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Dysfunctional uterine bleeding: Relation of endometrial histology to outcome
GYNECOLOGY .
Dysfunctional
uterine bleeding: Relation of
endometrial histology to outcome BERTRAND Chicago,
R.
NEDOSS,
M.D.
Illinois
Endometrial histopathological findings in a group of 136 patients with dysfunctional uterine bleeding were reviewed retrospectively. Anovulation could be documented in 16 per cent. Recurrence of bleeding occurred in 45.7 Qer cent of those followed for more than 3 months. Most of these patients did respond to cyclic hormonal therapy. Age and endometrial histology were not helpful in selecting those cases likely to recur.
UTERINE BLEEDING in the absence of abnormal palpatory findings of histopathology, a condition termed “dysfunctional uterine bleeding,” continues to be one of the most frequently encountered and perplexing problems in gynecology. Little has been done by way of investigation in recent years to clarify the situation. Conflicting concepts appear in the literature based on disparate and often confusing data. Beacham and Beacham defined this condition as “irregular, excessive, scant, or prolonged bleeding of endometrial origin occurring without neoplasia, infection, pregnancy, blood dyscrasia, trauma, or hormone administration as a cause.” KistneP reported that 5 per cent of all gynecological admissionsand 60 per cent of all diagnostic curettages at the Free Hospital for Women are due to this condition. From the Department Gynecology, Michael and Medical Center.
of Obstetrics and Reese Hospital
Presented before the Gynecological Society March 20, 1970.
Chicago on
only
This type of bleeding has frequently been said to be due to anovulation.4* 6 However, anovulation could not be substantiated in most seriesby histological study of endometrium. The not uncommonly encountered secretory endometrium signified that ovulation, or at least luteinization, had occurred. Sutherland9 collected 1,000 casesof abnormal bleeding and found that almost 50 per cent of those with normal endometrium showed secretory change. He showed that the endometrium in these patients was not different from endometrium of patients with palpable uterine irregularity present.8*9 Benson and Miller,s reviewing 647 casesat the University of California, found that only 19 per cent had proliferative endometrium when curettage was performed after the fourteenth day of the cycle. They further stated that the pattern of abnormal bleeding had little relation to the histopathological diagnosis. Israel4 was in accord with this concept. Arronet and Arratal recently advocated a rather extensive classification based upon 103
104
Nedoss
follicular maturation, corpus luteum function, and the presence or absence of ovulation. These were evaluated by basal body temperature, endometrial histology, endocrine assays, and vaginal cytology. Unfortunately, results of therapy were not given. Jeffcoate6 felt that ovular bleeding, which he termed epimenorrhea, was the most common form of dysfunctional bleeding. He stated that it arose as a result of the ovary going through its normal cycle too quickly with the acceleration affecting the follicular phase. Here, the pituitary gland was the presumed cause, although no evidence was given. With these considerations in mind, we felt that a review of our experience was in order to attempt to study the endometrial histology associated with this phenomenon and to correlate our findings with outcome. Material and methods A series of 321 patients discharged from Michael Reese Hospital and Medical Center during 1963 and 1964 with a diagnosis of menorrhagia or metrorrhagia was reviewed retrospectively. Those with palpatory abnormalities preoperatively (86) , discernible histologic abnormality (71)) a systemic medical disease that might be considered to have caused abnormal uterine bleeding (3)) and those receiving hormonal therapy ( 10) were eliminated together with the small group not subject to curettage (15). The remaining 136 subjects were studied in detail. Data obtained were stratified according to patient factors such as age, cycle day of performance of the initial surgical procedure, and the type of endometrium obtained. Tissue was obtained by diagnostic curettage in 127 instances. Nine had hysterectomy performed as an initial procedure. The subsequent course was determined from follow-up information available in hospital clinic and private office records. A complete menstrual cycle was taken to be 28 days, with secretory changes expected after day 14. This working definition is understood to be arbitrary, since the proliferative phase may be of shorter length in women who menstruate at more frequent in-
Amer
January J. Obstet.
