DYSFUNCTIONAL DYSFUNCTIONAL UTERINE UTERINE BLEEDINGBLEEDING

Gem Ashby MDGem Ashby MDOB/GYNOB/GYN

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DYSFUNCTIONAL UTERINE DYSFUNCTIONAL UTERINE BLEEDING BLEEDING

DUBDUB• Bleeding is heavier (passing large clots, soaking Bleeding is heavier (passing large clots, soaking

through a sanitary pad or tampon every hour for 2 through a sanitary pad or tampon every hour for 2 - 3 hours in a row) - 3 hours in a row)

• Bleeding or spotting that occurs between periods Bleeding or spotting that occurs between periods

• Time between menstrual periods changes with Time between menstrual periods changes with

each cycle each cycle

• Bleeding lasts for more days than normalBleeding lasts for more days than normal

CAUSES OF DUB CAUSES OF DUB

• GYN cancersGYN cancers• AnovulationAnovulation• FibroidsFibroids• PolypsPolyps

• Systemic illnessSystemic illness

WORK UP FOR DUBWORK UP FOR DUB

• History and examHistory and exam• Blood work/PAP smearBlood work/PAP smear• Pelvic USPelvic US• Endometrial biopsyEndometrial biopsy• D&C, hysteroscopyD&C, hysteroscopy

A: Cervical cancerA: Cervical cancerB: Endometrial(Uterine) cancerB: Endometrial(Uterine) cancerC: Ovarian cancerC: Ovarian cancer

Which two cause DUB?Which two cause DUB?

Which one has been linked to a viral Which one has been linked to a viral infection?infection?

Which one is often diagnosed at a very Which one is often diagnosed at a very late stage?late stage?

CERVICAL CANCERCERVICAL CANCER

• Cervical cancer is the second most frequent Cervical cancer is the second most frequent cancer in women in the world cancer in women in the world

• Third greatest cause of death from cancer in Third greatest cause of death from cancer in womenwomen

• 90% of cervical cancer is cause by HPV90% of cervical cancer is cause by HPV

• Of the estimated more than 270 000 deaths from Of the estimated more than 270 000 deaths from cervical cancer every year, more than 85% occur cervical cancer every year, more than 85% occur in developing countriesin developing countries

Stats from WHOStats from WHO

CERVICAL CANCER AND DUBCERVICAL CANCER AND DUB• Early cervical cancer is frequently asymptomaticEarly cervical cancer is frequently asymptomatic

• The most common symptoms at presentation are:The most common symptoms at presentation are:• Abnormal bleeding Abnormal bleeding • Postcoital bleeding Postcoital bleeding • Vaginal discharge that may be watery, mucoid, or Vaginal discharge that may be watery, mucoid, or

purulent and malodorous purulent and malodorous

TREATMENT OF CERVICALTREATMENT OF CERVICAL

• Surgery to remove the cancer

• Radiation therapy, which uses high-dose X-rays or implants in the vaginal cavity to kill cancer cells. It is used for certain stages of cervical cancer. It is often used in combination with surgery

• Chemotherapy, which uses medicines to kill cancer cells. Chemotherapy may be used to treat advanced cervical cancer

ENDOMETRIAL CANCERENDOMETRIAL CANCER

• Endometrial cancer is cancer of the lining of the uterusEndometrial cancer is cancer of the lining of the uterus

ENDOMETRIAL CANCERENDOMETRIAL CANCER• Endometrial cancer is rare in women under the age of 45

• The average chance of a woman being diagnosed is about one in 37

• This cancer is slightly more common in white women, but black women are more likely to die from it

RISK FACTORS FOR RISK FACTORS FOR ENDOMETRIAL CANCER ENDOMETRIAL CANCER

• Being obese. Fat cells make extra estrogen, but the body Being obese. Fat cells make extra estrogen, but the body doesn't make extra progesterone to balance it outdoesn't make extra progesterone to balance it out

• Taking estrogen without taking a progestinTaking estrogen without taking a progestin

• Polycystic ovary syndrome. This can cause you to produce Polycystic ovary syndrome. This can cause you to produce too much estrogen and not enough progesteronetoo much estrogen and not enough progesterone

• Having type 2 diabetesHaving type 2 diabetes

• Never having been pregnantNever having been pregnant

ENDOMETRIAL CANCER AND ENDOMETRIAL CANCER AND DUBDUB

The most common symptoms include:The most common symptoms include:

•DUBDUB•BLEEDING AFTER MENOPAUSEBLEEDING AFTER MENOPAUSE•Pain during sexPain during sex•Pelvic painPelvic pain

TREATMENTSTREATMENTS• Surgery to remove the uterus (and cervix), ovaries, and Surgery to remove the uterus (and cervix), ovaries, and

fallopian tubes (hysterectomy with bilateral salpingo-fallopian tubes (hysterectomy with bilateral salpingo-oophorectomy)oophorectomy)

• Surgery to remove lymph nodesSurgery to remove lymph nodes

• Radiation therapy to kill cancer cellsRadiation therapy to kill cancer cells

• Progestin hormone therapy to block cancer growthProgestin hormone therapy to block cancer growth

