*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)