1, 1971 Gynec.
tervals, but was found to be necessary and useful. Preliminary attempts were made to date the endometrium,? but as no differences could be seen between any of the subgroups, including those with and without recurrent bleeding, this was not pursued exhaustively. Results The 136 cases with normal palpatory findings are grouped in Table I according to age and endometrial histology. More than half (58.1 per cent) had secretory endometrium at the expected time of their menstrual cycle. A small additional number (8.1 per cent) had progestational changes at an inappropriate time. Those with proliferative endometrium before the fourteenth day (22.8 per cent) cannot be evaluated with regard to abnormality, of course. Persistence of this pattern beyond midcycle was found in only a small fraction of our material (11.0 per cent). Considering those 94 patients subjected to curettage in the second half of the cycle, we found that only 16.0 per cent showed proliferative endometrium. Only this last group showed definite evidence of anovulation. Furthermore, there was no increased trend to anovulation with advancing age. The total incidence of secretory endometrium, without regard to date of cycle, remains remarkably constant (62.1, 68.6, and 66.1 per cent, respectively) (Table I) with increasing age. Furthermore, the incidence of recurrences does not seem to be influenced by age either (Table II). The nine patients who were treated by hysterectomy could not be evaluated with reference to recurrent bleeding. Of the remaining 127, almost a third (46) did not return for further care or follow-up after the third postoperative month, leaving 81 patients for long-term evaluation. Recurrence of abnormal bleeding was seen in 37 patients observed for more than 3 months (27.2 per cent of the total series or 45.7 per cent of those followed). The time of recurrence is shown in Table III. Half had recurred before a year had elapsed ( 19 of 37, or 51.4 per cent). The original histo-
Volume Number
109 1
Dysfunctional
Table I. Breakdown
Age fY7.j
Secretory
Total
% calculated
1 Per
basis
of
> 1 Per
of
12-24 24-36 36-48 48 Cumulative total *Percentages
Secretory
cent*
No.
<
i
of original
number
16.5 5.1 6.3 3.8 1.3
0 0 0 1 0
0.0 0.0 0.0 9.1 0.0
-ii
32.9
i
iTi
on
the
basis
of
the
cent
original
specific
Proliferative days
cent
31
22.8
No.
No.
subgroup
logical picture was not related to the incidence of recurrence. The finding of secretory endometrium was followed by recurrence in 27 of 90, or 30.0 per cent, whereas those with proliferative changes recurred in 10 of 46, or 2 1.7 per cent, an insignificant difference. There was an apparent trend (not necessarily meaningful because of the small numbers involved) for recurrences to appear quickly (all within the first year) after curettage showing proliferative endometrium late in the cycle. Although the relative cumulative incidence was the same with secretory
cent 10.3 9.8 12.5
15
11.0
<
( Per
14
Proliferative days
cent
No.
>
1 Per
14 cent
i 1
12.5 27.3 8.3
1 2 2
33.3 40.0 28.6
s
16.1
5
33.3
3.2 6.5 3.2 3.2 0.0
5
14
category
1 2 1 1 0
5 0 0 0 0
16.1
number
1 Per
3 5 7
of uterine bleeding according
total
>
to age and initial
Proliferative days
9.1 in each
) Per
14
27.6 21.6 21.4
11.1
: 1
105
category.
14 days
1 Per
<
8 11 12
uterine bleeding according
13 4 5 3 1
calculated
No.
8.1 in given age
patients
Table III. Incidence and time of recurrence endometrial histology
<12
cent
0.0 3.9 16.1
11 number
32.9 on basis
1 Per
bleeding
histology
Prolifemtive days
14 days
ii
33.3 39.4 25.0
2s
<
0
14 days
6 13 7 calculated
No.
of recurrent
NO.
Total
cent*
58.1 on
by age and endometrial
Secretory
62.1 64.7 50.0
Secretory
20-30 30-40 40-50 *Percentages
14 days
18 33 28
Table II. Incidence histology
Age fyr.)
>
No.
