DYSFUNCTIONAL UTERINE BLEEDING DEFINITION: DUB is defined as a state of abnormal uterine bleeding without any clinically detectable organic,

systemic and iatrogenic cause. INCIDENCE: The prevalence varies widely but an incidence of 10% amongst new patients attending the outpatient seems logical. CAUSES: Abnormal menstrual bleeding: Menorrhagia Polymenorrhoea Metrorrhagia Oligomenorrhoea Inappropriate by age: - Precious - Delayed menopause - Postmenopausal

Non menstrual blleding: Foreign body Urethral caruncles Genital malignancy Postcoital Intermenstrual Abortion Breakthrough bleeding

PATHOPHYSIOLOGY: Local causes in the endometrium Disturbance of the endometrial blood vessels and capillaries and coagulation of blood in and around these vessels. Alteration in the ratio of endometrial prostaglandins which are delicately balanced in haemostasis of menstruation

Dysfunctional uterine bleeding Classification of DUB The abnormal bleeding may be associated with or without ovulation and accordingly grouped into: 1. 2. Ovular bleeding Anovular bleeding Ovular bleeding: Poly menorrhoea or polymenorrhagia:

The condition usually occurs following child birth and abortion, during adolescence and premenopausal period and in pelvic inflammatory disease. The follicular development is speeded up with resulting shortening of the follicular phase. This is probably due to hyper stimulation of the follicular growth by FSH. Rarely, the luteal phase may be shortened due to premature lysis of the corpus luteum. Sometimes, it is related to stress induced stimulation. Endometrial study prior to or within few hours of menstruation reveals secretory changes. Oligomenorrhoea:

Primary ovular oligomenorrhoea is rare. It may be met in adolescence and preceding menopause. The disturbance may be due to ovarian unresponsiveness to FSH or secondary to pituitary dysfunction. There is undue prolongation of the proliferative phase with normal secretory phase. Endometrial study prior to or within few hours of menstruation reveals secretory changes. Functional menorrhagia: Ovular menorrhagia is quite uncommon. Two varieties are found: Irregular shedding of the endometrium Irregular ripening of the endometrium

Irregular shedding of the endometrium: The abnormality is usually met in extremes of reproductive period. Normally, regeneration of the endometrium is completed by the end of third day of menstruation. In irregular shedding, desquamation is continued for a variable period with simultaneous failure of regeneration of the endometrium. The possible explanations are: Incomplete withdrawal of LH even on 26th day of cycle Incomplete atrophy of the corpus luteum Persistent secretion of progesterone Persistent LH

 Inhibition of FSH Suppresses ripening of the follicle in the next cycle Less oestrogen Less regeneration Variation of the endometrial receptors which are sensitive to the influence of oestrogen and progesterone. Endometrial sampling performed after 5th or 6th day of the onset of menstruation reveals a mixture of secretory and proliferative endometrium. There is total absence of any surface epithelium. Pregnanediol found in the urine during menstrual phase. Irregular ripening of the endometrium: There is poor formation and inadequate function of the corpus luteum. Secretion of both oestrogen and progesterone is inadequate to support the endometrial growth. As such, slight bleeding occurs and continues prior to the start of proper flow. The endocrine profile is the luteal phase shows persistent low level of urinary pregnanediol level of less than 3 mg or plasma progesterone level less than 5ng/ml. Endometrial study prior to or soon after spotting reveals patchy area of secretory changes amidst proliferative endometrium. Anovular bleeding: Menorrhagia: Anovular bleeding is usually excessive. In the absence of growth limiting progesterone due to anovulation, the endometrial growth is under the influence of oestrogen throughout the cycle. There is inadequate structural stromal support and the endometrium remains fragile. Thus, with the withdrawal of oestrogen due to negative feedback action of FSH, the endometrial shedding continues for a longer period in asynchronous sequences because of lack of compactness. Changes in the uterus: There is variable degree of myohyperplasia with symmetrical enlargement of the uterus to a size of about 8-10 weeks due to simultaneous hypertrophy of muscles. The endometrial changes are classical. On naked eye examination, the endometrium looks thick, congested and often polypoidal. Microscopically: a) There is marked hyperplasia of all the endometrial components. b) Absence of secretory changes c) Areas of necrosis in the superficial layers with small haemorrhages and leucocytic infiltration. Changes in the ovary:

Cystic changes may be observed involving one or both the ovaries. The cyst may be single or multiple and the fluid contains oestrogen. The cyst is of follicular type. There is no evidence of corpus luteum. Confusion in diagnosis: Phase of amenorrhoea followed by continued bleeding per vaginum with bulky uterus is too often confused with disturbed uterine pregnancy or ectopic gestation. DUB of this type is absolutely painless. Atrophy of the endometrium: This type of abnormality is commonly met in postmenopausal women but may occur in reproductive period as final involuntary state of a previous metropathia. The bleeding occurs from the rupture of the dilated capillaries beneath the atrophic surface epithelium. The cause of endometrial atrophy may be due to total absence of oestrogen or failure of uterine receptors to become responsive to oestrogen. INVESTIGATIONS: Aims: To confirm the menstrual abnormality To exclude the organic pelvic pathology To identify the possible etiology of DUB To workout the definite therapy protocol History collection Internal examination Special investigations: Blood values Dilatation and curettage Ultrasound and color Doppler Hysteroscopy Laparoscopy Hysterography

MANAGEMENT: Management is grouped into, General Medical Surgery General management: Rest is advised Assurance Correction of anemia Investigation for any other abnormality

 Medical management: Hormones: Norethisterone acetate Medroxyprogesterone acetate Dydrogesterone Equine conjugated oestrogen Combined oestrogens and progestogens (contraceptive pills) 19 norsteroid derivative Danazol Mifepristone Desmopressin Prostaglandin synthetase inhibitors: mefenamic acid Antifibrinolytic agents: Tranexamic acid Ethamsylate Epsilon amino caproic acid Surgical management: Uterine curettage Endometrial ablation/ resection-laser ablation, trans cervical resection, roller ball ablation, micro wave endometrial ablation, novasure. Hysterectomy