• Chemotherapy to kill cancer cellsChemotherapy to kill cancer cells

ANOVULATIONANOVULATION

• Anovulation is the absents of ovulation

ANOVULATION ANOVULATION • Polycystic ovarian syndrome• Peri-menopause• Thyroid dysfunction (either hyperthyroidism or

hypothyroidism)• Extremely high levels of stress

ANOVULATIONANOVULATIONTREATMENTTREATMENT

Hormonal manipulationHormonal manipulationOCP’sOCP’sNuvaringNuvaringDepo ProveraDepo ProveraNexplanonNexplanonMirena IUDMirena IUD

FIBROIDSFIBROIDS

• The most common pelvic tumor in women The most common pelvic tumor in women

• They are benign tumors arising from the smooth They are benign tumors arising from the smooth muscle cells of the myometriummuscle cells of the myometrium

• They can cause DUB, pain, voiding dysfunction They can cause DUB, pain, voiding dysfunction and may also have reproductive effects (e.g, and may also have reproductive effects (e.g, infertility, adverse pregnancy outcomes)infertility, adverse pregnancy outcomes)

FIBROID TREATMENTSFIBROID TREATMENTS

• There's no single best approach to uterine fibroid treatment; many treatment options exist

FIBROID TREATMENTSFIBROID TREATMENTS

• Hormonal Manipulation (OCP, Nuvaring, Depo Provera, Nexplanon, Mirena)

• Gonadotropin-releasing hormone (Gn-RH) agonists• Medications called Gn-RH agonists (Lupron, Synarel,

others) treat fibroids by putting you into a temporary postmenopausal state. With the decreased estrogen many fibroids tend to shrink

FIBROID TREATMENTSFIBROID TREATMENTS

• Uterine artery embolization• Small particles (embolic agents) are injected into the

arteries supplying the uterus, cutting off blood flow to fibroids, causing them to shrink and die

• SHOULD NOT BE DONE if the patient wants more children !!!

FIBROID TREATMENTSFIBROID TREATMENTS• Laparoscopic, robotic or open myomectomy

•  In a myomectomy, your surgeon removes the fibroids, leaving the uterus in place

FIBROID TREATMENTSFIBROID TREATMENTS

• Endometrial ablation and resection of submucosal fibroids• A specialized instrument inserted into your uterus;

uses heat, microwave energy, hot water or electric current to destroy the lining of your uterus, either ending menstruation or reducing your menstrual flow

• Ablations DO NOT remove the fibroids

• SHOULD NOT be done if the patient wants more children

ABLATIONABLATION

FIBROID TREATMENTSFIBROID TREATMENTSHYSTERECTOMYHYSTERECTOMY

• Abdominal• Vaginal

• Laparoscopic • Robotic

FIBROID TREATMENTSFIBROID TREATMENTSHYSTERECTOMYHYSTERECTOMY

• A hysterectomy is an operation to remove a woman's uterus• Definitions:

• In a supracervial or subtotal hysterectomy, a surgeon removes only the upper part of the uterus, keeping the cervix in place

• A total hysterectomy removes the whole uterus and cervix

• The ovaries may also be removed -- a procedure called oophorectomy -- or may be left in place

POLYPSPOLYPS

• Overgrowth of cells in the lining of the uterus (endometrium)

• Are usually noncancerous (benign), although some can be cancerous or can eventually turn into cancer (precancerous polyps)

POLYPSPOLYPS

TREATMENT FOR POLYPSTREATMENT FOR POLYPS

• Hormonal Manipulation (OCP, Nuvaring, Depo Provera, Nexplanon, Mirena)

• Surgical removal: D&C hysteroscopy• A camera is used to look inside the uterus and then the

polyp is scraped out  • An ablation can be done at the same time

AUBAUB

CausesCauses• GYN cancersGYN cancers• AnovulationAnovulation• FibroidsFibroids• PolypsPolyps

• Systemic illnessSystemic illness

TreatmentTreatmentSurgerySurgeryHormonal ContraceptionHormonal ContraceptionLupron, Surgery/UAELupron, Surgery/UAESurgerySurgery

Treatment based on Treatment based on affected organ systemaffected organ system

THANK YOUTHANK YOU

• Wright, Jason and Solange Wyatt. Wright, Jason and Solange Wyatt. The Washington Manual The Washington Manual Obstetrics and Gynecology Survival GuideObstetrics and Gynecology Survival Guide. Lippincott . Lippincott Williams and Wilkins, 2003. ISBN 0-7817-4363-X Williams and Wilkins, 2003. ISBN 0-7817-4363-X

• Bravender T, Emans SJ (June 1999). "Menstrual disorders. Bravender T, Emans SJ (June 1999). "Menstrual disorders. Dysfunctional uterine bleeding". Dysfunctional uterine bleeding". Pediatr. Clin. North Am.Pediatr. Clin. North Am. 4646 (3): 545–53, viii. PMID 10384806. (3): 545–53, viii. PMID 10384806.

• ^̂ "Dysfunctional Uterine Bleeding". "Dysfunctional Uterine Bleeding". http://www.sh.lsuhsc.edu/fammed/OutpatientManual/DUB.hthttp://www.sh.lsuhsc.edu/fammed/OutpatientManual/DUB.htm. Retrieved 2010-01-23. m. Retrieved 2010-01-23.