Dysfunctional uterine bleeding (DUB) is abnormal uterine bleeding without an underlying cause. It affects 50-60% of women and common symptoms include heavy or prolonged menstrual periods. The cause is often unknown but may involve imbalances in hormones that regulate the uterine lining. Diagnosis involves assessing symptoms, signs of anemia, and testing is usually not needed for young women. Treatment options range from intrauterine devices to relieve heavy bleeding, to oral medications, hormone therapy, endometrial ablation, and hysterectomy as a last resort. The goal is to control symptoms through minimally invasive options before considering more intensive surgeries.

1. Dysfunctional uterine bleeding
Aboubakr Elnashar
Benha university, Egypt
Aboubakr Elnashar

2. Define
DUB:
Any abnormal uterine bleeding in absence of
pregnancy, genital tract pathology, or systemic
disease
Menorrhagia;
commonest symptom
DUB: 50-60%
15-20% of gynaecological referrals to Hospital
Excessive blood loss:
>80mL are clinically meaningless
If periods are reported as unacceptably heavy. then
they are!
Aboubakr Elnashar

3. CLINICAL TYPES
Polymenorrhoea: frequent (<21 d) menstruation, at
regular intervals
Menorrhagia: Excessive & / or prolonged menstruation,
at regular intervals
Metrorrhagia: Excessive & / or prolonged menstruation
at irregular intervals.
Menometrorrhagia: both.
Intermenstual bleeding: episodes of uterine bleeding
between regular menstruations
Hypomenorrhoea: scanty menstruation.
Oligomenorrhea: infrequent menstruation (>35 d)
Aboubakr Elnashar

4. Aetiology
unknown.
Mechanisms
1. Abnormal PG ratios (+ other inflammatory
mediators) favoring VD and platelet non-
aggregation.
2. Excessive fibrinolysis.
3. Defects in expression/function of matrix
metalloproteinases (MMPs), vascular growth
factors, and endothelins.
4. Aberrant steroid receptor function.
5. Defects in the endomyometrial junctional zone.
Aboubakr Elnashar

5. Diagnosis
Symptoms
1. Heavy and/or prolonged vaginal bleeding (with
clots and flooding):
2. Irregular, heavy periods usually occur at the
extremes of reproductive life (post-menarche
and peri-menopausal).
3. ± dysmenorrhoea.
4. Systemic symptoms of anaemia and disruption
of life due to bleeding.
5. A smear history and contraceptive use are vital
information.
Totally irregular bleeding, IMB. or PCB:
prompt a search for cervical or endometrial
pathology. Aboubakr Elnashar

6. Clinical signs
1. Anaemia.
2. Abdomino-pelvic examination:
usually normal.
If the uterus is significantly enlarged. fibroids are
likely.
Aboubakr Elnashar

7. Differential diagnosis
1. Submucous fibroids.
2. Adenomyosis.
3. Endometrial polyps, hyperplasia, or cancer.
4. Very rarely
hypothyroidism or
coagulation defects.
Aboubakr Elnashar

8. Investigations
1. Pregnancy should always be considered and excluded.
2. CBC (Hb + MCV).
3. Not a routine
a. Ferritin, TFT s, and clotting screens:
investigations-only consider if clinically indicated.
b. Cervical smears: not done opportunistically if smear history
normal.
c. STI screen including Chlamydia.
Aboubakr Elnashar

9. Testing for coagulation disorders (von Willebrand’s disease)
1. HMB since menarche adolescents
2. Personal or family history suggesting a coagulation
disorder.
Prothrombin time, Partial thrmoplastin time, Bleeding time,
Platelets, Von Willebrand factor with the ristocetin cofactor
assay {the single best screening test for the disease. This
prevents false-negative results}
 Prolactin & TSH: especially in adolescents
Aboubakr Elnashar

10. 4. <45yrs
The risk of endometrial pathology is very small: No
further investigation: treat and await clinical
response.
Aboubakr Elnashar

11. 5. If >45yrs
risk factors for endometrial disease, or
no clinical response:
1. TVS US
 endometrial polyps
fibroids
measuring endometrial thickness.
The risk of endometrial pathology with a normal
TVS USS is small, but it may be less accurate
during menstruation
Aboubakr Elnashar

12. 2. Pipelle endometrial biopsy
Indication: erratic bleeding in
women >45yrs
To exclude hyperplasia or
cancer
Aboubakr Elnashar

13. 3. Hysteroscopy and biopsy
• Indication
1. Erratic bleeding in a woman >45yrs if USS
reveals focal pathology. e.g. polyp, or is unable
to assess the whole endometrium,
2. biopsy is inadequate
3. bleeding is persistent or repeated.
Aboubakr Elnashar

