Functional and symptomatic abnormal uterine bleeding Assoc. Prof. Małgorzata Walentowicz-Sadłecka, MD, PhD

Dysfunctional uterine bleeding (DUB) DUB is abnormal bleeding without specific cause. Intensity of bleeding ranges from light to heavy or prolonged, frequent bleeding. The diagnostic goal is to exclude other causes of bleeding (firstly, exlusion of malignancies). Pathological mechanism of DUB is: an absence of ovulation and the production of progesterone; the high level of estrogen (unoppsed by progesterone), which leads to hyperplasia of endometrium.

Abnormal uterine bleeding – ACOG reccomendation ACOG reccomend to use the term „abnormal uterine bleeding” In ACOG classification of abnormal uterine bleeding, there is „ovulatory dysfunction”, which is similar to the classic term „dysfunctional uterine bleeding”. The classification contains only non-pregnancy-related causes.

Differnetial diagnosis – abnormal menses Term Interval Duration Amount Menorrhagia Regular Prolonged Excessive Metrorrhagia Irregular +/- Prolonged Normal Menometrorrhagia Hypermenorrhea Hypomenorrhea Normal or less Less Oligomenorrhea Infrequent Variable Scanty Amenorrhea Absent No menses (90days)

Differential diagnosis Conditions assosiated with anovulation Eating disorders anorexia nervosa bulimia nervosa Excesive physical exercise Chronic illnes Alcohol or drug abuse Stress Thyroid disease Hypothyroidism hyperthyroidism Diabetes mellitus Policystic ovary syndrome

Differential diagnosis Pregnancy related bleeding Spontaneous abortion Ectopic pregnancy Exogenous hormones (using conraceptive hormones) Coagulopathies Von Willebrand’s disease Liver disease Infection causes Chlamydia trachomatis Exogenous hormones (using conraceptive hormones)- During first 1 to 3 months observation is reccomended. Long-term cases may require changing in hormonal delivery. Pregnancy - Spontaneous abortion

Differential diagnosis Anatomic causes: Endometrial polyps Fibroid (submucosal) Endometrial cancer/hyperplasia

Physical examination Pelvic examination: Speculum examination Bimanual examination Identification of any trauma to the genital tract Intensity of bleeding Uterine enlargement and irregularity Physical examination

Diagnosis Cytologic examination Endometrial biopsy Transvaginal sonography Hysteroscopy

Treatment of abnormal uterine bleeding The first line of treatment for patients with known or suspected bleeding cause should be specific. Ectopic pregnancy Pharmacologic uterine evacuation Thyroid disease Medical treatment Von Willebrand’s disease Desmopressin Bacterial Infections Antibiotic Surgical options, such as dialtion and curettage, myomectomy, endometrial ablation, utery artety embolization or hysterectomy, are required in structural abnormalities.

Treatment of ovulatory dysfunction ≤18 years low-dose combination hormonal contraceptive (20 - 35 μg ethinyl estradiol) 19-39 years low-dose combined hormonal contraceptive therapy or to progestin therapy high-dose estrogen therapy (cases of extremely heavy menstrual flow or hemodynamically unstablity) ≥40 years cyclic progestin therapy, low-dose oral contraceptive pills, the levonorgestrel intrauterine device, or cyclic hormone therapy these treatments can relieve perimenopausal symptoms such as hot flashes, night sweats, and vaginal atrophy

Summary Dysfunctional bleeding is a result of ovulatory dysfunction. Every patient with bleeding requires preliminary diagnostic with exclusion of malignancies. First step of abnormal uterine bleeding treatment should be specific for the bleeding cause. Contraceptive therapy may be benefit in ovulatory dysfunction cases. If childbearing is complete, women who have failed medical therapy may be considered for hysterectomy.