Dysfunctional Uterine Bleeding

DUB: -definition -description, caused by, diagnosis, age

Irregular uterine bleeding that occurs in absence of pathology or medical illness in a female who is not pregnant -unpredictable: heavy/light/prolonged/frequent/random -results from disruption of normal cyclic pattern of ovulatory hormonal stimulation to endometrial lining: most common cause if failure to ovulate but can be oligo-ovulations -diagnosis of exclusion -adolescents and women > 40 y/o

Workup: imaging

None necessary -US: obese patients with suboptimal pelvic exam; those with suspected uterine/ovarian pathology; endometrial hyperplasia, carcinoma, polyps, and uterine fibroids

Surgical treatment:

Reserved for when treatment has failed or is contraindicated -D&C not found to be effective: can be helpful diagnostically when hysteroscopy is included -Endometrial Ablation: medication to thin endometrium given before procedure; pt. satisfaction is high but may need redone; NOT a form of contraception; good choice for those who don't want to undergo or poor candidates for major surgery -Hysterectomy

Lab Workup:

-HCG: most common cause of abnormal uterine bleeding in reproductive years is abnormal pregnancy -CBC: H&H and platelet count if bleeding d/o suspected -PAP smear: cervical CA most common gyne CA -Endometrial Sampling: bx to r/o endometrial hyperplasia and CA in those at risk; most biopsies conform absence of secretory endometrium -Thyroid function tests/Prolactin level -LFTs if hepatitis or alcoholism suspected -Coags -Hormone assays: PCOS, hyperandrogenism, 21 hydroxylase deficiency, or adrenal/ovarian tumors

More treatment: -when, how, other benefits, r/o what

-Progestins: episodic or continuous exposure for chronic DUB; given as OCP or progestin-secreting IUD ---> added benefits include decreased dysmenorrhea, decreased blood loss, prophylaxis against ovarian CA Underlying bleeding/coagulation d/o must be treated Consider treating anemia: iron 325 mg (constipation)

Clinical Manifestations: -history -PE

-chronic stimulation by low levels of estrogen cause infrequent light bleeding -chronic stimulation by high levels of estrogen cause frequent episodes of heavy bleeding -typically symptoms which occurs during ovulatory cycle are absent -pregnancy? how many pads/tampons a day? PE: no significant findings

Polymenorrhea: Hypermenorrhea: Menorrhagia: Metrorrhagia: Menometrorrhagia: Ovulatory bleeding (Kleine regnen)

-menstruation at abnormally frequent intervals -abnormally profuse or prolonged menstrual flow -abnormally profuse menstrual flow -bleeding between periods -profuse menstrual flow between periods -scant bleeding at ovulation for 1-2 days

Treatment -mainstay -OC: MOA, when, control -Estrogen: when use, high dose, what else

Estrogen/progesterone is mainstay! -Oral contraceptives: suppress endometrial development, continually or in cyclic regimen, controlled within 24 hours -Estrogen alone: when bleeding is prolonged and endometrial lining is denuded --> used at higher doses for hemorrhagic uterine bleeding (D&C if bleeding not controlled 12-24 hours) --> progestin should be started after initiating estrogen therayp; avoid bleeding episodes due to unopposed estrogen

DDx:

Abortion: early and common finding -cervical CA -endometriosis -FMHx of bleeding d/o: PCOS, hormone therapy, hyperprolactinemia, thyroid disease, metabolic disorders -hepatitis/alcoholism impairs metabolism of estrogen