of flow 30- 40 ml > 80 ml
Cycle ( frequency) 21-35 days < 21 or > 35 days
Any deviation in normal frequency, duration or amount
of menstruation and any bleeding at other times in the
menstrual cycle or a cyclical perimenopausal bleeding
or postmenopausal bleeding should be regarded as
abnormal

3. Mechanism of normal
menstruation: 4 principal factors
involved
1- Vascular theory: increased coiling of spiral
arteries  slowing of blood flow (stasis).
This stasis is followed by V.C. of the
coiled arteries. About 4-24 hour after V.C.,
endometrium starts to shed. The straight
arteries supplying the basal layer of
endometrium does not constrict.

4. 2- Haemostasis: Menstrual blood does not clot and
the endometrium has high fibrinolytic activity
3- Lysosomal theory: withdrawal of ovarian
steroids lead to lysosomal destabilization and
leakage of enzymes that cause breakdown of
endometrial structure, dissolution of ground
subs. and VC
4- Tissue regeneration: reepithelialization starts
from basal glands on 2nd day and proceeds rapidly
to be completed by the 3rd or 4th day.

5. Factors that determine control of menstrual
bleeding:
The self-limited character of menstrual bleeding is attributed to:
1) Haemostatic plug formation: clotting factors seal off
exposed bleeding sites
2) VC
3) Endometrial repair and angiogenesis
Disturbance of any of these mechanisms is likely to
lead to excessive menstrual loss.
Factors affecting blood loss:
• Myometrial tone
• Surface area of endometrium
• Blood coagulability
• Congestion
• Vasodilatation and V.C

6. Definitions of abnormal uterine bleeding (AUB):
Descriptive Term Bleeding pattern
 Menorrhagia or
(hypermenorrhea)
prolonged (> 7 days) / or excessive (>80 ml) uterine
bleeding occurring at regular intervals.
 Metrorrhagia irregular or a cyclic bleeding (intermittent or continuous)
 Menometrorrhagia irregular or a cyclic bleeding and of excessive amount
 Menostaxis regular periods but prolonged duration
 Polymenorrhea or
(Epimenorrhea)
frequent menstruation (<21 days), at regular intervals
 Polymenorrhagia frequent heavy periods
 Intermenstual bleeding
(commonly called "spotting)
uterine bleeding of variable amounts occurring between
regular menstrual periods.
 Breakthrough bleeding spotting or mild bleeding during the intermenstrual period or
during hormonal therapy
 Hypomenorrhea scanty menstruation
 Oligomenorrhea infrequent menstruation (>35 days)

7. Causes of abnormal bleeding from the genital tract:
General causes Local causes Dysfunctional
1- Psychological Bleeding for which no organic
cause can be detected
2- Blood dyscariasis
3- Anemia
4- Hypertension
5- Congestive HF.
6- Hypothyroidism
7- Liver cirrhosis
Before puberty
1- Birth crisis
2- Precocious puberty
3- Non menstrual bleeding
Foreign body(F.B.)
Vaginitis
Neoplasm:
- Feminizing ov.tumour.
- Grape like sarcoma of
the cervix
- Clear cell carcinoma of
the vagina
In childbearing period
1- Pregnancy complication
2- Traumatic: FB ,IUD
3- Inflammatory:
 Erosion
 Endometritis
 T.B
 Salpingitis
4- Neoplastic
Polyps
Fibroid
Adenomyosis
Choriocarcinoma
Carcinoma
Postmenopausal
1- Malignant lesions
Endometrial carcinoma
Sarcoma
Ovarian tumours
Tubal cancer
2- Non malignant lesions
Urethral caruncle
Senile vaginitis
Senile endometritis
F.B: retained
pessary
3- Iatrogenic HRT.

8. Approach to abnormal uterine bleeding
according to the age:
Age group Etiology and characteristics
Pre-menarchal  Always abnormal
 Most common: Trauma (sexual abuse), FB, vulvovaginitis
 Rare: Precocious puberty, neoplasm
Adolescents and
teenagers
 Almost always dysfunctional (anovulation:80% of cycles are
anovulatory in first year after menarche)
 Rarely organic or pregnancy, hematologic, medical illness
 Exclude pregnancy and infection then assume anovulatory
Adult: 20 - 39 years  Commonly benign organic disease or pregnancy
 DUB is common and is due to dysfunction of HPO axis or PCO
Pre-menopausal  Almost always dysfunctional (anovulation:90%)
 Other causes: pregnancy or organic or, hematologic, IUD
 If normal physical examination, anovulatory DUB most likely
Peri-menopausal  Anovulation
 Anatomic (fibroids, adenomyosis, polyps)
 Endometrial hyperplasia
 Endometrial cancer
Post-menopausal  Endometrial carcinoma (5-10 %)
 Atrophic vaginitis
 Endometrial hyperplasia
 cervical cancer
 Endometrial polyps.
 HRT

