dysfunctional uterine bleeding uterine bleeding seddah moya, m.d. objectives ......
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Dysfunctional Uterine Bleeding
Seddah Moya, M.D.
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Objectives
Review normal menses
Review diagnosis and evaluation of DUB
Review treatment and management of DUB
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Background
Menorrhagia is a very common problem
– 10-35% of women complain of heavy menses
– 5% of women seek medical care annually for
excessive menstrual bleeding
– 50% of cases have no organic pathology
– Iron Deficiency Anemia develops in 21-67% of
cases
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Background
Impact on quality of life
– Absenteeism for work, school, sports
– Sexual activity
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Normal Menses
Mean interval: 28 days
– +/- 7 days
Mean duration of flow: 4 days
– +/- 2 days
<60 cc blood loss
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Normal Menses
Menstrual cycle length peaks 25-30 years
Cycle length most stable between age 20-40
Menstrual cycle most irregular 2 years after
menarche and 3 years prior to menopause
– Anovulation common
– Menstrual cycles can be shortened or prolonged
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Normal Menses – Physiology
Two phases of the cycle
– Follicular
Starts with onset of menses
Ends with LH surge
– Luteal
Starts with LH surge
Ends with onset of next menses
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Early Follicular Phase
Ovary is hormonally inactive
– Low serum estradiol and progesterone
concentrations
– Increase in GnRH pulse frequency
– Increase in FSH
– Slowing of LH pulses
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Early Follicular Phase
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Mid-Follicular Phase
FSH stimulates folliculogenesis and estradiol
– Growth of cohort of follicles
Increase in estradiol
– Negative feedback – suppresses FSH/LH
Dominant follicle is selected
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Normal Menses – Physiology
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Late Follicular Phase
Estradiol and inhibin A increase
– FSH and LH fall
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Luteal Phase
LH surge
– Switch from negative feedback from ovarian
hormones to positive feedback
Oocyte released from follicle 36 hours after
LH surge
Granulosa cells luteinize and produce
progesterone
– Acts to slow LH
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Late Luteal Phase
Corpus luteum produces progesterone
– Slows LH pulses
Decrease in LH
– Decrease in estradiol and progesterone
production
Loss of endometrial blood supply
Endometrial sloughing
Onset of menses in approximately 14 days
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Late Luteal Phase
With falling corpus luteum production
– Hypothylamic-pituitary axis released from
negative feedback
– FSH levels rise
– The cycle begins again
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Normal Menses – Physiology
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Abnormal Uterine Bleeding
Oligomenorrhea
– Cycles > 35 days-6 months
Amenorrhea
– No menses > 6 months
Excessive flow
Prolonged duration of flow
Intermenstrual bleeding
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Organic Causes of AUB
Systemic Disease
– Von Willebrand
– Prothrombin deficiency
– Thyroid dysfunction
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Von Willebrand Disease
The most common inherited bleeding
disorder
5-15% of women with menorrhagia
20% Women presenting with menorrhagia
will have an underlying bleeding disorder
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Von Willebrand Disease
Directed questions
If positive screening history then
– CBC
– PT, PTT
– Fibrinogen
If positive prolonged PTT, referral to
hematologist for further VWD testing
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Thyroid Dysfunction
Hyperthyroidism
– Amenorrhea, oligomenorrhea
Hypothyroidism
– Menorrhagia and intermenstrual bleeding
– Incidence in patients with menorrhagia is 0.3% to
2.5%
– Menorrhagia disappears 3-6 months after
treatment is started
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Organic Causes of AUB
Pregnancy Complications
– Threatened ab
– Incomplete or misses ab
– Ectopic pregnancy
Malignancy of genital tract
– Endometrial
– Cervix
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Organic Causes of AUB
Anatomic uterine abnormalities
– Submucous myomas
– Endometrial polyp
– Adenomyosis
Infection of upper genital tract
Foreign body
– IUD
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Organic Causes of AUB
Cervix
– Cervicitis
– Erosions
– Polyps
Iatrogenic
– Anticoagulants
– Hormonal treatment
– Psychotropic drugs
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Cervical Polyp
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Dysfunctional Uterine Bleeding
Diagnosed after organic, systemic, and
iatrogenic causes have been ruled out
Subdivided into ovulatory and anovulatory
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Diagnosis – History
Menarche?
