Dysfunctional uterine bleeding
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Dysfunctional uterine bleeding (DUB) is abnormal uterine bleeding without an underlying cause. It affects 50-60% of women and common symptoms include heavy or prolonged menstrual periods. The cause is often unknown but may involve imbalances in hormones that regulate the uterine lining. Diagnosis involves assessing symptoms, signs of anemia, and testing is usually not needed for young women. Treatment options range from intrauterine devices to relieve heavy bleeding, to oral medications, hormone therapy, endometrial ablation, and hysterectomy as a last resort. The goal is to control symptoms through minimally invasive options before considering more intensive surgeries.
Dysfunctional uterine bleeding
- 1. Dysfunctional uterine bleeding Aboubakr Elnashar Benha university, Egypt Aboubakr Elnashar
- 2. Define DUB: Any abnormal uterine bleeding in absence of pregnancy, genital tract pathology, or systemic disease Menorrhagia; commonest symptom DUB: 50-60% 15-20% of gynaecological referrals to Hospital Excessive blood loss: >80mL are clinically meaningless If periods are reported as unacceptably heavy. then they are! Aboubakr Elnashar
- 3. CLINICAL TYPES Polymenorrhoea: frequent (<21 d) menstruation, at regular intervals Menorrhagia: Excessive & / or prolonged menstruation, at regular intervals Metrorrhagia: Excessive & / or prolonged menstruation at irregular intervals. Menometrorrhagia: both. Intermenstual bleeding: episodes of uterine bleeding between regular menstruations Hypomenorrhoea: scanty menstruation. Oligomenorrhea: infrequent menstruation (>35 d) Aboubakr Elnashar
- 4. Aetiology unknown. Mechanisms 1. Abnormal PG ratios (+ other inflammatory mediators) favoring VD and platelet non- aggregation. 2. Excessive fibrinolysis. 3. Defects in expression/function of matrix metalloproteinases (MMPs), vascular growth factors, and endothelins. 4. Aberrant steroid receptor function. 5. Defects in the endomyometrial junctional zone. Aboubakr Elnashar
- 5. Diagnosis Symptoms 1. Heavy and/or prolonged vaginal bleeding (with clots and flooding): 2. Irregular, heavy periods usually occur at the extremes of reproductive life (post-menarche and peri-menopausal). 3. ± dysmenorrhoea. 4. Systemic symptoms of anaemia and disruption of life due to bleeding. 5. A smear history and contraceptive use are vital information. Totally irregular bleeding, IMB. or PCB: prompt a search for cervical or endometrial pathology. Aboubakr Elnashar
- 6. Clinical signs 1. Anaemia. 2. Abdomino-pelvic examination: usually normal. If the uterus is significantly enlarged. fibroids are likely. Aboubakr Elnashar
- 7. Differential diagnosis 1. Submucous fibroids. 2. Adenomyosis. 3. Endometrial polyps, hyperplasia, or cancer. 4. Very rarely hypothyroidism or coagulation defects. Aboubakr Elnashar
- 8. Investigations 1. Pregnancy should always be considered and excluded. 2. CBC (Hb + MCV). 3. Not a routine a. Ferritin, TFT s, and clotting screens: investigations-only consider if clinically indicated. b. Cervical smears: not done opportunistically if smear history normal. c. STI screen including Chlamydia. Aboubakr Elnashar
- 9. Testing for coagulation disorders (von Willebrand’s disease) 1. HMB since menarche adolescents 2. Personal or family history suggesting a coagulation disorder. Prothrombin time, Partial thrmoplastin time, Bleeding time, Platelets, Von Willebrand factor with the ristocetin cofactor assay {the single best screening test for the disease. This prevents false-negative results} Prolactin & TSH: especially in adolescents Aboubakr Elnashar
- 10. 4. <45yrs The risk of endometrial pathology is very small: No further investigation: treat and await clinical response. Aboubakr Elnashar
- 11. 5. If >45yrs risk factors for endometrial disease, or no clinical response: 1. TVS US endometrial polyps fibroids measuring endometrial thickness. The risk of endometrial pathology with a normal TVS USS is small, but it may be less accurate during menstruation Aboubakr Elnashar
- 12. 2. Pipelle endometrial biopsy Indication: erratic bleeding in women >45yrs To exclude hyperplasia or cancer Aboubakr Elnashar
- 13. 3. Hysteroscopy and biopsy • Indication 1. Erratic bleeding in a woman >45yrs if USS reveals focal pathology. e.g. polyp, or is unable to assess the whole endometrium, 2. biopsy is inadequate 3. bleeding is persistent or repeated. Aboubakr Elnashar