9. Diagnosis of abnormal uterine bleeding:
History: menstrual pattern, sexual activity, trauma, infection,
systemic disease, medications, stress
Examination:
– General: Hirsutism, acne, galactorrhea, thyroid enlargement,
bruising
– Abdominal: Pelviabdominal swelling, liver, spleen
– Pelvic: infections, lesions, lacerations, polyps, fibroids
Investigation:
– CBC, B-HCG, cervical cultures, PAP smear
– TSH, prolactin, estradiol, progesterone, D-HEAS, testosterone,
fasting insulin
– Transvaginal ultrasound to detect any pelvic pathology and to assess
the thickness of theendometrium especially in postmenopausal
women ( < 5 mm, endometrial cancer is unlikely and > 5 mm require
further evaluation)
– Endometrial biopsy, HSG, hysteroscopy

10. Treatment of abnormal uterine bleeding: when
an organic cause is detected treatment is directed to
it, eg. :
• Fibroids: GnRH agonists, myomectomy or
hysterectomy
• Adenomyosis: Hysterectomy or medical
(progestins, GnRH analogues)
• Endometrial polyps: currettage
• Endometrial carcinoma: TAH + BSO +/- radiation
N.B. When an organic cause can not be detected, it is
considered (DUB)
•

11. Dysfunctional uterine bleeding (DUB(
Definition: abnormal uterine bleeding in absence of organic cause.
Incidence: 60 % of abnormal uterine bleeding
Classification & pathology:
A) Anovulatory DUB: unpredictable
cycle, frequent spotting, infrequent menorrhagia
B) Ovulatory DUB: regular length, PMS, dysmenorrhea,
mittelschmirz, biphasic temperature, cervical mucous change
Endocrine abnormality Endometrium
Anovulatory (90%) - Insufficient follicles
- Persistent follicles
- Inadequate proliferative or atrophic
- Proliferative or hyperplastic
Ovulatory (10%) - Short proliferative phase
- Long proliferative phase
- Insufficient C. luteum
leading to short luteal phase
- Persistent C luteum leading to
long luteal phase
- Normal
- Normal
- Irregular or deficient secretory
- Irregular shedding

12. Etiology of DUB:
A) Abnormality of the endocrine
(hypothalamo- pituitary ovarian axis)
B) Abnormality of the paracrine control of
endometrial spiral arterioles:
1. Abnormal vascular morphology
2. Prostaglandins: the most important vasoactive substance.
The level of PGE2  relative to PG F2
3. Other vasoactive substance: leukotriens, cytokines and
endothelins.
4. Abnormalities of local coagulation cascade: increased
local fibrinolysis due to increased tissue plasminogen
activator (TPA) which is a fibrinolytic enzyme.
5. Nitric oxide (NO): potent VD and inhibitory of platelet
aggregation.

13. (DUB cont.)
Clinical presentation:
I) According to the age group:
a) Adolescent and teenage: usually dysfunctional, rarely
organic or malignancy. It is due to immaturity of
hypothalamus and inadequate +ve feed back. 50% resolve in
2years and treatment is always conservative.
b) Adult (20 - 39 years): commonly benign organic disease
but also DUB is common and is due to dysfunction of HPO
axis or PCO
c) Perimenopausal: commonly dysfunctional due to incipient
ovarian failure but also organic disease is common with
increased frequency of cancer. Hysterectomy is often indicated

14. (DUB cont.)
II) According to bleeding pattern:
a) Regular cyclic bleeding: due to benign
organic cause but also, DUB is common
(ovulatory). It is rarely due to malignancy
b) Irregular or acyclic: due to organic disease
especially cancer endometrium and cervix. Also,
DUB is common (anovulatory).
c) Intermenstrual bleeding: may be associated
with polypi or submucus fibroid. If regular
cyclic, it is often dysfunctional due to fall of
estrogen following ovulation

15. Diagnosis of DUB:
History:
• Age:
- < 20 years ( almost always dysfunctional)
- 20-40 years ( probably organic or pregnancy complication)
- > 40 years (usually dysfunctional but exclude malignancy )
- After menopause ( may be organic cause which is usually cancer)
• Menstrual history:
- Amount: assess blood loss
- Rhythm: cyclic  usually ovulatory A cyclic  usually
anovulatory
• Associated symptoms:
- With colicky pain (pregnancy complication – organic uterine
disease e.g. fibroid polyp.)
- Without pain ( DUB - extrauterine lesion)

16. Diagnosis of DUB (cont.)
• History of bleeding tendency, hormonal therapy or IUD
Examination:
A) General examination:
- Weight - Anemia - B.P.
- Signs of bleeding tendency - Signs of liver disease
- Stigmata of endocrine disorder
( hirsutism - galactorrhea - thyroid abnormality)
B) Local examination:
- Detect the source of bleeding
- Detect organic pathology
Investigations: include the following
1] Assessment of blood loss:
2] U/S, saline infusion sonography and MRI: to detect pelvic masses or
possible pregnancy complications.
3] HSG ( Hysterography): reveal intrauterine pathology

