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
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