*Dysfunctional uterine bleeding - DUB

many different diagnoses

early preg complications endometrial uterine cervical pathology herbals thyroid disease infection genital injury foreign object liver/renal dis coagulopathy or anticoagulants contraceptives or HRT side effects

progesterone withdrawal bleeding

follows normal corpus luteum degeneration only occurs if the endometrium previously primed with estrogen this can stimulate the luteal phase with exogenous progesterone in anovulatory women, and withdrawal results in endometrial shedding

polymenorrhea

intervals <21 days

metrorrhagia

irregular intervals, normal flow

menometrorrhagia

irregular/ excessive

estrogen withdrawal bleeding

is not DUB occurs after oophorectomy irradation of mature ovarian follicles

Menstrual bleeding

it occurs after the secretion of estrogen and progesterone taper off (when theres no pregnancy)

estrogen breakthrough bleeding

low continuous levels of estrogen causes intermittent spotting high continuous levels of estrogen will cause endometrial proliferation, resulting in amenorrhea followed by menometrorrhagia = build up

menorrhagia

normal intervals, excessive flow and duration

progesterone breakthrough bleeding

only occurs in presence of high ratio of progesterone to estrogen progesterone > estrogen (progesterone dominance) norplant, implanon, depo provera, minipill causes insuff stabilization of endometrium with estrogen --> which causes intermittent irregular small amounts of bleeding **

treatment of DUB

oral contra (1st line of txt) prostaglandin inhibitors progesterone (if withdrawal bleeding -> OCPs) estrogen (if you need estrogen) GnRH agonist progestin-releasing IUD- marians Desmopressin (for coag problems)

evaluation of the DUB

rule out worrisome factors look at the history pelvic exam pap smear endometrial biopsy- age and risk factors considered

hypomenorrhea

scent menses, normal intervals

bleeding in normal cycle control factors

simultaneous histological changes in all areas of endometrium orderly, there are progressive waves of vasoconstriction causing ischemic endometrial disintegration (the blood supply is cut off and is getting ready to be shed) Mechanism which initiates the menstrual flow is the same mechanism to stop the flow

if there is no ovulation-

the progesterone levels DON'T rise so the typical withdrawal of estrogen / progesterone doesn't happen (theres no normal rise after the ovulation)

oligomenorrhea-

cycle intervals > 35 days

secretory stage

day 15-28 beings with the ovulation- it triggers the PROGESTERONE production estrogen & progesterone combo stabilization in the THICKNESS of the endometrium (waiting for that fertilized egg)

proliferative stage

day 5-14 estrogen > progesterone (estrogen dominance) endometrium layer build up

surgical management of DUB

dilation and curettage D&C - which treats current episode- shed lining endometrial ablation hysterectomy- done with child bearing

definition of DUB

Anovulatory bleeding in the absence of reproductive tract pathology or medical illness diagnosis of exclusion- you want you rule out first to diagnose this Theres no pelvic pathology or underlying medical cause

Estrogen breakthrough hormonal bleeding

Estrogen breakthrough- is DUB -- is a type of hormonal bleeding Estrogen withdrawal- is not DUB, neither is progesterone breakthrough progesterone withdrawal is NORMAL MENSES

normal menstrual cycle days

28 days +/- 7

duration of normal menstrual cycle

4 days +/- 2 days

blood loss of normal menses

40 mL / + 20 mL

amenorrhea

absence of menses for 3 cyles

DUB is common in

adolescents and perimenopausal women its frustrating and often recurring

estrogen breakthrough bleeding is caused by

anovulation, when the progesterone is not present to induce a secretory endometrium with eventual shedding (no progesterone present)