14. Management
Regular DUB
1. Mirena IUCD
•Releases measured doses of levonorgestrel into the
endometrial cavity for 5yrs inducing an atrophic
endometrium.
•Effects:
Blood loss dec by up to 90%
30% will be amenorrhoeic at 12mths.
major dec in number of hysterectomies.
Provides contraception.
•Side effects:
insertional issues
irregular PV bleeding for first 4-6mths (usually abates)
progestagenic side effects: rare {minimal systemic
absorption}. Aboubakr Elnashar

15. 2. Antifibrinolytics:
tranexamic acid
•1g tds days 1-4
•40% dec in loss
•Safe, non-hormonal, non-contraceptive
•Side effects
leg cramps
minor GI upset
•Caution in cardiac disease.
The majority of women will respond to medical
therapy, especially tranexamic ± mefenamic add.
Aboubakr Elnashar

16. 3. NSAIDS:
mefenamic acid
•500mg tds days 1-5
•20-30% dec in loss
•significant dec in dysmenorrhoea
•Safe, non-hormonal contraceptive.
•Side effects
GI upset including ulceration.
renal impairment
•Caution:
Asthmatic
CV disease
renal impairment
peptic ulcer.
Aboubakr Elnashar

17. 4. COCP:
•20-30% dec loss
•improvement in dysmenorrhoea
•provides contraception
•Side effects
BTB
Headache
Wt gain
Aboubakr Elnashar

18. •Contraindications
1. Breast cancer
2. Breast feeding, postpartum less than 1 month
3. Cirrhosis Severe
4. DVT/PE
5. DM: nephropathy, retinopathy,
6. GB disease
7. Headache: Migraine with aura
8. Hypertension
9. Liver tumors: adenoma, malignancy
10.Multiple risk factors for arterial vas Dis
11.Smoking +above 35 y
12.SLE
13.Viral hepatitis: acute
14.Drug interaction: Anticonvulsant, Rifampicin,Aboubakr Elnashar

19. 5. Oral progestagens:
no benefit in regular menorrhagia
other than-short term continuous treatment to stop
bleeding.
Aboubakr Elnashar

20. Irregular DUB
1. Mirena IUCD:
as above.
2. Tranexamic
3. mefenamic acid
useful to dec loss during periods.
4. COCP
regulate an irregular cycle
safe up to the menopause if no other cardiovascular
risk factors.
Aboubakr Elnashar

21. 4. Progestagen
•Cyclical (days 5-26)
•Norethisterone
5mg tds or
medroxyprogesterone acetate
5-10 mg tds
•Regulates cycle. but little evidence to suggest dec
in loss
•Side effects
Bloating
headache.
Aboubakr Elnashar

22. 5. further medical treatment
Indications
1. First-line therapy has failed
2. Very anaemic women, bleeding continuously.
having their life disrupted
3. Cautions or contraindications to surgery.
a. GnRH analogues
•Achieve amenorrhoea quickly by inducing a
medical menopausal state
•Side effects
vasomotor symptoms
•use limited to 6-12mths maximum {bone loss}.
Aboubakr Elnashar

23. b. High-dose progestagens:
•medroxyprogesterone acetate
10mg tds continuously
•induce amenorrhoea.
•may be time-limited due to side effects.
Danazol and ethamsylate: no longer indicated.
Aboubakr Elnashar

24. Surgical management
Indications
1. Failure to respond to medical management
2. Women have completed her family
Aboubakr Elnashar

25. 1. Endometrial ablation
 Destruction of the endometrium
down to the basalis layer
Effective for most women
Methods:
1. Hysteroscopic resection, or
rollerball ablation
now used much less often {operative
complications}
2. New
A. Microwave (MEA).
B. Thermal balloon (Thermachoice).
C. Novasure (electrical impedance).
Aboubakr Elnashar

26. Therma Choice: Heating element within the balloon
(Neuwirth et al 1994)
Aboubakr Elnashar

27. Nova sure: The bipolar radio frequency wire mesh over
a triangular frame (Cooper et al 2002)
Aboubakr Elnashar

28. Microwave endometrial
ablation (Bain et al., 2002)
MEA
Aboubakr Elnashar

29. Results
•less effective
if the endometrial cavity is >10cm.
•in normal size cavities:
80-90%: significantly improved.
30%: amenorrhoeic.
20%: need a second procedure by 5yrs.
Risk: Small
bleeding, infection, uterine perforation, and failed
procedure.
very safe and straight­forward
Carried out under GA but may occasionally be
done under cervical block.
Aboubakr Elnashar

30. 2. Hysterectomy
The only guaranteed cure for DUB
Compared to ablation
higher morbidity
longer recovery
financial costs
Complications
Haemorrhage
Infection
bladder, ureteric, or bowel injury «1%).
Death is extremely rare.
Long-term satisfaction rates
very high and regardless of method most women
report improved sexual function
Aboubakr Elnashar

31. Aboubakr Elnashar

32. Aboubakr Elnashar
Thank you