- 14. Management Regular DUB 1. Mirena IUCD •Releases measured doses of levonorgestrel into the endometrial cavity for 5yrs inducing an atrophic endometrium. •Effects: Blood loss dec by up to 90% 30% will be amenorrhoeic at 12mths. major dec in number of hysterectomies. Provides contraception. •Side effects: insertional issues irregular PV bleeding for first 4-6mths (usually abates) progestagenic side effects: rare {minimal systemic absorption}. Aboubakr Elnashar
- 15. 2. Antifibrinolytics: tranexamic acid •1g tds days 1-4 •40% dec in loss •Safe, non-hormonal, non-contraceptive •Side effects leg cramps minor GI upset •Caution in cardiac disease. The majority of women will respond to medical therapy, especially tranexamic ± mefenamic add. Aboubakr Elnashar
- 16. 3. NSAIDS: mefenamic acid •500mg tds days 1-5 •20-30% dec in loss •significant dec in dysmenorrhoea •Safe, non-hormonal contraceptive. •Side effects GI upset including ulceration. renal impairment •Caution: Asthmatic CV disease renal impairment peptic ulcer. Aboubakr Elnashar
- 17. 4. COCP: •20-30% dec loss •improvement in dysmenorrhoea •provides contraception •Side effects BTB Headache Wt gain Aboubakr Elnashar
- 18. •Contraindications 1. Breast cancer 2. Breast feeding, postpartum less than 1 month 3. Cirrhosis Severe 4. DVT/PE 5. DM: nephropathy, retinopathy, 6. GB disease 7. Headache: Migraine with aura 8. Hypertension 9. Liver tumors: adenoma, malignancy 10.Multiple risk factors for arterial vas Dis 11.Smoking +above 35 y 12.SLE 13.Viral hepatitis: acute 14.Drug interaction: Anticonvulsant, Rifampicin,Aboubakr Elnashar
- 19. 5. Oral progestagens: no benefit in regular menorrhagia other than-short term continuous treatment to stop bleeding. Aboubakr Elnashar
- 20. Irregular DUB 1. Mirena IUCD: as above. 2. Tranexamic 3. mefenamic acid useful to dec loss during periods. 4. COCP regulate an irregular cycle safe up to the menopause if no other cardiovascular risk factors. Aboubakr Elnashar
- 21. 4. Progestagen •Cyclical (days 5-26) •Norethisterone 5mg tds or medroxyprogesterone acetate 5-10 mg tds •Regulates cycle. but little evidence to suggest dec in loss •Side effects Bloating headache. Aboubakr Elnashar
- 22. 5. further medical treatment Indications 1. First-line therapy has failed 2. Very anaemic women, bleeding continuously. having their life disrupted 3. Cautions or contraindications to surgery. a. GnRH analogues •Achieve amenorrhoea quickly by inducing a medical menopausal state •Side effects vasomotor symptoms •use limited to 6-12mths maximum {bone loss}. Aboubakr Elnashar
- 23. b. High-dose progestagens: •medroxyprogesterone acetate 10mg tds continuously •induce amenorrhoea. •may be time-limited due to side effects. Danazol and ethamsylate: no longer indicated. Aboubakr Elnashar
- 24. Surgical management Indications 1. Failure to respond to medical management 2. Women have completed her family Aboubakr Elnashar
- 25. 1. Endometrial ablation Destruction of the endometrium down to the basalis layer Effective for most women Methods: 1. Hysteroscopic resection, or rollerball ablation now used much less often {operative complications} 2. New A. Microwave (MEA). B. Thermal balloon (Thermachoice). C. Novasure (electrical impedance). Aboubakr Elnashar
- 26. Therma Choice: Heating element within the balloon (Neuwirth et al 1994) Aboubakr Elnashar
- 27. Nova sure: The bipolar radio frequency wire mesh over a triangular frame (Cooper et al 2002) Aboubakr Elnashar
- 28. Microwave endometrial ablation (Bain et al., 2002) MEA Aboubakr Elnashar
- 29. Results •less effective if the endometrial cavity is >10cm. •in normal size cavities: 80-90%: significantly improved. 30%: amenorrhoeic. 20%: need a second procedure by 5yrs. Risk: Small bleeding, infection, uterine perforation, and failed procedure. very safe and straightforward Carried out under GA but may occasionally be done under cervical block. Aboubakr Elnashar
- 30. 2. Hysterectomy The only guaranteed cure for DUB Compared to ablation higher morbidity longer recovery financial costs Complications Haemorrhage Infection bladder, ureteric, or bowel injury «1%). Death is extremely rare. Long-term satisfaction rates very high and regardless of method most women report improved sexual function Aboubakr Elnashar