DYSFUNCTIONAL UTERINE BLEEDING

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DYSFUNCTIONAL UTERINE BLEEDING

• AHMED ABDULWAHAB

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• Definition.
• It is abnormal vaginal bleeding in the child
  bearing period where no organic pathology is
  found like fibroid, malignancy pregnancy.
• It is almost always a problem in the
  hypothalamic-pituitary-ovarian hormonal axis
  resulting in ovulation problems.

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• Diagnosis by exclusion.
• It is a common gynecological problem that usually
  occurs at the extreme of reproductive life,
  menarche and perimenopause. And mostly
  attributable to anovulation so deficient corpus
  luteum and hence lack of progesterone that
  ultimately results in irregular uterine
  bleeding.

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• Polymenorrhea. Abnormal frequent menses lt 21
  days.
• Menorrhagia. Excessive and-or prolonged menses
  more than 80 ml and or ore than 7 days that
  occurs at a normal intervals.
• Metrorrhagia. Irregular episodes of uterine
  bleeding.
• Oligomenorrhea infrequent menses more than 35
  days.

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• Since diagnosis is by exclusion a good effort is
  made to rule out any organic causes .
• A good history is made to exclude .
• -Iatrogenic.
• Exogenous estrogen , OCP.
• Aspirin, heparin, warfarin, tamoxifen ,IUCD.

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• Blood dyscrasias.
• Thrombocytopenia, leukemia, von willebrands
  disease..
• Systemic disorders.
• Hepatic renal and thyroid diseases.
• Trauma.
• Laceration abrasion and foreign body.

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• Cont.
• Local organic causes.
• Pregnancy complications
• Uterine leiomoymas and endometrial polyp
• Endometrial and cervical malignancy.
• Adenomyosis.
• Endometritis .
• Endometrial hyperplasia

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• Laboratory evaluation.
• CBC, platelet count, coagulation profiles .
• Serum iron
• .pregnancy test, thyroid function test , liver
  function test,.
• Diagnostic procedures .
• Cervical cytology, endometrial sampling,
  hysteroscopy and pelvic imaging .

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• Management .
• In young girls and when organic causes are
  usually excluded observation is recommended
  especially when it is not threatening the health
  of the patient
• Otherwise can be given hormonal thereby in form
  of OCP, or progesterone .

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• In older patients and after exclusion of organic
  causes medical treatment is tried first ,
  hormones , NSAIDS.
• Hormonal intrauterine contraceptive device .
• Surgical.
• Endometrial ablation , laser, endometrial
  resection,.
• Hysterectomy .

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POST MENOPOSAL BLEEDING

• Any bleeding after the menopause should be viewed
  as abnormal until proven otherwise .
• Causes .
• Atrophic vaginitis is responsible for the
  majority of the cases due to loss of structural
  integrity within the vagina secondary to hypo
  estrogenic state .

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• Endometrial hyperplasia in 15 .
• Endometrial polyp in 10.
• Endometrial malignancy in 7- 10 .
• Cervical malignancy .
• Uterine sarcoma is very uncommon .

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• It is very important to exclude any underline
  pathology .
• In all cases endometrial sampling will be
  required .
• A throrugh examination looking for signs of
  systemic disease is extremely important
• Pelvic examination should include the estrogenic
  status of the vagina and cervix

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• Cervical smear is a routine is routinely done.
• Ultrasound as an initial step and an endometrial
  thickness of 4 mm and more will require more
  investigations .
• Outpatient aspiration can be used .
• Hysteroscopically directed biopsy should be
  performed in cases of continuous bleeding despite
  a normal aspiration sample .

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• Treatment .
• Is directed toward the underline cause .
• If no pathology is found then hypoestrogenic
  atrophic state is the most likely cause and can
  be treated with either systemic or local hormonal
  replacement.