When did AUB start?
Family history?
Medicines?
Bruising and bleeding tendencies?
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Diagnosis – History
Menses – Duration
– Frequency
– Flow
Quantify Flow – How often do you change tampon/pad?
– How many pads/tampons used in a single menstrual period?
– Do you ever need to change pad/tampon at night?
– Do you pass clot? How big?
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Evaluation – Physical Exam
Signs of anemia
Check skin
Visualize cervix and external genitalia
Bimanual exam
– Size, contour, and tenderness of uterus
– Adnexal masses or tenderness
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Diagnosis – Lab work
Hemoglobin
Iron studies
Ferritin
HCG
TSH
Coagulation studies *
Day 21 progesterone *
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Diagnosis
Rule out presence of uterine lesion
– TVUS
– Sonohysterogram
– Hysteroscopy
– D and C
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Sonohysterogram
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Hysteroscopy
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Evaluation
Sampling of endometrium
– Done to exclude neoplasia, hyperplasia, endometritis
– Should be done on all women > 35 with AUB
– Should be done < 35 if risk factors for endometrial cancer
Personal history of breast, ovarian, or endometrial cancer
Tamoxifen use
Chronic anovulation
Obesity
Estrogen therapy
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Management
Considerations
– Desire for fertility and contraception
– Acute treatment or long term
– Medical comorbidities
– Age – close to menopause?
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Medical Therapy
Combined OCPs
– Used to treat ovulatory and anovulatory DUB
– Reduce blood flow
– Regulate cycles
– Provide contraception
– Prevent hyperplasia
– Treat dysmenorrhea
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Medical Therapy
Estrogens
– High dose IV estrogen beneficial in acute uterine
bleeding
– Promotes rapid regrowth of endometrium
– Results in cessation of bleeding within 5 hours in
most women
– Premarin 25mg IV Q 6 hours
– Once bleeding stops, switch to OCPs
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Medical Therapy
Progestens
Stop endometrial growth
Support and organize endometrium
In anovulatory women 10 mg po for 10 days
can lead to regular withdrawal bleeding
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Medical Therapy
Levonogestrol IUD
– 80% reduction in menstrual blood loss in 3
months
– Also reduces blood loss secondary to fibroids and
adenomyosis
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Medical Therapy
NSAIDs
– Useful in ovulatory DUB
– Reduces menstrual blood loss 20-50%
– Reduces prostaglandin PGE2 and PGF2
synthesis in endometrium
Vasoconstriction
Reduced bleeding
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Medical Therapy
NSAIDs
– Low cost
– Treat dysmenorrhea
– Do not need to be taken daily
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Antifibrinolytic agents
Tranexamic Acid
– Lowers endometrial tissue plasminogen activator
activity
– Prevents plasmin formation and menstrual fluid
fibrinolysis
– Contraindicated in women with increased risk of
or history of thrombosis
– Cannot be used along with estrogen treatment
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Surgical Therapy
Dilation and Curettage
– Can be diagnostic and therapeutic
– Rarely curative
– Not useful with ovulatory menorrhagia
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Surgical Therapy
Endometrial Ablation
– Surgical destruction of the endometrium
– Minimally invasive
– 60% amenorrhea
– 95% patient satisfaction
– Need contraception
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Surgical Therapy
Hysterectomy
– Definitive treatment
– High patient satisfaction
– Reserved for women who have failed all other
measures
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References
Comprehensive Gynecology, Fifth Edition; Katz, Lendtz, Lobo
ACOG Committee opinion #451 – Von Willebrand disease in Women
“Effective Treatment of Heavy Menstrual Bleeding with Estradiol Valerate and Dienogest” The American College of Obstericians and Gynecologists, Vol. 117, No 4, April 2011
ACOG Committee opinion #349 – Menstruation in girls and adolescents: Using the Menstrual Cycle as a Vital Sign
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