1. DYSFUNCTIONAL UTERINE BLEEDING Ozgul Muneyyirci-Delale

2. Dysfunctional Uterine Bleeding Dysfunctional uterine bleeding is a diagnosis of exclusion, and will apply in 40-60% of cases of excessive menstrual bleeding.

4. Patterns of Abnormal Bleeding Oligomenorrhea Infrequent, irregular episodes of bleeding, usually occurring at intervals greater than 35 days Polymenorrhea Frequent, but regular episodes of uterine bleeding, usually occurring at intervals of 21 days or less Hypermenorrhea (Menorrhagia) Uterine bleeding, prolonged or excessive occurring at regular intervals (80 ml or more)

5. MetrorrhagiaMetrorrhagia Uterine bleeding, usually not excessive, occurring at irregular intervalsUterine bleeding, usually not excessive, occurring at irregular intervals MenometrorrhagiaMenometrorrhagia Uterine bleeding, usually excessive and prolonged, occurring at frequent and irregular intervalsUterine bleeding, usually excessive and prolonged, occurring at frequent and irregular intervals HypomenorrheaHypomenorrhea Uterine bleeding that is regular but decreased in amountUterine bleeding that is regular but decreased in amount Intermenstrual bleedingIntermenstrual bleeding Uterine bleeding, usually not excessive, occurring between otherwise regular menstrual periodsUterine bleeding, usually not excessive, occurring between otherwise regular menstrual periods

6. MetrostaxisMetrostaxis Continuous bleedingContinuous bleeding Ovulation bleeding (pseudopolymenorrhea)Ovulation bleeding (pseudopolymenorrhea) Spotting or light flow at time of midcycle estrogen nadirSpotting or light flow at time of midcycle estrogen nadir Premenstrual stainingPremenstrual staining Spotting or light flow up to 7 days prior to menstruation in ovulatory cycleSpotting or light flow up to 7 days prior to menstruation in ovulatory cycle

7. The Major Categories of Dysfunctional Uterine Bleeding Estrogen breakthrough bleedingEstrogen breakthrough bleeding Estrogen withdrawal bleedingEstrogen withdrawal bleeding Progestin breakthrough bleedingProgestin breakthrough bleeding Progestin withdrawal bleedingProgestin withdrawal bleeding

9. Physiologic Causes of Anovulation AdolescenceAdolescence PerimenopausePerimenopause LactationLactation PregnancyPregnancy

10. Etiologies of Dysfunctional Uterine Bleeding EndocrinologicEndocrinologicThyroid Hyperthyroid Hyperthyroid Hypothyroid HypothyroidAdrenal Hyperplasia Hyperplasia Benign/malignant tumor Benign/malignant tumor

11. Hypothalamic-pituitary Failure Failure Neoplasia Neoplasia Hyperprolactinemia Hyperprolactinemia Diabetes mellitus

12. Ovarian Polycystic ovarian syndrome Functioning ovarian tumors Sertoli-Leydig cell tumor Granulosa or theca cell tumors Hilus cell tumor Chronic pelvic inflammatory disease Endometriosis Premature menopause

13. Gonadal steroidsGonadal steroidsProgesteroneTestosterone Adrenal androgens Estrogens Oral contraceptives StressStressEmotional Excessive exercise NutritionalNutritional Marked obesity Malnutrition Anorexia nervosa Anorexia nervosa Malabsorption syndromes Malabsorption syndromes

14. DrugsDrugs Nonsteroidal hypothalamic depressants Morphine Morphine Reserpine Reserpine Phenothiazine Phenothiazine Monoamine oxidase inhibitors Monoamine oxidase inhibitors Anticholinergic drugs Anticholinergic drugs Chlorpromazine Chlorpromazine

15. Etiologic Classification of Abnormal Uterine Bleeding Associate with Anovulation Central causes Functional and organic disease Traumatic, toxic, and infectious lesions Polycystic Ovary Syndrome Immaturity of the hypothalamo-pituitary axis Psychogenic factors Stress, anxiety, emotional trauma Neurogenic factors Psychotropic drugs, drug addiction Exogenous steroid administration

16. Intermediate causes Chronic illness Metabolic or endocrine disease Nutritional disturbances Peripheral causes Ovarian Functional or inflammatory cysts Functional tumors, especially estrogenic Premature ovarian failure PhysiologicPerimenarchealPerimenopausal

17. Anatomic Factors Causing Nonuterine Bleeding Cervical lesionsCervical lesions Neoplasia, benign and malignant PolypsCarcinoma Cervical eversion Cervicitis Cervical condylomata

