Dysfunctional uterine bleeding

(DUB)

Dr S.A.UZOIGWE
• Definition
• Abnormal bleeding from the uterus in the absence of
organic disease of the genital tract. OR
• Abnormal bleeding from the uterus unassociated with
tumour,inflammation or pregnancy.
The term may be applied to any abnormal pattern of
uterine bleeding but it is commonly applied to bleeding
which is excessive in amount, duration or frequency.
• Occurs during the reproductive years (between
menarche and menopause).
• It is a diagnosis of exclusion(i.e. excluding organic
disease of the genital tract).In theory the underlying
dysfunction should be identified.
• Bleeding patterns
• Excessive or heavy menstrual loss (menorrhagia)

• Irregular bleeding (metrorrhagia)

• Frequent bleeding with shortened cycle (polymenorrhoea).

• Prolonged bleeding

• Attention:oligomenorrhoea >35days,amenorrhoea
>6months,hypomenorrhoea(days of menstruation is reduced but it is
cyclical:scanty menstruation)
• What is organic disease of the genital
tract?
• Any disease of the
vulva,vagina,cervix,uterus Fallopian tubes
and ovaries
• Classification
• Primary: No detectable disease in genital tract. No intrauterine contraceptive
device (IUCD) present. No prior administration of sex steroids or other
hormones.Due to dysfunction arising within the genital tract or reproductive
system e.g. of the pituitary,hypothalamus

• Secondary: No detectable disease of the genital tract but a known disorder

outside the genital tract
e.g.myxoedema,leukaemia,thrombocytopenia,Minot-Von Willebrand
syndrome

• Iartrogenic : Abnormal bleeding is associated with IUCD,depot

medrxyprogesterone acetate(depo-provera) or oestrogen administration.

Another classification(aetiology and symptoms)

Ovulatory : long proliferative or secretory phase(oligomenorrhoea):short proliferative or secretary phase(polymenorrhea)
Anovulatory: cyclical(oligomenorrhoea or menorrhagia).Acyclical: metrorrhagia.
Corpus luteum abnormality:insufficiency( decresed secretion of E2 and progesterone in the second half), premenstrual spotting, menorrhagia,
polymenorrhoea.Prolonged,menorrhagia,metrorrhagia
• Extent of investigation
• Exclude organic disease of the genital
tract: abdominal and pelvic examination.
• Curettage or endometrial sampling must
be performed
• Incidence
• Frequently encountered in gynaecological
practice occurs in about 10% of new
patients
• Contrary to the belief that it occurs only at
the extremes of life,50% does occur in 20-
40 years age group.
 Classification according to aetiology and common symptoms
Disorders with normal ovulation
• Ovulatory oligomenorrhoea:
-proliferative phase is prolonged
-secretive phase is normal
-common in adolescents
-may be a normal feature of menarche
-may be a forerunner of polycystic ovarian disease

Ovulatory polymenorrhoea:
-proliferative phase is shortened especially in adolescence
-shortened secretive phase may also occur especially in older women
-due to premature degeneration of the corpus luteum

