Dysfunctional Uterine Bleeding Nigus Bililign MSc Introduction Dysfunctional

Dysfunctional Uterine Bleeding Nigus Bililign, MSc

Introduction • Dysfunctional uterine bleeding (DUB) is defined as abnormal uterine bleeding in the absence of uterine pathology or medical illness. • It is more often seen in the pubertal and perimenopausal periods, and in most cases, it is associated with anovulation.

Categories of DUB § Estrogen Withdrawal Bleeding—can occur after bilateral oophorectomy, radiation of mature follicles, chemotherapy for malignancy, or administration of estrogen to a castrated woman followed by discontinuation of therapy § Estrogen Breakthrough Bleeding—is a result of the amount of estrogen that is stimulating the endometrium. üLow levels of estrogen—intermittent spotting that may be prolonged but is usually light in the amount of flow. üHigh levels of estrogen for prolonged periods of time result in lengthy periods of amenorrhea followed by acute, often heavy, bleeding with excessive blood loss

Categories of DUB § Progesterone Withdrawal Bleeding—Removal of the corpus luteum, or administration and then discontinuation of progesterone or a nonestrogenic synthetic progestin result in endometrial desquamation. ü For progesterone withdrawal bleeding to occur, the endometrium must first be proliferated by endogenous or exogenous estrogen. § Progesterone Breakthrough Bleeding—occurs with an abnormally high ratio of progesterone to estrogen. Continuous progesterone therapy without adequate estrogen results in bleeding of variable duration. üPattern of bleeding that can be seen with long-acting progestin-only contraceptive methods

FIGO classification of DUB v. Systemic disorders of hemostasis (the coagulopathies) (AUB-C) v. Ovulatory disorders (AUB-O) – dysfunctional relationships in the hypothalamic-pituitary-ovarian axis that typically manifest with symptoms of the irregular onset of uterine bleeding. v. Primary disorders of endometrial origin (AUB-E) – Disturbances principally caused by the molecular and cellular mechanisms responsible for regulation of the volume of blood lost at menstruation. ØOther infectious endometrial disorders, such as chlamydial endometritis, should be included here.

Anovulatory uterine bleeding • Anovulatory bleedings are the result of estrogen withdrawal or estrogen breakthrough bleeding. • . High sustained levels of estrogen and heavy bleeding are associated with polycystic ovaries, obesity, immaturity of the hypothalamicpituitary-ovarian axis • When there is unopposed estrogen stimulation to the endometrium and no periodic desquamation, the endometrium reaches abnormal heights and lacks structural support.

Differential diagnosis § Anatomic uterine abnormalities (e. g. endometrial hyperplasia, endometrial cancer, polyps, leiomyomas, infection, foreign bodies) § Pregnancy abnormalities (e. g. abortion, ectopic pregnancy, gestational trophoblastic disease) § Coagulopathies (e. g. von Willebrand's disease-factor VIII, idiopathic thrombocytopenia purpura) § Anatomic cervical abnormalities (e. g. cervical cancer, infection, endocervical polyps) § Liver disease (e. g. cirrhosis, hepatitis) § Anticoagulant therapy

DDX… § Drugs: Narcotics (e. g. morphine and other abused substances), reserpine, monoamine oxidase inhibitors, phenothiazines, anticholinergic drugs § Thyroid disease (e. g. hypothyroidism, hyperthyroidism) § Chronic renal failure § Exogenous hormones (e. g. estrogen replacement, oral contraceptives) § Adrenal disease (e. g. insufficiency, hyperplasia) § Functional estrogen-producing tumors of the ovary (e. g. granulosa cell tumors of the ovary, Sertoli-Leydig cell tumors) § Pituitary disease (e. g. prolactin level)

Diagnosis of DUB • Obtaining a physical examination and a detailed clinical history with an in-depth understanding of the patient's menstrual characteristics is important initial step. • Detailed questioning about the medical history should include • Endocrine or medical illnesses such as galactorrhea, thyroid enlargement, hirsutism, exogenous medicine ingestion, and eating or bleeding disorders. • Most important, the possibilities of intrauterine and ectopic pregnancies must be considered

DX… • Complete blood count • Quantitative human chorionic gonadotropin • Thyroid function tests • Prolactin • Liver and renal function tests Clotting studies • Prothrombin time • Activated partial prothrombin time • Antithrombin III • Protein C • Protein S • Fibrinogen • Plasminogen

Treatment q. Medical therapy ØEstrogens üCause rapid growth of the endometrium üStimulate clotting at the capillary level ØProgestational agents üMedroxyprogesterone acetate ØProgestin IUCD ØLow dose oral contraceptives üLess than 50 μg estrogen, 2 pills for 5 -7 days

TX… ØAndrogen steroids üDanazol 400– 800 mg daily ØGonadotropin-releasing hormone analogs ØAntiprostaglandins (NSAIDs) ØAntifibrinolytic agents üA last resort for patients with coagulation problems ØDesmopressin ØErgot derivatives (Methylergonovine maleate)—not recommended.

TX… q. Surgical therapy ØDilation & curettage ØEndometrial ablation ØHysterectomy

References • GLOWM • Uptodate 2018.