Dysfunctional Uterine Bleeding

DUB is defined as abnormal uterine bleeding in the absence of any organic lesion in the genital tract. Most common occurs between menarche and menopause Diagnosis of DUB is made by excluding other treatable causes of abnormal uterine bleeding.

Types- Primary-Due to disturbance in hypothalamo pituatry ovarian axis and no cause can be found. Secondary-cause can be found but no organic lesion in genital tract like systemic disorders like hypothyorodism,coagulopathy or medications like IUCD, oral contraception,anticogulant drugs.

pathophysiology Anovulatory DUB: Anovulatory DUB: common at extremes of reproductive life i.e.during puberty and perimenopause The bleeding is mainly from proliferative or discordant endometrium During premenopausal years,the anovulatory bleeding is caused by decreasing functin of the ovaries During adolocence the anovulatory bleeding is due to failiur of hypothalamic-pitutary axis

Ovulatory DUB Ovulatory DUB: regular cycle, disturbance in amount/duration of flow

Patterns of DUB Polymenorrhea(abnormally frequent menses at intervals <24 days Menorrahgia or hypermenorrhea ( exessive or prolong menses >80ml and >7 days occuring at normal intervals Metrorrhagia (irregular episodes of uterine bleeding ) menometrorhagia_(heavy and irregular uterine bleeding

Approach to a patient with abnormal uterine bleeding Evaluation emphasizes on establishing the cause and ruling out organic pathology Thorough history. Important factors age parity last menstrual period last normal menstrual period Amount, duration & regularity of bleeding, intermenstrual bleeding postcoital bleeding,

associated problems like dysmenorrhea,infertility, menopausal symptoms medications (especially hormonal agents, NSAIDS, or anticoagulants) symptoms of pregnancy symptoms of bleeding disorders contraceptive history history of trauma Emotional upsets

Physical examination If abnormal uterine bleeding is not severe and does not require emergency management evaluation begins with Thorough general & systemic +gynecologic examination. Pelvic examination is usually unnecessary in patients who are not sexually active and are within 18 months of menarche.

Gynecologic examination includes inspection of the vulva/vagina speculum examination of cervix for organic lesions (polyps, tears, malignancy, or incomplete abortion) or infection. The size, shape, position, consistency,mobility of the uterus,cervical os closed/open. Note any signs of excessive blood loss.

Investigations Varies according to cases sp age group To assess the severity of the condition To exclude organic genital pathology and pregnancy To establish underlying dysfunction, if possible 1.Hematological: Hb%, bl gr, CBC including platelet count, BT, CT, Thyroid function test 2. Urine for pregnancy test 3.Ultrasonogram: exclude uterine pathology like fibroid, polyp,

Endometrial biopsy: OPD setting- vabra aspirator Dilatation & Curettage: to exclude intrauterine pathology sp carcinoma to know functional state of endometrium in 2 nd half of cycle. Hysteroscopy Laparoscopy

Management Depends on exclusion of organic disease, diagnosis of underlying dysfunction, type and severity of DUB, age, parity and wishes of patient regarding contraception and future fertility

General measures Menstrual calendar for 2-3 months: when active treatment is not urgent, sp in puberty Oral iron therapy routinely, blood transfusion in severe bleeding and anemia Treatment of sec. Causes : removal of IUCD, thyroid dysfunction, bleeding disorders etc.

Medical management of DUB 1.Prostaglandin synthetase inhibitors (NSAID): Beneficial in ovulatory DUB, dysmenorrhea Need to be given just before and during first 2 days of period Good first line agents Mefenamic acid, diclofenac, ibuprofen etc.

2.Hormones : according to bleeding pattern or functional state of endometrium i.Combined estrogen+progesterone (COC) ii.Progestogen alone iii.Estrogen therapy

3.Antifibrinolytic drugs: tranexamic acid

Surgical management of DUB D & C, hysteroscopy Endometrial ablation/resection Hysterectomy Hysterectomy