Dysfunctional Uterine Bleeding[DUB]

DefinitionA state of abnormal uterine bleedingNo clinically detectable organic pathology in the reproductive tract[Might be excessively heavy / light / prolonged / frequent / random]

IncidenceDetection based on exclusion incidence based on ability of exclusionRace no predilectionAge - in extremes of menstrual life

PathophysiologyDisruption in normal cyclic pattern of ovulation & hormonal stimulation to endometrial lining Normal physiology of menstrual cycleAny imbalance of,Pulsatile release of GnRHRelease of FSH & LH Synthesis & release of oestrogen & progesterone

DUB

anovulatory cycles (-) Ovulation (-) corpus luteamDefective production of progesteoneOestrogen levels constant & noncyclingOvergrowth of endometrium outgrows blood supply necrosis irregular bleeding oestrogen secreted endometrial proliferationIn premenopausal ovariesIrregular menstrual shedding

Ovulatory cyclesAnovulatory cycles

Ovulatory cyclesOvulation defective /incomplete

Corpus luteal disfunction oestrogen & progesterone Abnormally short cycles

Corpus luteal cyst Abnormally long cycles

Morbidity & mortalitySingle episodes - good prognosisRepetitive episodesChronic anovulation infertilityRisk of endometrial hyperplasia & endometrial carcinomaFe defeciancy anaemia

Presentation / DDMenorhagiaOrganicpelvicSystemicEndocrinalBlood dyscrasisOligomenorrhoeaWt relatedStress & exercise relatedEndocrine

EpimenorrhoeaOvarian hyperaemiaMetrorrhagiaUterine polypsCA cervix,Endometrium Submucous fibroidHypomenorrhoeaUterine synarcheEndocrinalsystemic

HistoryMenstrual irregularityQuantityQualityHypovolemia/anaemiaPregnancy/termination/abortionContraceptionOCP,IUCD,DMPA

PMHxDM,HT,Hypo/ Hyperthyroidism, liver disease, hyperprolactinaemiaMedication-anticoagulants, anticonvulsants, antibiotics

ExaminationInitial evaluation-volume status,degree of anaemiaCutaneous evidence of bleeding disorders, petechiae, purpura, mucosal bleedingStigmata of liver disease, PCOD, Hypothyroidism, Hyperthyroidism , Hyperprolactinaemia

InvestigationPregnancy testFBCTFTHormone profilesTVSHysteroscopy

ManagementExclusion of the underlying pathology in the genital tractDiagnosis of underlying dysfunction if possibleAssessment of the nature & severity of the problemEstablishing the age,parity & future fertility wishes of the patient

Medical management Non hormonal treatment (without contraception)Tranexamic acid +/- Mefenamic acidCont for 3 monthsIf responding & no side effects continue

Hormonal treatment (with contraception)COC 3/12Progesterone releasing IUCD 6/12Long acting progestogens 6/12

heavy menstrual bleeding despite drug treatment menstrual Hx reevaluated abdominal,bimanual & speculum examination Ix FBC,TFT & coagulation profile if (+) history TVS NLIf normal Endometrial Bx AbnormalIf abnormal -Endometrial Bx + hysteroscopy

If above tests are normalReassure & R/V in OPDIf patient requests further treatment, discuss options with the patient & provide information about outcomes & quality of life of theSecond line drug treatment(Ex.Danazol)Progestogen releasing IUDSurgery endometrial ablation & hysterectomy

The post menarcheal adolescent patientInvestigations ? Cause of bleedingD&C contraindicated - Ashermanns syndromeDiagnosed DUB reassurance & regular follow upIf recurrent cases hysteroscopy may be necessary to exclude uterine abnormality

The young adult & middle aged

The middle aged>40yrsD&C in all - to exclude malignancy & other endometrial pathologiesInitial episode Mefenamic acid or tranexamic acid D&C If D&C normal,to regularize the cycles Levenogestral releasing IUCD, Danazol, GnRH analoguesFailing Above surgical MxTherapeutic curettage, laser ablation, hysterectomy

Perimenopausal patientsD&C exclude underlying endometrial malignancy (pap smear to exclude cervical carcinoma)

If malignancy excluded, HRT / Other medical management

Not responding,hysterectomy

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