17. Diagnosis of DUB (cont.)
4] Biochemical and hematological investigations:
- Estimation of FSH & LH or Progesterone on day 21
- Thyroid function test - Coagulation profile
- Blood picture - Liver function
- Renal function
5] Endometrial biopsy (D&C):
Advantages:
1- Exclude intrauterine disease
2- Provide endometrial sample
3- Arrest bleeding if severe
Disadvantages: may miss intrauterine focal lesion
6] Hysteroscopy
Advantage of hysteroscopy over D & C:
1- No missed pathology
2- Diagnose endometrial atrophy
3- Directed biopsy of choice

18. Management of DUB:
First: exclude an organic cause
Second: diagnose the underlying abnormality
Third: individualize therapy according to age, parity, and wishes of
pregnancy, severity of hemorrhage and the endometrial pathology
Management strategy:
<20years 20-40years >40years
Medical Always Firstresortafterendometrialbiopsy Temporary&if surgeryisrefusedor
imminentmenopause&afterD&C
Surgical Never Seldom,onlyifmedicaltreatmentfail Firstresortifbleeding isrecurrent

19. (DUB cont.)
Treatment Goals:
• Alleviation of any acute bleeding
• Prevention of future noncyclic bleeding
• Decrease in the patient’s future risk of long-term health problems
secondary to anovulation
• Improvement in the patient’s quality of life
I) Medical treatment: is the 1st option especially in patients desiring
future childbearing
1] Iron therapy
2] Non steroidal anti-inflammatory drugs (NSAIDs):
– Tablets consistently taken during menses
– Mefenamic acid 500 mg tds, Naproxyn 250mg tds , Ibuprofen 400mg 4 times
daily
– Dysmenorrhea and other menstrual symptoms may improve
– Menstrual blood loss (MBL) reduction 30%
– Minor side-effects

20. Medical treatment of DUB (cont)
3] Antifibrinolytic drugs: (tranexamic acid)
- Taken first 4 days of cycle
- Tranexamic acid 1-15 g times daily
- MBL reduction 50%
- MBL in association with IUCD 50% reduced
- Complications rare
4] Ethamesylate: (Epsilon aminocaproic acid)
5] Diosmine:
- It mobilizes venous stasis by increasing tone (phelebotonic)
- It restores the integrity of endothelial lining  capillary
permeability
- It improves lymphatic drainage
- It is effective in 70-90% of cases

21. 6] Hormonal therapy of DUB:
a) Progestins:
• Oral progestogens:
- Anovulatory DUB ( Short regimen - 10 days, Long regimen - 21
days)
- 5-10 mg daily MPA or Norethisterone 10-30 mg/day
- MBL reduction 20-40%
- Minor side-effects
• Intramuscular Progestogen:
- Depot medroxy progesterone acetate
- Produces amenorrhea or slight bleeding
- Sometimes prolonged bleeding or spotting
- Unpredictable delay in return of fertility
• Levonorgestrel (LNG) releasing IUD:
- 20 µg daily over 5 year period
- MBL reduction: 50% first month, 85% third month
- Patients ovulate
-  in E2 and P receptors  endometrial atrophy

22. Hormonal therapy of DUB (cont.)
b) Estrogens:
- Given in acute heavy bleeding
- Conjugated oestrogen – 25 mg IV 4 hourly until bleeding stops (not >6 doses)
c) Estrogen + Progestin ( combined monophasic O.Cs):
- Effective if the bleeding is not severe
- Minor side-effects
- MBL reduction 50%
- 70-80% patients benefit
- Few minor side-effects
d) Androgens: Danazol- Gestrinone
- Taken continuously - Dosage: Danazol 200mg daily; Gestrinone 25 mg twice weekly
- MBL reduction 90% over 3 months - Expensive
- Troublesome side-effects (Hypo-estrogenic & androgenic, muscle cramps, hot flushes)
e) Gonadotropin releasing hormone analogues (Gn Rha):
- Causes amenorrhea - Used in special circumstances
- Expensive
- Troublesome side-effects (hypo-estrogenic, bone loss, hot flushes, vaginal dryness)

23. II) Surgical therapy of DUB: if medical therapy for
3-6 months failed
A) Dilatation and curettage:
• Arrest of the bleeding, if it is severe or persistent,
particularly hyperplastic endometrium.
• Curettage is essentially a diagnostic & not a
therapeutic procedure.
B) Endometrial ablation techniques:
• Electrocautery, laser, cryoablation, or thermoablation
• Become an alternative to hysterectomy for treatment
of DUB.
• Any ablation technique should adequately destroy the
basal layer of endometrium.
• Most women will not experience long term
amenorrhea after treatment

24. Surgical therapy of DUB (cont.)
C) Hysterectomy: is the final step
Advantages: 1- complete cure
2- Avoid medical treatment
3- Remove any missed pathology
Disadvantages:
1- Major operative procedure
2- Long hospitalization
3- Significant morbidity
4- Long term sequel (pain - urinary
dysfunction - sexual dysfunction)

25. III) Radiotherapy for treatment of DUB:
Has little place in treatment of
DUB. Used in patients in need for
hysterectomy but unfit for
operation. External irradiation of
the ovaries is performed resulting
in amenorrhea in 95% of cases.