Friday, February 24, 2012

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

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