Anovulatory dysfunctional uterine bleeding

Specialty: Gynecology and breast.

• Anovulatory uterine hemorrhage
• dysfunctional uterine bleeding due to lack of ovulation
• dysfunctional metrorrhagia

Why it occurs

• Lack of progesterone production due to the absence of the corpus luteum, which conditions a continuous unopposed estrogenic stimulus on the endometrium, resulting in an unstable hyperplastic endometrium that sheds irregularly
• Polycystic ovary syndrome
• Severe obesity
• Anorexia or extreme weight loss
• Immaturity of the hypothalamus-pituitary-ovarian axis in early adolescents

Initial workup

Complete blood count with platelet count. Determination of progesterone levels in the middle of the supposed luteal phase (day 21 of the cycle) to confirm anovulation (<3 ng/mL confirm anovulation). Complete hormonal profile (TSH, Prolactin, Free Testosterone, DHEA-S). Transvaginal ultrasound to assess endometrial thickness and rule out intracavitary pathology. Mandatory endometrial biopsy if the patient is over 45 years old or under 45 years of age with risk factors to rule out endometrial hyperplasia/neoplasia.

Standard management

• Micronized progesterone 200 mg/day orally during the last 10-12 days of each cycle to regularize endometrial shedding
• Monophasic combined oral contraceptives to induce regular cycles and protective endometrial atrophy
• Medroxyprogesterone acetate 10 mg/day orally during the last 10 to 14 days of the cycle
• In cases of severe acute non-organic bleeding: regimen of conjugated equine estrogens intravenously at high doses or combined oral contraceptives prescribed in descending doses every 6-8 hours (note: ensure adequate replacement of elemental iron if there is secondary iron deficiency).