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DYSFUNCTIONAL UTERINE BLEEDING

INVESTIGATION AND MANAGEMENT

SITI NUR BAITI BINTI SHAIK


KHAMARUDIN

OUTLINE
Dysfunctional uterine bleeding (DUB)
Aim of investigation
Investigations
History
Internal examination
Special investigation

Management
Medical
Non-hormonal
Surgical
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DYSFUNCTIONAL UTERINE
BLEEDING
Defined as:
A state of abnormal uterine bleeding
WITHOUT any clinically detectable
organic, systemic and iatrogenic cause.

INCIDENCE
DUB occur in:
50% before menopause
30% reproductive age
20% adolescence
Thus, the abnormal bleeding may be
associated with or without ovulation and
accordingly grouped into:
l

Anovular
bleeding

Ovular bleeding
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ANOVULAR BLEEDING
Have
developing
follicle
Alteration of
Absence of
prostaglandin
progesterone
No mature
production
Endometrial follicle
growth
under influence
Increase PGE2 and
No the
corpus
estrogen through
PGI2
cycle
luteum
Only have
Inadequatestructural
Vasodilate,
stromal support
increase
estrogen, but fibrinolytic
activity
no progestrone
No ovulation occur

Remain fragile

BLEEDING

OVULAR BLEEDING

Irregular ripening of
endometrium
Irregular shedding of
endometrium
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OVULAR BLEEDING
IRREGULAR RIPENNG OF
ENDOMETRIUM

Inadequate formation
and function of corpus
luteum
Luteal phase is short
Inadequate secretion
of progesterone and
estrogen

IRREGULAR SHEDDING OF
ENDOMETRIUM
Incomplete withdrawal of LH
incomplete atrophy of
Corpus Luteum persistent
secretion of Progesterone
Persistant LHinhibit
FSHsuppresses ripening of
follicle in next cycle less
Estrogen less regeneration
Clinical presentation:

Clinical presentation :
polymenorrhea

Delayed onset of menses with


hypermenorrhea
Regular cycles with
hypermenorrhea

AIMS OF INVESTIGATION
To confirm the menstrual abnormality
as stated by patient
To exclude the systemic, iatrogenic
and organic pelvic pathology
To identify possible etiology of DUB
To workout definite therapy protocol

HISTORY
1. Firstly to confirm the
bleeding is through
vagina, not the urethra
or rectum.
2. Excessive bleeding
assessment?

Number of pads used


Passage of clots (size and
number)
Duration of bleeding

* If ambiguity is found, it is
better to assess by admitting
the patient during period.

3. Nature of menstrual
abnormality

Cyclic or acyclic
Last normal cycle

4. Any emotional upset


or psychosexual
problem.
5. Use of steroidal
contraceptives or
IUCD insertion

INTERNAL EXAMINATION
To exclude palpable pelvic pathology.
Bimanual examination including speculum
examination should be done in all cases
except in virgins.
Rectal examination

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SPECIAL
INVESTIGATION
Full blood
count
(FBC)

Colour
Doppler

Transvagin
al
sonograph
y (TVS)

Hysterosco
py

Saline
infusion
sonograph
y (SIS)

D&C

Endometri
al
sampling
Laparosco
py

SPECIAL INVESTIGATIONS
1. Full blood count

Hb level
Platelet count
Prothrombin time
Bleeding time
PTT
TSH, T3 and T4 for suspected thyroid cases

2. Transvaginal sonography (TVS)

Anatomical abnormalities of uterus,


endometrium and adnexae
Fibroid, adenomyosis

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3. Color Doppler

In endometrial hyperplasia, ET >


12mm, hyperechoic and regular
outline, angiogenesis and neovascular
signal study

4. Saline Infusion Sonography (SIS)

To dx endometrial polyps, submucous


fibroids and uterine abnormality
(septate/subseptate uterus)

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5. Hysteroscopy

Better evaluation of endometrial lesion


and to take biopsy from offending site.

6. Endometrial sampling

As outpatient basis
Pipelle sampler a blind procedure
hence IU pathology (polyps, submucous
fibroids) cannot be detected.

7. Laparoscopy

Urgent, associated with pelvic pain


To exclude unsuspected pelvic pathology

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8. Diagnostic uterine curettage (D & C)


Is indicated in DUB
To exclude organic lesions in
endometrium (incomplete abortion,
endometrial polyp, tubercular
endometritis or endometrial carcinoma)
To determine functional state of
endometrium
Incidental therapeutic effect

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Medical
Management
Orally
active
progestins

IU
progestog
en

Estrogen
Danazol

GnRH
agonist
Mifepriston
e

5TH-25TH day
ORALLY
ACTIVE
PROGESTIN

CYCLIC
15th-25th day
CONTINUOU
S

MEDICAL MANAGEMENT
ORALLY ACTIVE PROGESTINS
Common preparations used are
norethisterone acetate and
medroxyprogesterone acetate.
Isolated PG is highly effective in
anovular DUB.
Combined PG&E are effective in
ovular DUB.
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Preparation used
Cyclic therapy
Continuous therapy
Norethisterone preparations
5mg tablet
3x daily until bleeding stops, usually
3-7 days