20-30 30-40 40-50 *Percentages
of total case material
uterine
with
s histological
findings
to initial
33.3 0.0 0.0 0.0 0.0
19 6 6 5 1
14.0 4.4 4.4 3.7 0.7
33.3
37
27.2
indicated.
endometrium, the latter did not recur quite so rapidly. Forty-four patients did not have any further abnormal bleeding. Proliferative pattern was seen in four late in the cycle and 27 had shown a secretory pattern. The length of follow-up averaged just under three years. Therapeutic measures for recurrence of bleeding included cyclic hormones in 22 instances, repeat curettage in nine, and hysterectomy in seven. Of interest was the presence of previously unknown leiomyoma uteri in four patients who had been sub-
106
Nedoss
Amer.
jetted to hysterectomy. Only one of these was submucous in location; others were small and subserous. Even if these four cases were eliminated from the recurrent group, the incidence of recurence after secretory endometrium had been found would still be quite high (22 in 33, or 66.7 per cent). It is recognized, of course, that patients with minimal pathological changes may still have been included despite efforts at exclusion, Hormonal therapy was deemed successful in 16 of the 22 patients in which it was used, including 9 of 14 who had secretory endometrium and 7 of 8 with proliferative endometrium. The reported effectiveness of this conservative approach is confirmed. Comment
Study of the endometrial histology of this group of patients and their subsequentcourse points toward certain conclusions while at the same time indicating the necessity for further investigation of this problem. There is no basis to conclude that dysfunctional bleeding is most often associated with anovulation. Only 11 per cent of patients in our entire group or 16 per cent of those studied late in their menstrual cycles had documentation of proliferative endometrium after the designated midcycle. It is not known, of course, how many more of the patients with proliferative endometrium found early in the cycle would have shown secretory changes if curettage had been performed at a more appropriate time of the menstrual cycle.
January J. Obstet.
1, 1971 Gynec
Nevertheless, the number of presumed anovulators actually found is surprisingly small, corroborating foregoing reports. We are left without a clear-cut explanation for the presenting symptoms in these cases.Few attempts have been made to detect a possible local endometrial histochemical abnormality. Townsend and associates10 studied 19 cases of dysfunctional bleeding and found that 15 had depressed endometrial peroxidase activity. They comment parenthetically that endometrial histology was normal in his series.Whether the abnormality is in the responsive uterine end-organ or in the ovarian hormonal production, and whether cellular or subcellular in nature, is open to speculation. There is need for detailed prospective analysesof casesand correlation of more specific parameters of ovarian function and endometrial function based on results from timed curettage. From our data we have seen that dysfunctional bleeding is not infrequently associated with secretory endometrium, indicating that anovulation is not necessarily a factor in this disorder. Neither age nor endometrial histology seems to be related to frequency of recurrence, although recurrences appear earlier if proliferative endometrium has been found. Most patients treated by cyclic hormonal therapy will respond. Hysterectomy seemsto represent an overly aggressive approach, warranted only after failure of a more conservative regimen.
REFERENCES
1.
2. 3. 4. 5.
Arronet, G. H., and
Arrata, Obstet. Gvnec. 29: 97, 1967. Beacham, OD. W., and Beacham, Crossen’s Synopsis of Gynecology, Louis, 1967, The Cl. V. Mosby Benson, R. C., and Miller, J. Gynec. 8: 523, 1956. Israel, S. L.: Menstrual Disorders ity, ed. 5, New York, 1959, Paul Inc. Jeffcoate, T. N. A.: Principles
W.
S.
W. D.: In ed. 7, St. Company. N.: Obstet. and SterilB. Hoeber, of
Gynecol-
ogy, ed. 3, London, 1967, Butterworth & Co.,
Ltd.
Kistner, R.: Gynecology: Principles and
M.:
10.
Practice, Chicago, 1964, Year Book Medical Publishers, Inc. Noyes, R. W., Hertig, A. T., and Rock, J.: Fertil. Steril. 1: 3, 1950. Sutherland, A. M.: Lancet 2: 742, 1950. Sutherland, A. M.: In Meigs. T. V.. and Sturgis, S.. H., editors: Progress h Gy&coIYork, 1957, Grune h Stratton, OSY, New Inc., Vol. III. Townsend, J. F., Hall, D. G., Cavazos, F., and Lucas, F. V.: AMER.J. OBSTET. GYNEO.
93: 1013,1965.