18. Vaginal lesionsVaginal lesions Carcinoma, sarcoma, or adenosis Laceration or trauma Abortion attempts Coital injury Infections Foreign bodies Pessaries Tampons, chronic usage Vaginal adhesions Atrophic vaginitis

19. Bleeding from other sitesBleeding from other sites Urinary tract and urethra Urethral caruncle, infected diverticulum Urethral caruncle, infected diverticulum Gastrointestinal tract and rectum Gastrointestinal tract and rectum External genitaliaExternal genitalia Labial varices, condylomata Labial traumas, inflammation Neoplasia, benign and malignant Infections Atrophic conditions

20. Abnormal Uterine Bleeding Associated with Ovulatory Cycles Complications of a past pregnancy Retained secundines, placental polyps Ectopic pregnancy Organic pelvic disease Neoplastic disease (benign or malignant) Sarcoma, carcinoma, or myomata of uterine fundus, Fallopian tube, and/or ovary fundus, Fallopian tube, and/or ovary Infectious diseases Tuberculosis Pelvic inflammatory disease

21. OtherEndometriosis Bleeding at ovulation (Kleine Regel) Polymenorrhea due to Follicular shortening Luteal shortening Irregular endometrial shedding Premenstrual staining Prolonged menses Persistent corpus luteum (Halban’s disease) Blood dyscrasias ITP, von Willebrand’s disease LeukemiaIatrogenic Drugs - anticoagulants, progestational agents Drugs - anticoagulants, progestational agents Intrauterine device

22. Systemic Bleeding Disorders Associated with Abnormal Uterine Bleeding Abnormalities in primary hemostasis Thrombocytopenia Bone marrow failure Immune: AITP, drug related, HIV Nonimmune: TTP, HUS, HELLP Qualitative platelet abnormalities vWD

23. Abnormalities in secondary hemostasis Congenital factor deficiencies Oral anticoagulants Acquired factor VIII inhibitors Hyperfibrinolytic states  2-antiplasmin deficiency ?PAI-1 deficiency Complex coagulopathies DIC Liver disease

25. The Incidence of Endometrial Cancer in 1995 Age 15 – 19 years:0.1 / 100,000 Age 30 – 34 years:2.3 / 100,000 Age 35-39 years:6.1 / 100,000 Age 40 – 49 years:36.2 / 100,000

26. Medical Option for the Management of DUB IronIron Antifibrionolytics (transexamic acid)Antifibrionolytics (transexamic acid) Cyclo-oxygenase inhibitorsCyclo-oxygenase inhibitors ProgestinsProgestins Cyclic administration Continuous systemic administration Local administration (IUD) Estrogens Estrogens plus progestins Androgens (Danazol) Gonadotropin-releasing hormone agonist and antiagonists

27. Surgery for Dysfunctional Uterine Bleeding HysterectomyHysterectomy Endometrial ablationEndometrial ablation Hysteroscopic Hysteroscopic neodymium:yttrium aluminum garnet (Nd:YAG) laser electrocoagulation Non hysteroscopic endometrial ablation Non hysteroscopic endometrial ablation radio frequency electrosurgical ablation location hyperthermia cryotherapymicrowave other (low-power Nd:YAG laser and photodynamic therapy

28. Follow-up Studies of Endometrial Ablation 8.5% needed repeat ablation in 3 years8.5% needed repeat ablation in 3 years 8.5% had undergone hysterectomy in 3 years8.5% had undergone hysterectomy in 3 years According to Chulloprem et al 1996 34% of women had hysterectomy in 5 years34% of women had hysterectomy in 5 years According to Unger et al 1996

29. Dysfunctional Uterine Bleeding (DUB) Hormonal Therapy 2.5 mg Premarin po TID x 7 days, then OCP’s x 3 weeks or OCP’s QID x 7 days, then q day x 3 weeks or OCP’s TID x 3 days, then BID x 3 days then q day Persistent Bleeding I.V. Premarin 25 mg q 4 hr for 24 hr or until bleeding stops Surgical Evaluation (Hysteroscopy, D&C) If bleeding persists in spite of hormonal therapy will provide tissue for pathologic diagnosis

31. The initial choice of therapy should be estrogen in the following situation: When bleeding has been heavy for many days and it is likely that the uterine cavity is now lined only by a raw basalis layer.When bleeding has been heavy for many days and it is likely that the uterine cavity is now lined only by a raw basalis layer. When the endometrial curet yields minimal tissue.When the endometrial curet yields minimal tissue.

32.  When the patient has been on progestin medication (oral contraceptives, intramuscular progestins) and the endometrial is shallow and atrophic. When follow-up is uncertain, because estrogen therapy will temporarily stop all categories of dysfunctional bleeding.When follow-up is uncertain, because estrogen therapy will temporarily stop all categories of dysfunctional bleeding.