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CYCLIC THERAPY
5th 25th day
course
5th 25th day course
In ovular bleeding, any low dose OCP
are effective, given from 5th to 25th
day of cycle for 3 consecutive cycles.
More effective than PG as it suppress
HP axis more effectively.
Normal menstruation is expected.
Reduce menstrual blood loss by 50%.
Serves as contraceptive as well.
In anovular bleeding, cyclic PG of
medroxyprogesterone acetate (MPA)
10mg, or
Norethisterone 5mg
From 5th to 25th day of cycle for 3
cycles

15th 25th day


course
15th to 25th day course
In ovular bleeding, where
patient wants pregnancy/
irregular shedding/
irregular ripening of
endometrium
Drydogesterone 1 tab
10mg daily or twice a day
Less effective than 5th25th day course.
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CONTINUOUS PROGESTINS
Medroxyprogesterone acetate (MPA)
10mg thrice daily, continued for at
least 90 days.
Preparations are various:
Oral
Long-acting IM injections
DMPA implants
Progesterone only pill
* Effective in reducing menstrual blood loss
but may also result in oligomenorrhea or
amenorrhea

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Mechanism: Helps organized


endometrial shedding upto basal
layer and increases endometrial ratio
of PGF2 / PGE2 and thromboxane.

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ESTROGEN:
in situations where bleeding is acute and severe,
conjugated estrogen 25mg IV is given.

Mechanisms:
Helps with rapid growth of denuded endometrium
and promotes platelet adhesiveness.
Controls bleeding by process of healing.
Proliferation of endometrium, increase level of
fibrinogen, factors V, X and platelet aggregation.

May be repeated every 4 hours till bleeding is


controlled, when oral therapy is started.
Once bleeding stops, progestin (MPA 10mg a day)
is to be added.
COC is used for long-term treatment.
If bleeding continues, D&C is indicated.

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IU progestogen
Levonorgestrel intrauterine system (LNGIUS) induce endometrial glandular atrophy,
stromal decidualization and endometrial cell
inactivation.
Effective for 5 years.
Reduction of blood loss is upto 97%.

Danazol (synthetic steroid)


Suitable in cases with recurrent symptoms and
patient waiting for hysterectomy.
Dose varies 200-400mg daily in 4 divided dose
cont. for 3 months.
Small dose tends to minimize blood loss, higher
dose produce amenorrhea.
Reduces blood loss by 60%.

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Mifepristone
An antiprogesterone.
Inhibits ovulation and induce amenorrhea.

GnRH agonists
Subtherapeutic doses reduce blood loss,
therapeutic doses produce amenorrhea.
Valuable as short-term use in severe DUB
(infertile & wants pregnancy).
SC or intranasal
Improves anemia & helpful when used before
ablation.
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NON-HORMONAL
MANAGEMENT
Anti-fibrinolytic agents (Tranexamic acid)
It counteracts endometrial fibrinolytic system.
GI side effects are common.
Can be used as second line therapy.

Prostaglandin synthetase inhibitors


Mefenamic acid is effective in women >35
years old and in cases of ovulatory DUB.
Doses 150-600mg orally divided doses during
bleeding phase.
NSAIDS reduces blodd loss 25-40%.
Improvement of dysmenorrhea, headache or
nausea are added benefits.

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Desmopressin
A synthetic analogue of argininevasopressin
Especially indicated in cases with von
Willebrands disease and factor VIII
deficiency.
Given IV 0.3g/kg or intranasally.

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SURGICAL MANAGEMENT
Uterine curettage
Hemostatic and therapeutic effect by removing
necrosed and unhealthy endometrium.
Done following USG.
Indication: Urgent, acyclic bleeding & endometrial
pathology is suspected.
Endometrial ablation
Indications:

(a) failed medical tx


(b) women who do not wish to preserve
menstrual or reproductive function
(c) normal size uterus
(d) small uterine fibroids (<3cm)
(e) women who wants to avoid longer
surgery
(f) preserve uterus
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Hysterectomy
Not recommended as first line therapy for heavy
menstrual bleeding (HMB) or DUB.
Indication: when conservative treatment fails or
contraindicated, and blood loss impairs health and
life quality, presence of endometrial hyperplasia
and atypia.
Routes of procedures: vaginal, abdominal or
laparoscopic assisted vaginal method (less invasive)
Depending on uterine size, mobility, descent,
previous surgery and cormobidities (obesity,
diabetes, heart disease or hypertension).
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REFERENCE
Duttas Textbook of Gynaecology, 6th
Edition
Gynaecology by Ten Teachers
http://www.acog.org/Patients/FAQs/En
dometrial-Hyperplasia

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