Volume 109 Number 1
Discussion DR. MELVYN A. BAYLY, Chicago, Illinois. Next to uterine bleeding caused by complications of pregnancy, dysfunctional uterine bleeding is the most common type of abnormal uterine bleeding. Most of us choose to put the histological picture of endometrial hyperplasia in a special category, attributing its presence to the unopposed effect of estrogen, and restricting the term “dysfunctional uterine bleeding” to the instances wherein no demonstrable lesions of any kind can be found. Because no lesions are seen in dysfunctional uterine bleeding, it is most diEicult to study, and is most annoying when it occurs because the differential diagnosis includes endometrial carcinoma; further, the diagnosis is a retrospective one, and is usually made only after obtaining normal tissue following diagnostic curettage . . . yet, adenomyosis and occasionally a small submucous fibroid may indeed be present and undetected. I suspect that we cover up abnormal bleeding from these lesions occasionally with the use of cyclic hormonal therapy. Doctor Nedoss has pointed up the dilemma nicely, and presents meticulous documentation that 82.9 per cent of his patients curetted when past cycle day 14 did have secretory endo-
Dysfunctional
uterine bleeding
107
metrium, while 73 per cent of his patients that were curetted before cycle day 14 had proliferative endometrium. It would be interesting to know what the endometrium was like in the 86 patients with “palpatory abnormalities.” I suspect that the distribution would be the same. A few years ago we reported two series of patients whose uteri and ovarian tissue were available to study the relationship of abnormal uterine bleeding to endometriosis, and again to non-hormone-producing tumors. In both series there was an unexplained increment of abnormal uterine bleeding. It is interesting to note that in one series of unexplained abnormal uterine bleeding over one third of the group had secretory endometrium and in the other over one half had secretory endometrium. It is unfortunate that so many patients did not return; however, if the reason for the patient delinquency was due to success of the initial curettage, the over-all recurrence rate would be more in the neighborhood of 28 per cent . . . more in keeping with the success rate we like to think that we get following curettage where dysfunctional uterine bleeding is the final diagnosis. I noticed that no therapy was given in 43 instances. I wonder if these patients became asymptomatic after one more abnormal cycle?
Dysfunctional
uterine bleeding: Relation of
endometrial histology to outcome BERTRAND Chicago,
R.
NEDOSS,
M.D.
Illinois
Endometrial histopathological findings in a group of 136 patients with dysfunctional uterine bleeding were reviewed retrospectively. Anovulation could be documented in 16 per cent. Recurrence of bleeding occurred in 45.7 Qer cent of those followed for more than 3 months. Most of these patients did respond to cyclic hormonal therapy. Age and endometrial histology were not helpful in selecting those cases likely to recur.
UTERINE BLEEDING in the absence of abnormal palpatory findings of histopathology, a condition termed “dysfunctional uterine bleeding,” continues to be one of the most frequently encountered and perplexing problems in gynecology. Little has been done by way of investigation in recent years to clarify the situation. Conflicting concepts appear in the literature based on disparate and often confusing data. Beacham and Beacham defined this condition as “irregular, excessive, scant, or prolonged bleeding of endometrial origin occurring without neoplasia, infection, pregnancy, blood dyscrasia, trauma, or hormone administration as a cause.” KistneP reported that 5 per cent of all gynecological admissionsand 60 per cent of all diagnostic curettages at the Free Hospital for Women are due to this condition. From the Department Gynecology, Michael and Medical Center.
of Obstetrics and Reese Hospital
Presented before the Gynecological Society March 20, 1970.
