DYSFUNCTIONAL UTERINE BLEEDING (DUB)

Abnormal bleeding from the uterus in the absence of any organic disease in the genital tract

10 % of women attending gynecologycal OPD

Classification

According to functional abnormality

Anovulatory DUB

Ovulatory DUB

Clinical time of presentation

5-7 yrs following menarche (puberty menorrhagia)

20-25 yrs of mature reproductive life (corpus luteum dysfunction)

5-7 yrs preceding menopause (perimenopausal DUB)

Pathophysiology of DUB :

Anovulatory DUB

Dysfunction of hypothalamo-pituitary ovarian axis due to impaired response of hypothalamus or immaturity of estrogen feedback mechanism

Under the estrogenic influence

Hyperplasia of endometrium

Fragile supporting stromal tissue of endometrium

Endometrium outgrow the estrogen support

Estrogen threshold bleeding – not enough estrogen to support endometrial growth

Causes local disturbance in the endometrium due to imbalance in the production of vasodilator and vasoconstrictor prostaglandin (↑ PG E2- ↑ vasodilatation)

Ovulatory DUB

Corpus luteum hypo function (insufficiency/ irregular ripening)- disordered growth of endometrium

Corpus luteum hyper function (persistent corpus luteum)- continued secretion of estrogen and progesterone - absence of sharp fall- irregular shedding

↑ PGF2α -↑vasoconstriction- endothelial damage

↑ plasminogen/ fibrinolytic activity -↑ bleeding

Histopathology

Normal endometrium

Proliferative endometrium/Secretory endometrium

Disordered growth, irregular ripening, irregular shedding

Atrophic endometrium

After menarche

Immaturity of hypothalamic –pituitary-ovarian axis – anovulatory DUB

In the mature reproductive age group

Hypo or hyperfunction of corpus luteum

Local disturbance in the endometrium -ovulatory DUB

In the perimenopausal group

Increased resistance of ovarian follicles

Decreased number of follicles - anovulatory DUB

Diagnosis--History

Abnormal bleeding P/V

Excessive, prolonged duration, irregular bleeding, with clots

Irregular cycle/ preceded by a variable period of amenorrhoea

Symptom of anemia

Change in daily routine activity

Clinical examination

Normal pelvic finding

Signs of anemia if bleeding is severe

Rule out secondary causes (normal pelvic findings)

IUCD, Norplant, Depo provera

Thyroid problem

Coagulation disorder

Differential diagnosis of abnormal bleeding PV

Pregnancy related bleeding

Fibroid uterus

Adenomyosis, endometriosis

PID

Endometrial / endocervical polyps, hyperplasia,

IUCD/Norplant/Depo

Malignancy of cervix / uterus

Hormone producing ovarian tumor

Trauma

Investigations

To assess severity of condition

Hb, PCV, Blood grp Rh typing

To exclude organic pathology and confirm diagnosis

USG

Endometrial biopsy

Hysteroscopy

Platelet, BT, CT

Thyroid function test

Treatment

General measures

Oral iron capsule / menstrual calendar

Blood transfusion

Medical treatment

Non hormonal – prescribed during menstruation

Tranexamic acid- Anti fibrinolytic agent

Ethamsylate- increases capillary wall strength, anti fibrinolytic activity

Anti prostaglandins-mefenamic acid

Hormonal

Progesterone for anovulatory bleeding

Reverses effect of estrogen mediated endometrial proliferation

Induce endometrial maturation

For acute control of bleeding

Cyclically for 21 days

Progesterone containing IUCD

Estrogen and Progesterone ( COCP), for needing contraceptive as well

Danazol ( testosterone derivative)-competitive inhibitor of sex steroid

GnRH analogues- suppresses gonadotropin release from pituitary

Surgical management

Therapeutic D and C

Conservative surgery or minimal invasive

surgery under hysteroscopy

Endometrial resection and endometrial ablation

Non conservative surgery

Hysterectomy