Diagnosis & management of DUB
Dr Manjula M
Senior lecturer in O&G
SAT Hospital
Definition
Normal menstruation
Pathology
Types of DUB
Evaluation and diagnosis
Management

DEFINITION

abnormal uterine bleeding without any clinically detectable organic pelvic pathology

Novak-bleeding of uterine origin in the absence of pregnancy,tumour or inflammation
DUB is a diagnosis of
exclusion

An incorrect and improper diagnosis leads to failure of medical management and unnecessary surgical interventions
Normal menstruation
21-35 days cycle,3-8 days flow,30-60ml
Normal HPO axis
Decreased O&P- decre. BF to endometrium- endo. necrosis
Pathophysiology of DUB
↑ PGE2, PGF2 ratio
↑tpA - endometrial fibrinolysis
Abn. vascularity of endometrium
Delayed regn. of endometrium
↑endo. tissue necrosis
↑Prostacycline,TxA2 ratio
DUB-Diag of exclusion.
Organic disease of the genital tract
Pregnancy and its related complications
Organ failure
Genital injury, FB
Pathology of outflow tract

TERMS
Menorrhagia
Metrorrhagia
Polymenorrhea
Oligomenorrhea
Amenorrhea
Classification
Aetiological
Primary
Secondary
Iatrogenic
Types
Anovulatory
Ovulatory
HISTORY
Full menstrual history,medical history
Asso. mens. symptoms,h/o PID
Symptoms of endocrine / organic diseases /bleeding disorder
Stress,psych abn.
Drugs,IUCD
Family history
Future preg , contraception
Examination

Built
Pallor,icterus,hirsuitism
Petechial rashes,LNE
Thyroid,breast,abdomen
L/E- lesions ,FB,injury,anomalies
P/V-uterus ,adnexa
P/R- unmarried
Investigations
Hb, CBC,BT ,CT ,PS
LFT,RFT
PT,APTT
TFT
UPT
PAP smear

USG-TAS,TVS
Prolactin
RBS
R/O CAH ,Cushing synd.
F C ,D/C,endom. biopsy
Lap, hysteroscopy, sonohysterography
Endometrial Assessment
Array of methods

Dilatation and curettage
Hysteroscopy and endometrial
Endometrial sampling
Ultrasonography
CURETTAGE-primarily diagnostic,rarely therapeutic
In adolescents-deferred until severe bleeding
In reproductive –postponed till 3 months
Perimenopausal-done immediately
Postmenopausal-mandatory
Timing of curettage
Cyclic menorrhagia-5-6 days prior to onset of pds
Irregular shedding-5-6 days after pds start
Irregular ripening-soon after pds start
Acyclic-soon after pds start
Continuous-anytime
D&C
Rarely indicated in 5mm

Management
Medical
Non-hormonal
Hormonal
Surgical
Conservative
Hysterectomy
Non-hormonal
NSAIDs
Inhibits cyclooxygenase,blocks PGE2
20-30%redn in bld loss –ovulatory DUB
Antifibrinolytics –EACA,Tranexamic A
Inhibits tpA
50% redn in bld loss
IUCD related menorrhagia

Hormones
Progestogens
Norethisterone
MPA
Dydrogesterone
IU Progestogens
LNG IUS (Mirena)
Progestasert

Hormones
Combined O/P
OCP
HRT
OTHERS
Danazol
Gestrinone
GnRH analogues


Surgical therapy
Curettage

E A /RESECTION

HYSTERECTOMY
Management
Puberty and adolescent -40 yrs
Pubertal
75%- Primary DUB
Anovulatory (90%)
15% - Coaguln. defects
10% -condns like ovarian trs

Life style modificn, diet ,exercise ,wt. redn
Mild-reassurance, iron and vitamin supplementation,menstrual calender,periodic reevaluation
Moderate
PROGESTINS for 3-6 months

Progestogens reverses the effect of unopposed estrogens due to anovulation

In married women-contraceptive action also
Severe-hospitalisation,exclude coagulative pathology rapidly ,blood transfusion,iron and vitamin supplementation,
Trt CCF if present
Role of progestogens
NEA 10mg 1-1-1 * 3days till bleeding stops .taper over 3 days_

Withdrawal bleed _

Restart from 5th day of menstrual bleed
If progestogens fail

Can start on parenteral estrogens(premarin 25 mg 4th hrly,max 6 doses
After achieving haemostasis give progestogens concurrently

D&C-very rarely indicated
Helps to know hormonal status,and tissue diagnosis of tuberculous endometritis
Majorily return to normal pattern within 3-4 yrs of menarche
If anovulation exceeds 4 yrs,increased risk of PCOD,infertility, Ca endometrium
REPRODUCTIVE AGE GROUP
80% OVULATORY
20% ANOVULATORY
Take a careful h/o,detailed general and pelvic examination,r/o pregnancy complications,USS,r/o PID,irregular hormone intake/r/o malignancy,D&C
OPTIONS AVAILABLE—medical and surgical therapy
Prescribing practically
Progesterones-androgenic progesterones mainstay of treatment in anovulatory cycles. Produces “MEDICAL CURETTAGE”

Used to
Arrest hge in endometrial hyperplasia
Luteal phase trt in C L insufficiency d15-d25
Whole cycle trt in endometrial hyperplasia d5-d25
Give for 6 months and reevaluate.
Estrogen and Progesterone
Cyclical therapy
COC
2 – 4 tab 6 – 12 hrly for 5 – 7 days
withdrawal bleed
Low dose pill from 5th day
COC may be tapered
(4 times, 3 times, 2 times)
Over 3 – 6 days and 1 everyday
ESTROGENS - limited use to arrest acute
haemorrhage uncontrolled
by progesterones
Acts as a stimulus to clotting at capillary level
CONTRAINDICATIONS
DANAZOL
200mg/d decreases MBL
Antiestro,antiprogesto,androgenic

800mg/d produces amenorrhoea

Used in cases of recurrent bleed,awaiting hysterectomy
GESTRINONE-2,5 mg twice a week for 3 months

CLOMEPHINE citrate-used in anovulatory DUB with infertility ,wanting pregnancy

GnRH analogues-produces hypoestrogenic state and decreases MBL.These are indicated only in cases with adverse effects to sex steroid therapy,failure of sex steroid therapy,in haematologic disorders
PG SYNTHETASE INHIBITORS-decreases MBL by 20-30%
Used in ovulatory DUB
given during menses


ANTIFIBRINOLYTIC AGENTS-tranexamic acid used in IUCD induced menorrhagia and ovulatory DUB. CI in patients with h/o thrombosis
DESMOPRESSIN-increases factor VIII levels –used in DUB PATIENTS WITH COAGULOPATHY

LNG IUD –decreases MBL by 96% after 12 months of use
HPR
proliferative endometrium and pregnancy desired-CC
proliferative endometrium and pregnancy not desired-prog 2nd half*12 days
Secretory endometrium and pregnancy desired-PG synthetase inhibitors
Secretory endometrium and pregnancy not desired-OCP* 6 mths
Atrophic endometrium-est dominant OCP
Hyperplastic endometrium-prog dominant OCP

Surgical treatment
Conservative
ABLATIVE PROCEDURES-Thermal,roller ball
RESECTION
Radical
vaginal hysterectomy
TAH
Indications for endometrial ablation
Heavy menstrual loss
Endometrial atypia excluded
Uterus

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