Chicago on
only
This type of bleeding has frequently been said to be due to anovulation.4* 6 However, anovulation could not be substantiated in most seriesby histological study of endometrium. The not uncommonly encountered secretory endometrium signified that ovulation, or at least luteinization, had occurred. Sutherland9 collected 1,000 casesof abnormal bleeding and found that almost 50 per cent of those with normal endometrium showed secretory change. He showed that the endometrium in these patients was not different from endometrium of patients with palpable uterine irregularity present.8*9 Benson and Miller,s reviewing 647 casesat the University of California, found that only 19 per cent had proliferative endometrium when curettage was performed after the fourteenth day of the cycle. They further stated that the pattern of abnormal bleeding had little relation to the histopathological diagnosis. Israel4 was in accord with this concept. Arronet and Arratal recently advocated a rather extensive classification based upon 103
104
Nedoss
follicular maturation, corpus luteum function, and the presence or absence of ovulation. These were evaluated by basal body temperature, endometrial histology, endocrine assays, and vaginal cytology. Unfortunately, results of therapy were not given. Jeffcoate6 felt that ovular bleeding, which he termed epimenorrhea, was the most common form of dysfunctional bleeding. He stated that it arose as a result of the ovary going through its normal cycle too quickly with the acceleration affecting the follicular phase. Here, the pituitary gland was the presumed cause, although no evidence was given. With these considerations in mind, we felt that a review of our experience was in order to attempt to study the endometrial histology associated with this phenomenon and to correlate our findings with outcome. Material and methods A series of 321 patients discharged from Michael Reese Hospital and Medical Center during 1963 and 1964 with a diagnosis of menorrhagia or metrorrhagia was reviewed retrospectively. Those with palpatory abnormalities preoperatively (86) , discernible histologic abnormality (71)) a systemic medical disease that might be considered to have caused abnormal uterine bleeding (3)) and those receiving hormonal therapy ( 10) were eliminated together with the small group not subject to curettage (15). The remaining 136 subjects were studied in detail. Data obtained were stratified according to patient factors such as age, cycle day of performance of the initial surgical procedure, and the type of endometrium obtained. Tissue was obtained by diagnostic curettage in 127 instances. Nine had hysterectomy performed as an initial procedure. The subsequent course was determined from follow-up information available in hospital clinic and private office records. A complete menstrual cycle was taken to be 28 days, with secretory changes expected after day 14. This working definition is understood to be arbitrary, since the proliferative phase may be of shorter length in women who menstruate at more frequent in-
Amer
January J. Obstet.
1, 1971 Gynec.
tervals, but was found to be necessary and useful. Preliminary attempts were made to date the endometrium,? but as no differences could be seen between any of the subgroups, including those with and without recurrent bleeding, this was not pursued exhaustively. Results The 136 cases with normal palpatory findings are grouped in Table I according to age and endometrial histology. More than half (58.1 per cent) had secretory endometrium at the expected time of their menstrual cycle. A small additional number (8.1 per cent) had progestational changes at an inappropriate time. Those with proliferative endometrium before the fourteenth day (22.8 per cent) cannot be evaluated with regard to abnormality, of course. Persistence of this pattern beyond midcycle was found in only a small fraction of our material (11.0 per cent). Considering those 94 patients subjected to curettage in the second half of the cycle, we found that only 16.0 per cent showed proliferative endometrium. Only this last group showed definite evidence of anovulation. Furthermore, there was no increased trend to anovulation with advancing age. The total incidence of secretory endometrium, without regard to date of cycle, remains remarkably constant (62.1, 68.6, and 66.1 per cent, respectively) (Table I) with increasing age. Furthermore, the incidence of recurrences does not seem to be influenced by age either (Table II). The nine patients who were treated by hysterectomy could not be evaluated with reference to recurrent bleeding. Of the remaining 127, almost a third (46) did not return for further care or follow-up after the third postoperative month, leaving 81 patients for long-term evaluation. Recurrence of abnormal bleeding was seen in 37 patients observed for more than 3 months (27.2 per cent of the total series or 45.7 per cent of those followed). The time of recurrence is shown in Table III. Half had recurred before a year had elapsed ( 19 of 37, or 51.4 per cent). The original histo-
Volume Number
109 1
Dysfunctional
Table I. Breakdown
Age fY7.j
Secretory
Total
% calculated
1 Per
basis
of
> 1 Per
of
12-24 24-36 36-48 48 Cumulative total *Percentages
Secretory
cent*
No.
<
i
of original
number
16.5 5.1 6.3 3.8 1.3
0 0 0 1 0
0.0 0.0 0.0 9.1 0.0
-ii
32.9
i
iTi
on
the
basis
of
the
cent
original
specific
Proliferative days
cent
31
22.8
No.