•
• Dysfunctional uterine bleeding with corpus
luteum abnormality:
• -failure in the development of corpus luteum
• -decreased secretion of E2 and progesterone
-occurs mainly in the adult reproductive years
- shortening of the menstrual cycle and
polymenorrhoea.
Prolonged activity of the corpus luteum.
- results in prolonged and excessive
menstruation
• Anovulatory DUB
• -failure of ovulation is the most common
abnormality
• -may result in apparently normal periods
e.g. regular cycles but with excessive loss
• -irregular menstruation with periods of
amenorrhoea followed by excessive loss
• -occurs at extremes of reproductive life i.e.
at menarche and just before menopause
• Clinical presentation
• There is no specific pattern of bleeding.May be
abnormal in amount,duration,frequency and its
relation to menstruation.The incidence of
pathological disease and prognosis varies with
age. Therefore, we consider it under 3 age
groups:
• -under 20 years (adolescent DUB)
• -20-40 years
• -over 40 years
• Under 20 years
• -almost always dysfunctional in origin(30-
40 cycles following menarche may be
anovulatory)
• -rarely malignant
• -unsuspected tb may be responsible
• -abnormality of menstruation will return to
normal in 2 -10years.
• 20-40 years
• -benign tumours are common
• -PID
• -complications of pregnancy
• -exclude organic disease first in this age group
• -bleeding is usually ovulatory
• -prognosis is generally good
• -anovulatory carries a poor prognosis as
endometrial hyperplasia tend to occur.
• Over 40 years
• -commonly due to organic disease
• -ca of the endomtrium or the Cx is
common
• -however, there is a high incidence of
DUB due to alteration in ovarian pituitary
function preceding menopause
• -apr. 50% is associated with endometrial
hyperplasia
• Clinical diagnosis
• Hx,abdominal,pelvic examination,D&C or endometrial sampling
• In adolescents, if abnormality persists after 3months,carry out rectal
and abdominal examination to exclude uterine and ovarian
pathology.
• Special investigations:
• -D&C exclude: incomplete abortion,polyp,tb,ca.May be ommited in
adolescent but a must in adults. Carry out this procedure in the 2nd
half of the cycle preferably on the 5th-6th day before menstruation
• -Haematological:FBC,platelet count,bleeding time
• -Endocrine:progesterone on the 21st day of the cycle (will indicate
whether ovulation has occurred or if there is corpus luteum
insufficiency.Thyroid function tests.

• Others:hysteroscopy,laparoscopy,hysterosalpingogram
• Management
• History
• Exclude organic disease
• Individualize treatment accoding to age,
parity,severity,nature of the underlying defect
and likelihood of organic disease
• General measures:
• -explanation of the situation
• -reassurance esp. in adolescence
• -if in doubt, keep record of loss for about 2-
3months
• Under 20 years
-dilatation & curettage only if bleeding persists,hormone,antifbrinolytic
therapy. Never hysterectomy.

20-40years
-always D&C
-next line of action after D&C ( hormone therapy,antifibrinolytic
therapy)
-seldom hysterectomy

Over 40 years
-D&C mandatory
-hormone and antifibrinolytic therapy only after D&C in the absence
of organic disease
-hysterectomy first resort if bleeding persists.
• Hormone therapy
• -oestrogens in cases of severe haemorrhage.Large dose is given
about 25mg i.v.( conjugated equine oestrogen).Follow with cyclical
combined oestrogen/progestogen.Oestrogen regenerates the
endometrium.
• -progestogens:administered orally,
• -19-nortestosterone derivatives e.g.primolut-n, 20-30mg dly for 3
days or until bleeding stops and this usually happens within 24-48
hours. This treatment is mainly to arrest haemorrhage.Withdrawal
bleeding will occur 2-4 days after stopping treatment.This will stop
on its own.This may be continued for 3-9 months.Commence on the
4th-5th day of the withdrawal bleed.
• -cyclical progesterone therapy:from day 5-25 of the cycle. Continue
for 3 months.This may be combined with E2. Normal menstruation
resumes after discontinuation of treatment.Mech.rebound
phenomenon by restoring normal functioning of pituitary-ovarian-
endometrial axis.
• Androgens and Danazol
• The fear of masculinization with androgens has
made it less attractive but can be used in the
premenopausal women e.g.methyltestosterone
is given 10mg for 7days preceding menstruation.
• Danazol is 17-alfa-ethinyl-testosterone.Has
progestogenic action. Does not produce any
change in blood coagulation.Dose:200mg dly for
3 months
• Antifibrinolytic agents.
• Epsilonaminocaproic acid
• Tranexamic acid

• Prostaglandin synthetase inhibitors

• -mefenamic acid
• -flufenamic acid
• Surgery
• -D&C
• -hysterectomy
• Radiotherapy. For those who are unfit for
surgery and over 40 years. Produces
amenorrhea in 99% of cases.