DYSFUNCTIONAL UTERINE BLEEDING Ralph Boling, DO, FACOG, FACOOG

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DYSFUNCTIONAL UTERINE BLEEDINGRalph Boling, DO,
FACOG, FACOOG
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Definition

• Abnormal uterine bleeding in the absence of
  uterine pathology or medical illness.
• Associated with anovulation, which results in
  unopposed estrogen stimulation to the endometrium

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Menstrual Cycle

• The normal menstrual cycle occurs at regular
  intervals of 24-35 days.
• Average duration of flow is 4-6 days can be
  as few as 2 days and as many as 7 days.
  
• Flow of longer than 7 days deserves evaluation.
• Average blood loss during one menses is about 30
  mL

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Changes During Menstrual Cycle

• Normal ovulatory endometrial changes throughout
  the menstrual cycle can be divided into five
  phases a) menstrual endometrium phase b)
  proliferative phase c) secretory phase d)
  implantation phase e) exfoliative phase or
  endometrial breakdown

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Types of Bleeding

• Menorrhagia - excessive and prolonged uterine
  bleeding at regular intervals
• Metrorrhagia - irregular, intramenstrual bleeding
• Menometrorrhagia - heavy, prolonged, irregular
  bleeding at frequent, irregular intervals
• Polymenorrhea - frequent, regular episodes of
  uterine bleeding at intervals of less than 21
  days
• Oligomenorrhea - irregular bleeding occurring at
  prolonged intervals of more than 35 days
• Amenorrhea - absence of uterine bleeding

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Diagnosis

• Most cases of anovulatory bleeding are the result
  of estrogen withdrawal or estrogen breakthrough
  bleeding
• High sustained levels of estrogen and heavy
  bleeding are associated with polycystic ovaries
• When there is unopposed estrogen stimulation to
  the endometrium and no periodic desquamation, the
  endometrium reaches abnormal heights and lacks
  structural support

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Diagnosis (cont.)

• The first and most important step in the
  diagnostic process is obtaining a physical
  examination and a detailed clinical history with
  an in-depth understanding of the patient's
  menstrual characteristics

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Diagnosis (cont.)

• Blood tests may include a) a complete blood
  count b) quantitative human chorionic
  gonadotropin c) thyroid function tests d)
  prolactin e) clotting studies (prothrombin time,
  activated partial thromboplastin time,
  antithrombin III, protein C, protein S,
  fibrinogen, plasminogen) f) liver and renal
  function tests
• g) glucose and insulin evaluation

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Diagnosis (cont.)

• Abnormalities of the uterus can be detected
  by a) abdominal or transvaginal ultrasound b)
  hysterosalpingography
• A sampling of the endometrial cavity should be
  considered in all cases of abnormal uterine
  bleeding

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Diagnosis (cont.)

• Although not mandatory in the perimenarchal
  patient, it is mandatory in the perimenopausal
  patient to exclude a premalignant or malignant
  condition
• It is not the age of the patient that is critical
  when considering an endometrial sampling but the
  duration of unopposed estrogen exposure

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Progestational Agents

• Once pathology has effectively been ruled out,
  progestin therapy can restore synchrony to the
  endometrial lining and return the menstrual
  patterns to normal

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ESTROGEN

• If bleeding has been prolonged and there is
  insufficient tissue for progestin action,
  estrogen therapy is indicated to cause rapid
  growth of the endometrium.

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Low-Dose Oral Contraceptives

• In young anovulatory women in whom there is
  prolonged unopposed endogenous estrogen
  low-dose (less than 50 mg estrogen) oral
  contraceptive

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Antiprostaglandins

• Nonsteroidal anti-inflammatory drugs inhibit the
  action of cyclo-oxygenase, and therefore a
  decrease occurs in the various members of the
  prostaglandin family
• a complete understanding of the mechanism of
  action of nonsteroidal anti-inflammatory drugs is
  unknown

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Dilation and Curettage

• Appropriate in women with dysfunctional bleeding
  in whom medical management has been unsuccessful

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Hysterectomy

• Hysterectomy a) on occasion is the proper
  treatment for abnormal uterine bleeding b)
  appropriate in extreme cases, such as
  failed medical management or endometrial
  hyperplasia with atypia
• Endometrial Ablation When medical therapy has
  been unsuccessful, endometrial ablation is
  an alternative therapy

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How it works
GYNECARE THERMACHOICEUterine Balloon Therapy
System

• Catheter with heater at tip enclosed in a balloon
• Balloon catheter inserted through cervix into
  uterus

• Balloon filled with sterile fluid
• Expands to fit uterus size, shape
• Fluid in balloon is heated and circulated during
  8 minute treatment cycle

• Uterine lining is destroyed by heat
• Fluid and catheter removed nothing stays in
  uterus
• Uterine lining will slough off like a period in
  the next 7-10 days

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Follow-up Treatment

• After successful treatment of acute episode of
  anovulatory uterine bleeding, patient must be
  followed.
• Chronic anovulation can lead to further abnormal
  bleeding episodes more importantly, chronic
  unopposed estrogen stimulation to the
  endometrium can lead to atypical tissue
  changes
• Becomes extremely important for patients to
  undergo periodic progestational withdrawal
  bleeding

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Medication

• Ovulating women with menorrhagia can have their
  bleeding controlled with a) nonsteroidal
  anti-inflammatory agents b) progestin
  administered daily for 7 days preceding
  menses c) oral contraceptives given in the
  routine manner