No.
subgroup
logical picture was not related to the incidence of recurrence. The finding of secretory endometrium was followed by recurrence in 27 of 90, or 30.0 per cent, whereas those with proliferative changes recurred in 10 of 46, or 2 1.7 per cent, an insignificant difference. There was an apparent trend (not necessarily meaningful because of the small numbers involved) for recurrences to appear quickly (all within the first year) after curettage showing proliferative endometrium late in the cycle. Although the relative cumulative incidence was the same with secretory
cent 10.3 9.8 12.5
15
11.0
<
( Per
14
Proliferative days
cent
No.
>
1 Per
14 cent
i 1
12.5 27.3 8.3
1 2 2
33.3 40.0 28.6
s
16.1
5
33.3
3.2 6.5 3.2 3.2 0.0
5
14
category
1 2 1 1 0
5 0 0 0 0
16.1
number
1 Per
3 5 7
of uterine bleeding according
total
>
to age and initial
Proliferative days
9.1 in each
) Per
14
27.6 21.6 21.4
11.1
: 1
105
category.
14 days
1 Per
<
8 11 12
uterine bleeding according
13 4 5 3 1
calculated
No.
8.1 in given age
patients
Table III. Incidence and time of recurrence endometrial histology
<12
cent
0.0 3.9 16.1
11 number
32.9 on basis
1 Per
bleeding
histology
Prolifemtive days
14 days
ii
33.3 39.4 25.0
2s
<
0
14 days
6 13 7 calculated
No.
of recurrent
NO.
Total
cent*
58.1 on
by age and endometrial
Secretory
62.1 64.7 50.0
Secretory
20-30 30-40 40-50 *Percentages
14 days
18 33 28
Table II. Incidence histology
Age fyr.)
>
No.
20-30 30-40 40-50 *Percentages
of total case material
uterine
with
s histological
findings
to initial
33.3 0.0 0.0 0.0 0.0
19 6 6 5 1
14.0 4.4 4.4 3.7 0.7
33.3
37
27.2
indicated.
endometrium, the latter did not recur quite so rapidly. Forty-four patients did not have any further abnormal bleeding. Proliferative pattern was seen in four late in the cycle and 27 had shown a secretory pattern. The length of follow-up averaged just under three years. Therapeutic measures for recurrence of bleeding included cyclic hormones in 22 instances, repeat curettage in nine, and hysterectomy in seven. Of interest was the presence of previously unknown leiomyoma uteri in four patients who had been sub-
106
Nedoss
Amer.
jetted to hysterectomy. Only one of these was submucous in location; others were small and subserous. Even if these four cases were eliminated from the recurrent group, the incidence of recurence after secretory endometrium had been found would still be quite high (22 in 33, or 66.7 per cent). It is recognized, of course, that patients with minimal pathological changes may still have been included despite efforts at exclusion, Hormonal therapy was deemed successful in 16 of the 22 patients in which it was used, including 9 of 14 who had secretory endometrium and 7 of 8 with proliferative endometrium. The reported effectiveness of this conservative approach is confirmed. Comment
Study of the endometrial histology of this group of patients and their subsequentcourse points toward certain conclusions while at the same time indicating the necessity for further investigation of this problem. There is no basis to conclude that dysfunctional bleeding is most often associated with anovulation. Only 11 per cent of patients in our entire group or 16 per cent of those studied late in their menstrual cycles had documentation of proliferative endometrium after the designated midcycle. It is not known, of course, how many more of the patients with proliferative endometrium found early in the cycle would have shown secretory changes if curettage had been performed at a more appropriate time of the menstrual cycle.
January J. Obstet.
