Dysfunctional Uterine Bleeding (dub)

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)

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Irregular bleeding (metrorrhagia)

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Frequent bleeding with shortened cycle (polymenorrhoea).

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Prolonged bleeding

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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

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Classification

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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

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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

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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 2040 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

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• 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(3040 cycles following menarche may be anovulatory) • -rarely malignant • -unsuspected tb may be responsible • -abnormality of menstruation will return to normal in 2 -10years.

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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 • • • • • •

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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

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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 23months

• 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-ovarianendometrial 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

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