59. Dysfunctional uterine bleeding.Diagnosis.Differential diagnosis.

Question 1

what is dysfunctional uterine bleeding ?

Answer 1

bleeding as a result of hypothalamus – pituitary – ovarian axis dysfunction

in the absence of recognizable pelvic pathology (fibroids/polyps) , general medical disease, or pregnancy.

The bleeding is unpredictable in many ways. It may be excessively heavy or light and may be prolonged, frequent, or random

Question 2

what is the different types of DUB

Answer 2

ovulatory an anovulatory

Question 3

anovulatory bleeding is associated with two types of bleeding what are they ?

Answer 3

oestrogen breakthrough bleeding

and oestrogen withdraws bleeding

Question 4

pathophysiology anovulatory estrogen breakthrough DUB

Answer 4

In adolescents!

the HPO axis takes time to mature after menarche, which can lead to anovulation. In the first 2 years after menarche cycles are mostly anovulatory

Without ovulation, progesterone is not subsequently produced from the corpus luteum of the ovary. This leads to a state of unopposed estrogen

causing an overgrowth of the endometrium which is unstable - breaks down irregularly and unpredictably. This leads to heavy bleeding and prolonged menstruation.

Question 5

what is oestrogen withdrawal anovulatory bleeding ?

Answer 5

frequently occurs in women approaching the end of reproductive life

Ovarian follicles in these women secrete less estradiol or
Fluctuating estradiol levels might lead to insufficient endometrial proliferation with irregular menstrual shedding.

This bleeding might be experienced as light, irregular spotting.

Question 6

what is ovulatory DUB ?

Answer 6

this is when progesterone production are long causing irregular shedding of the endometrium

Question 7

how to diagnose DUB ?

Answer 7

Tanner stage of breast and pubic hair should also be noted.

anamnesis - of duration , interval and intensity of bleeding
age of menarche
normal uterine bleeding : 28 days (+-7 days) (21-35days)
duration - 5-7 days
amount - 10-35ml of blood
menorrhagia >80ml

Upon physical examination, height, weight, BMI, orthostatic blood pressure and pulse should be recorded.

exclusions of abnormal uterine bleeding

painless :
fibroids

coagulation defect through VWB , thrombocytopnea and leukemias
or anticogulants prescribed = coagulation study and compete blood count

endometrial cancer /cervical cancer

endometrial polyp

painful
pelvic inflammatory disease - STI

endometriosis

adenomyosis

pregnancy related complication such as miscarriage or ectopic pregnancy ,

PCOS

hyperthyroidism

bleeding from urinary or rectal tract

Question 8

Ovulatory DUB occurs when ?

Answer 8

stage of sexual maturity and at the beginning of the climacterium

Question 9

ovulatory Dub presents with ?

Answer 9

Intermenstrual bleeding

 Ovulatory olygomenorrhea
 Ovulatory polymenorrhea
 Persistent corpus luteum
Corpus luteum insufficiency

Question 10

anovulatory dub present with ?

Answer 10

occurs at unpredictable times and in unpredictable patterns and is not accompanied by cyclic changes in basal body temperature

Anovulatory olygomenorrhea
 Anovulatory hypermenorrhea
 Anovulatory menometrorrhagia

Question 11

which DUB occur the most ?

Answer 11

anovulatory DUB - 80 percent

Question 12

Ovulatory DUB may occur in which diseases ?

Answer 12

thyroid dysfunction, coagulation defects (most commonly von Willebrand disease)
include
diabetes mellitus

Question 13

the treatment of DUB is ?

Answer 13

If there is no anemia, patient stress is minimal and the flow is only slightly to moderately increased, observation is appropriate

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women who desire pregnancy:
a nonsteroidal anti-inflammatory drug (NSAID)
Naproxen sodium and mefenamic acid decrease menstrual blood loss - not good for blood disorder

antifibrinolytics - s tranexamic acid and aminocaproic acid, can reduce menstrual loss

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do no desire pregnancy :
hormone therapy - BEST -combined oral contraceptives,
Estrogen provides hemostasis and progesterone stabilizes the endometrium

There are several regimens documented, but a common approach is to give one pill four-times daily until bleeding stops, then one pill three-times daily for 3 days, then

one pill twice daily for 2 days, followed by one pill once daily.

After completing the OCP taper, the patient can continue cycling OCPs for 6 months

Prescribing OCPs in a continuous, rather than cyclic fashion, is another option to suppress menses

successful in treating menorrhagia in adolescents with bleeding disorders, and OCPs can be used as first-line treatment

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cyclic progestins can be used. Oral medroxyprogesterone / norethindrone acetate can be given for 10-14 days each month to induce a withdrawal bleed that is cyclic and predictable. This pattern is continued for 3-6 months.

Medroxyprogesterone acetate IM injection can also be used to reduce endometrial proliferation and blood loss.

Medroxyprogesterone acetate is now available in a subcutaneous form- bleeding disorders

levonorgestrel intrauterine device (IUD) is effective in decreasing menstrual blood loss.

Gonadotropin-releasing hormone (GnRH) agonists - induce amenorrhea

Endometrial ablation
Hysterectomy