1, 1971 Gynec
Nevertheless, the number of presumed anovulators actually found is surprisingly small, corroborating foregoing reports. We are left without a clear-cut explanation for the presenting symptoms in these cases.Few attempts have been made to detect a possible local endometrial histochemical abnormality. Townsend and associates10 studied 19 cases of dysfunctional bleeding and found that 15 had depressed endometrial peroxidase activity. They comment parenthetically that endometrial histology was normal in his series.Whether the abnormality is in the responsive uterine end-organ or in the ovarian hormonal production, and whether cellular or subcellular in nature, is open to speculation. There is need for detailed prospective analysesof casesand correlation of more specific parameters of ovarian function and endometrial function based on results from timed curettage. From our data we have seen that dysfunctional bleeding is not infrequently associated with secretory endometrium, indicating that anovulation is not necessarily a factor in this disorder. Neither age nor endometrial histology seems to be related to frequency of recurrence, although recurrences appear earlier if proliferative endometrium has been found. Most patients treated by cyclic hormonal therapy will respond. Hysterectomy seemsto represent an overly aggressive approach, warranted only after failure of a more conservative regimen.
REFERENCES
1.
2. 3. 4. 5.
Arronet, G. H., and
Arrata, Obstet. Gvnec. 29: 97, 1967. Beacham, OD. W., and Beacham, Crossen’s Synopsis of Gynecology, Louis, 1967, The Cl. V. Mosby Benson, R. C., and Miller, J. Gynec. 8: 523, 1956. Israel, S. L.: Menstrual Disorders ity, ed. 5, New York, 1959, Paul Inc. Jeffcoate, T. N. A.: Principles
W.
S.
W. D.: In ed. 7, St. Company. N.: Obstet. and SterilB. Hoeber, of
Gynecol-
ogy, ed. 3, London, 1967, Butterworth & Co.,
Ltd.
Kistner, R.: Gynecology: Principles and
M.:
10.
Practice, Chicago, 1964, Year Book Medical Publishers, Inc. Noyes, R. W., Hertig, A. T., and Rock, J.: Fertil. Steril. 1: 3, 1950. Sutherland, A. M.: Lancet 2: 742, 1950. Sutherland, A. M.: In Meigs. T. V.. and Sturgis, S.. H., editors: Progress h Gy&coIYork, 1957, Grune h Stratton, OSY, New Inc., Vol. III. Townsend, J. F., Hall, D. G., Cavazos, F., and Lucas, F. V.: AMER.J. OBSTET. GYNEO.
93: 1013,1965.
Volume 109 Number 1
Discussion DR. MELVYN A. BAYLY, Chicago, Illinois. Next to uterine bleeding caused by complications of pregnancy, dysfunctional uterine bleeding is the most common type of abnormal uterine bleeding. Most of us choose to put the histological picture of endometrial hyperplasia in a special category, attributing its presence to the unopposed effect of estrogen, and restricting the term “dysfunctional uterine bleeding” to the instances wherein no demonstrable lesions of any kind can be found. Because no lesions are seen in dysfunctional uterine bleeding, it is most diEicult to study, and is most annoying when it occurs because the differential diagnosis includes endometrial carcinoma; further, the diagnosis is a retrospective one, and is usually made only after obtaining normal tissue following diagnostic curettage . . . yet, adenomyosis and occasionally a small submucous fibroid may indeed be present and undetected. I suspect that we cover up abnormal bleeding from these lesions occasionally with the use of cyclic hormonal therapy. Doctor Nedoss has pointed up the dilemma nicely, and presents meticulous documentation that 82.9 per cent of his patients curetted when past cycle day 14 did have secretory endo-
Dysfunctional
uterine bleeding
107
metrium, while 73 per cent of his patients that were curetted before cycle day 14 had proliferative endometrium. It would be interesting to know what the endometrium was like in the 86 patients with “palpatory abnormalities.” I suspect that the distribution would be the same. A few years ago we reported two series of patients whose uteri and ovarian tissue were available to study the relationship of abnormal uterine bleeding to endometriosis, and again to non-hormone-producing tumors. In both series there was an unexplained increment of abnormal uterine bleeding. It is interesting to note that in one series of unexplained abnormal uterine bleeding over one third of the group had secretory endometrium and in the other over one half had secretory endometrium. It is unfortunate that so many patients did not return; however, if the reason for the patient delinquency was due to success of the initial curettage, the over-all recurrence rate would be more in the neighborhood of 28 per cent . . . more in keeping with the success rate we like to think that we get following curettage where dysfunctional uterine bleeding is the final diagnosis. I noticed that no therapy was given in 43 instances. I wonder if these patients became asymptomatic after one more abnormal cycle?