DYSFUNCTIONAL UTERINE DYSFUNCTIONAL UTERINE BLEEDINGBLEEDING

AHMED ABDULWAHABAHMED ABDULWAHAB

• Definition.Definition.

• It is abnormal vaginal bleeding in the It is abnormal vaginal bleeding in the child bearing period where no organic child bearing period where no organic pathology is found like fibroid, pathology is found like fibroid, malignancy pregnancy.malignancy pregnancy.

• It is almost always a problem in the It is almost always a problem in the hypothalamic-pituitary-ovarian hormonal hypothalamic-pituitary-ovarian hormonal axis resulting in ovulation problems.axis resulting in ovulation problems.

• Diagnosis by exclusion.Diagnosis by exclusion.• It is a common gynecological problem It is a common gynecological problem

that usually occurs at the extreme of that usually occurs at the extreme of reproductive life, menarche and reproductive life, menarche and perimenopause. And mostly perimenopause. And mostly attributable to anovulation so attributable to anovulation so deficient corpus luteum and hence deficient corpus luteum and hence lack of progesterone that ultimately lack of progesterone that ultimately results in irregular uterine bleeding. results in irregular uterine bleeding.

• Polymenorrhea. Abnormal frequent Polymenorrhea. Abnormal frequent menses < 21 days.menses < 21 days.

• Menorrhagia. Excessive and-or prolonged Menorrhagia. Excessive and-or prolonged menses more than 80 ml and or ore than menses more than 80 ml and or ore than 7 days that occurs at a normal intervals.7 days that occurs at a normal intervals.

• Metrorrhagia. Irregular episodes of Metrorrhagia. Irregular episodes of uterine bleeding.uterine bleeding.

• Oligomenorrhea infrequent menses more Oligomenorrhea infrequent menses more than 35 days.than 35 days.

• Since diagnosis is by exclusion a Since diagnosis is by exclusion a good effort is made to rule out any good effort is made to rule out any organic causes .organic causes .

• A good history is made to exclude .A good history is made to exclude .• -Iatrogenic.-Iatrogenic.• Exogenous estrogen , OCP.Exogenous estrogen , OCP.• Aspirin, heparin, warfarin, Aspirin, heparin, warfarin,

tamoxifen ,IUCD.tamoxifen ,IUCD.

• Blood dyscrasias.Blood dyscrasias.

• Thrombocytopenia, leukemia, von Thrombocytopenia, leukemia, von willebrands disease..willebrands disease..

• Systemic disorders.Systemic disorders.

• Hepatic renal and thyroid diseases.Hepatic renal and thyroid diseases.

• Trauma.Trauma.

• Laceration abrasion and foreign body.Laceration abrasion and foreign body.

• Cont.Cont.

• Local organic causes.Local organic causes.

• Pregnancy complications Pregnancy complications

• Uterine leiomoymas and endometrial polypUterine leiomoymas and endometrial polyp

• Endometrial and cervical malignancy.Endometrial and cervical malignancy.

• Adenomyosis.Adenomyosis.

• Endometritis .Endometritis .

• Endometrial hyperplasiaEndometrial hyperplasia

• Laboratory evaluation.Laboratory evaluation.• CBC, platelet count, coagulation profiles CBC, platelet count, coagulation profiles

..• Serum iron Serum iron .pregnancy test, thyroid function test , .pregnancy test, thyroid function test ,

liver function test,.liver function test,.Diagnostic procedures .Diagnostic procedures .Cervical cytology, endometrial sampling, Cervical cytology, endometrial sampling,

hysteroscopy and pelvic imaging .hysteroscopy and pelvic imaging .

• Management .Management .

• In young girls and when organic causes In young girls and when organic causes are usually excluded observation is are usually excluded observation is recommended especially when it is not recommended especially when it is not threatening the health of the patient threatening the health of the patient

• Otherwise can be given hormonal Otherwise can be given hormonal thereby in form of OCP, or thereby in form of OCP, or progesterone .progesterone .

• In older patients and after exclusion of In older patients and after exclusion of organic causes medical treatment is tried organic causes medical treatment is tried first , hormones , NSAIDS.first , hormones , NSAIDS.

• Hormonal intrauterine contraceptive device Hormonal intrauterine contraceptive device . .

• Surgical.Surgical.

• Endometrial ablation , laser, endometrial Endometrial ablation , laser, endometrial resection,.resection,.

• Hysterectomy .Hysterectomy .

POST MENOPOSAL POST MENOPOSAL BLEEDING BLEEDING • Any bleeding after the menopause Any bleeding after the menopause

should be viewed as abnormal until should be viewed as abnormal until proven otherwise .proven otherwise .

• Causes .Causes .

• Atrophic vaginitis is responsible for the Atrophic vaginitis is responsible for the majority of the cases due to loss of majority of the cases due to loss of structural integrity within the vagina structural integrity within the vagina secondary to hypo estrogenic state . secondary to hypo estrogenic state .

• Endometrial hyperplasia in 15 % .Endometrial hyperplasia in 15 % .

• Endometrial polyp in 10%.Endometrial polyp in 10%.

• Endometrial malignancy in 7- 10 % .Endometrial malignancy in 7- 10 % .

• Cervical malignancy .Cervical malignancy .

• Uterine sarcoma is very uncommon .Uterine sarcoma is very uncommon .

• It is very important to exclude any It is very important to exclude any underline pathology .underline pathology .

• In all cases endometrial sampling will be In all cases endometrial sampling will be required .required .

• A throrugh examination looking for signs A throrugh examination looking for signs of systemic disease is extremely importantof systemic disease is extremely important

• Pelvic examination should include the Pelvic examination should include the estrogenic status of the vagina and cervix estrogenic status of the vagina and cervix

• Cervical smear is a routine is routinely Cervical smear is a routine is routinely done.done.

• Ultrasound as an initial step and an Ultrasound as an initial step and an endometrial thickness of 4 mm and more endometrial thickness of 4 mm and more will require more investigations .will require more investigations .

• Outpatient aspiration can be used .Outpatient aspiration can be used .

• Hysteroscopically directed biopsy should be Hysteroscopically directed biopsy should be performed in cases of continuous bleeding performed in cases of continuous bleeding despite a normal aspiration sample .despite a normal aspiration sample .

• Treatment .Treatment .

• Is directed toward the underline Is directed toward the underline cause .cause .

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