Transcript Persistent Bleeding - Saint Francis Hospital and Medical Center

DYSFUNCTIONAL UTERINE
BLEEDING
Ozgul Muneyyirci-Delale
Dysfunctional Uterine Bleeding
Dysfunctional uterine bleeding is a diagnosis of exclusion, and will
apply in 40-60% of cases of excessive menstrual bleeding.
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)
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Metrorrhagia
Uterine bleeding, usually not excessive, occurring at irregular intervals
Menometrorrhagia
Uterine bleeding, usually excessive and prolonged, occurring at frequent and
irregular intervals
Hypomenorrhea
Uterine bleeding that is regular but decreased in amount
Intermenstrual bleeding
Uterine bleeding, usually not excessive, occurring between otherwise regular
menstrual periods
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Metrostaxis
Continuous bleeding
Ovulation bleeding (pseudopolymenorrhea)
Spotting or light flow at time of midcycle estrogen nadir
Premenstrual staining
Spotting or light flow up to 7 days prior to menstruation in
ovulatory cycle
The Major Categories of
Dysfunctional Uterine Bleeding
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Estrogen breakthrough bleeding
Estrogen withdrawal bleeding
Progestin breakthrough bleeding
Progestin withdrawal bleeding
Physiologic Causes of Anovulation
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Adolescence
Perimenopause
Lactation
Pregnancy
Etiologies of Dysfunctional Uterine Bleeding
• Endocrinologic
Thyroid
Hyperthyroid
Hypothyroid
Adrenal
Hyperplasia
Benign/malignant tumor
Hypothalamic-pituitary
Failure
Neoplasia
Hyperprolactinemia
Diabetes mellitus
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
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Gonadal steroids
Progesterone
Testosterone
Adrenal androgens
Estrogens
Oral contraceptives
Stress
Emotional
Excessive exercise
Nutritional
Marked obesity
Malnutrition
Anorexia nervosa
Malabsorption syndromes
• Drugs
Nonsteroidal hypothalamic depressants
Morphine
Reserpine
Phenothiazine
Monoamine oxidase inhibitors
Anticholinergic drugs
Chlorpromazine
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
Intermediate causes
Chronic illness
Metabolic or endocrine disease
Nutritional disturbances
Peripheral causes
Ovarian
Functional or inflammatory cysts
Functional tumors, especially estrogenic
Premature ovarian failure
Physiologic
Perimenarcheal
Perimenopausal
Anatomic Factors Causing Nonuterine Bleeding
• Cervical lesions
Neoplasia, benign and malignant
Polyps
Carcinoma
Cervical eversion
Cervicitis
Cervical condylomata
• Vaginal lesions
Carcinoma, sarcoma, or adenosis
Laceration or trauma
Abortion attempts
Coital injury
Infections
Foreign bodies
Pessaries
Tampons, chronic usage
Vaginal adhesions
Atrophic vaginitis
• Bleeding from other sites
Urinary tract and urethra
Urethral caruncle, infected diverticulum
Gastrointestinal tract and rectum
• External genitalia
Labial varices, condylomata
Labial traumas, inflammation
Neoplasia, benign and malignant
Infections
Atrophic conditions
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
Infectious diseases
Tuberculosis
Pelvic inflammatory disease
Other
Endometriosis
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
Leukemia
Iatrogenic
Drugs - anticoagulants, progestational agents
Intrauterine device
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
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
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
Medical Option for the Management of DUB
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Iron
Antifibrionolytics (transexamic acid)
Cyclo-oxygenase inhibitors
Progestins
Cyclic administration
Continuous systemic administration
Local administration (IUD)
Estrogens
Estrogens plus progestins
Androgens (Danazol)
Gonadotropin-releasing hormone agonist and antiagonists
Surgery for Dysfunctional Uterine Bleeding
• Hysterectomy
• Endometrial ablation
Hysteroscopic
neodymium:yttrium aluminum garnet (Nd:YAG) laser
electrocoagulation
Non hysteroscopic endometrial ablation
radio frequency electrosurgical ablation
location hyperthermia
cryotherapy
microwave
other (low-power Nd:YAG laser and photodynamic therapy
Follow-up Studies of Endometrial Ablation
• 8.5% needed repeat ablation in 3 years
• 8.5% had undergone hysterectomy in 3 years
According to Chulloprem et al 1996
• 34% of women had hysterectomy in 5 years
According to Unger et al 1996
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
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 the endometrial curet yields minimal tissue.
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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.