DYSFUNCTIONAL UTERINE BLEEDING

1. DYSFUNCTIONAL UTERINE BLEEDING Ozgul Muneyyirci-Delale

2. Dysfunctional Uterine Bleeding Dysfunctional uterine bleeding is a diagnosis of exclusion, and will apply in 40-60% of cases of excessive menstrual bleeding.

4. Patterns of Abnormal Bleeding Oligomenorrhea Infrequent, irregular episodes of bleeding, usually occurring at intervals greater than 35 days Polymenorrhea Frequent, but regular episodes of uterine bleeding, usually occurring at intervals of 21 days or less Hypermenorrhea (Menorrhagia) Uterine bleeding, prolonged or excessive occurring at regular intervals (80 ml or more)

5. Metrorrhagia • Uterine bleeding, usually not excessive, occurring at irregular intervals • Menometrorrhagia • Uterine bleeding, usually excessive and prolonged, occurring at frequent and irregular intervals • Hypomenorrhea • Uterine bleeding that is regular but decreased in amount • Intermenstrual bleeding • Uterine bleeding, usually not excessive, occurring between otherwise regular menstrual periods

6. Metrostaxis • Continuous bleeding • Ovulation bleeding (pseudopolymenorrhea) • Spotting or light flow at time of midcycle estrogen nadir • Premenstrual staining • Spotting or light flow up to 7 days prior to menstruation in ovulatory cycle

7. The Major Categories of Dysfunctional Uterine Bleeding • Estrogen breakthrough bleeding • Estrogen withdrawal bleeding • Progestin breakthrough bleeding • Progestin withdrawal bleeding

9. Physiologic Causes of Anovulation • Adolescence • Perimenopause • Lactation • Pregnancy

10. Etiologies of Dysfunctional Uterine Bleeding • Endocrinologic Thyroid Hyperthyroid Hypothyroid Adrenal Hyperplasia Benign/malignant tumor

11. Hypothalamic-pituitary Failure Neoplasia Hyperprolactinemia Diabetes mellitus

12. Ovarian Polycystic ovarian syndrome Functioning ovarian tumors Sertoli-Leydig cell tumor Granulosa or theca cell tumors Hilus cell tumor Chronic pelvic inflammatory disease Endometriosis Premature menopause

13. Gonadal steroids Progesterone Testosterone Adrenal androgens Estrogens Oral contraceptives • Stress Emotional Excessive exercise • Nutritional Marked obesity Malnutrition Anorexia nervosa Malabsorption syndromes

14. Drugs Nonsteroidal hypothalamic depressants Morphine Reserpine Phenothiazine Monoamine oxidase inhibitors Anticholinergic drugs Chlorpromazine

15. Etiologic Classification of Abnormal Uterine Bleeding Associate with Anovulation Central causes Functional and organic disease Traumatic, toxic, and infectious lesions Polycystic Ovary Syndrome Immaturity of the hypothalamo-pituitary axis Psychogenic factors Stress, anxiety, emotional trauma Neurogenic factors Psychotropic drugs, drug addiction Exogenous steroid administration

16. Intermediate causes Chronic illness Metabolic or endocrine disease Nutritional disturbances Peripheral causes Ovarian Functional or inflammatory cysts Functional tumors, especially estrogenic Premature ovarian failure Physiologic Perimenarcheal Perimenopausal

17. Anatomic Factors Causing Nonuterine Bleeding • Cervical lesions Neoplasia, benign and malignant Polyps Carcinoma Cervical eversion Cervicitis Cervical condylomata

18. Vaginal lesions Carcinoma, sarcoma, or adenosis Laceration or trauma Abortion attempts Coital injury Infections Foreign bodies Pessaries Tampons, chronic usage Vaginal adhesions Atrophic vaginitis

19. Bleeding from other sites Urinary tract and urethra Urethral caruncle, infected diverticulum Gastrointestinal tract and rectum • External genitalia Labial varices, condylomata Labial traumas, inflammation Neoplasia, benign and malignant Infections Atrophic conditions

20. Abnormal Uterine Bleeding Associated with Ovulatory Cycles Complications of a past pregnancy Retained secundines, placental polyps Ectopic pregnancy Organic pelvic disease Neoplastic disease (benign or malignant) Sarcoma, carcinoma, or myomata of uterine fundus, Fallopian tube, and/or ovary Infectious diseases Tuberculosis Pelvic inflammatory disease

21. Other Endometriosis Bleeding at ovulation (Kleine Regel) Polymenorrhea due to Follicular shortening Luteal shortening Irregular endometrial shedding Premenstrual staining Prolonged menses Persistent corpus luteum (Halban’s disease) Blood dyscrasias ITP, von Willebrand’s disease Leukemia Iatrogenic Drugs - anticoagulants, progestational agents Intrauterine device

22. Systemic Bleeding Disorders Associated with Abnormal Uterine Bleeding Abnormalities in primary hemostasis Thrombocytopenia Bone marrow failure Immune: AITP, drug related, HIV Nonimmune: TTP, HUS, HELLP Qualitative platelet abnormalities vWD

23. Abnormalities in secondary hemostasis Congenital factor deficiencies Oral anticoagulants Acquired factor VIII inhibitors Hyperfibrinolytic states 2-antiplasmin deficiency ?PAI-1 deficiency Complex coagulopathies DIC Liver disease

25. The Incidence of Endometrial Cancer in 1995 Age 15 – 19 years: 0.1 / 100,000 Age 30 – 34 years: 2.3 / 100,000 Age 35-39 years: 6.1 / 100,000 Age 40 – 49 years: 36.2 / 100,000

26. Medical Option for the Management of DUB • Iron • Antifibrionolytics (transexamic acid) • Cyclo-oxygenase inhibitors • Progestins Cyclic administration Continuous systemic administration Local administration (IUD) Estrogens Estrogens plus progestins Androgens (Danazol) Gonadotropin-releasing hormone agonist and antiagonists

27. Surgery for Dysfunctional Uterine Bleeding • Hysterectomy • Endometrial ablation Hysteroscopic neodymium:yttrium aluminum garnet (Nd:YAG) laser electrocoagulation Non hysteroscopic endometrial ablation radio frequency electrosurgical ablation location hyperthermia cryotherapy microwave other (low-power Nd:YAG laser and photodynamic therapy

28. Follow-up Studies of Endometrial Ablation • 8.5% needed repeat ablation in 3 years • 8.5% had undergone hysterectomy in 3 years According to Chulloprem et al 1996 • 34% of women had hysterectomy in 5 years According to Unger et al 1996

29. Dysfunctional Uterine Bleeding (DUB) Hormonal Therapy 2.5 mg Premarin po TID x 7 days, then OCP’s x 3 weeks or OCP’s QID x 7 days, then q day x 3 weeks or OCP’s TID x 3 days, then BID x 3 days then q day Persistent Bleeding I.V. Premarin 25 mg q 4 hr for 24 hr or until bleeding stops Surgical Evaluation (Hysteroscopy, D&C) If bleeding persists in spite of hormonal therapy will provide tissue for pathologic diagnosis

31. The initial choice of therapy should be estrogen in the following situation: • When bleeding has been heavy for many days and it is likely that the uterine cavity is now lined only by a raw basalis layer. • When the endometrial curet yields minimal tissue.

32. When the patient has been on progestin medication (oral contraceptives, intramuscular progestins) and the endometrial is shallow and atrophic. • When follow-up is uncertain, because estrogen therapy will temporarily stop all categories of dysfunctional bleeding.