Dysfunctional

Uterine Bleeding
[DUB]

Definition
A state of abnormal uterine bleeding
No clinically detectable organic
pathology in the reproductive tract
[Might be excessively heavy / light /
prolonged / frequent / random]

Incidence
Detection based on exclusion
incidence based on ability of
exclusion
Race no predilection
Age - in extremes of menstrual life

Pathophysiology
Disruption in normal cyclic pattern
of ovulation & hormonal stimulation
to endometrial lining
Normal physiology of menstrual
cycle
Any imbalance of,
Pulsatile release of GnRH
Release of FSH & LH
Synthesis & release of oestrogen &
progesterone

Ovulatory cycles

DUB

Anovulatory cycles

anovulatory cycles

(-) Ovulation

(-) corpus luteam

Defective production of progesteone

Oestrogen levels constant & noncycling
Overgrowth of endometrium
outgrows
blood supply
necrosis
irregular
bleeding

oestrogen secreted
proliferation

endometrial

In premenopausal ovaries

Ovulatory cycles
Ovulation defective /incomplete
Corpus luteal disfunction
oestrogen & progesterone
Abnormally short cycles
Corpus luteal cyst
Abnormally long cycles

Morbidity & mortality

Single episodes - good prognosis
Repetitive episodes
Chronic anovulation infertility
Risk of endometrial hyperplasia &
endometrial carcinoma
Fe defeciancy anaemia

Presentation / DD

Menorhagia
Organic

pelvic
Systemic
Endocrinal
Blood dyscrasis

Oligomenorrhoea
Wt related
Stress & exercise
related
Endocrine

Epimenorrhoea
Ovarian hyperaemia

Metrorrhagia
Uterine polyps
CA
cervix,Endometrium
Submucous fibroid

Hypomenorrhoea
Uterine synarche
Endocrinal
systemic

History
Menstrual
irregularity
Quantity
Quality

Hypovolemia/anaem
ia
Pregnancy/terminati
on/abortion
Contraception
OCP,IUCD,DMPA

PMHx
DM,HT,Hypo/
Hyperthyroidism,
liver disease,
hyperprolactinaemi
a
Medicationanticoagulants,
anticonvulsants,
antibiotics

Examination
Initial evaluation-volume
status,degree of anaemia
Cutaneous evidence of bleeding
disorders, petechiae, purpura,
mucosal bleeding
Stigmata of liver disease, PCOD,
Hypothyroidism, Hyperthyroidism ,
Hyperprolactinaemia

Investigation
Pregnancy test
FBC
TFT
Hormone profiles
TVS
Hysteroscopy

Management
Exclusion of the underlying
pathology in the genital tract
Diagnosis of underlying dysfunction
if possible
Assessment of the nature & severity
of the problem
Establishing the age,parity & future
fertility wishes of the patient

Medical management
Non hormonal treatment (without
contraception)

Tranexamic acid +/- Mefenamic acid

Cont for 3 months
If responding & no side effects continue

Hormonal treatment (with contraception)

COC 3/12
Progesterone releasing IUCD 6/12
Long 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
N
L

If normal Endometrial Bx
Abnormal
If abnormal -Endometrial Bx +
hysteroscopy

If above tests are normal

Reassure & R/V in OPD
If patient requests further
treatment, discuss options with the
patient & provide information about
outcomes & quality of life of the

Second line drug treatment(Ex.Danazol)

Progestogen releasing IUD
Surgery endometrial ablation &
hysterectomy

The post menarcheal

adolescent patient
Investigations
? Cause of bleeding
D&C contraindicated - Ashermanns
syndrome
Diagnosed DUB reassurance &
regular follow up
If recurrent cases hysteroscopy may
be necessary to exclude uterine
abnormality

The young adult &

middle aged
? Aetiology <40yrs

D&C is not indicated in all

OCP cont.5-25ds for 3 consecutive
cycles until the cycles are
regularised

The middle aged

>40yrs

D&C in all - to exclude malignancy &

other endometrial pathologies
Initial episode Mefenamic acid or
tranexamic acid
D&C
If D&C normal,to regularize the
cycles
Levenogestral releasing IUCD, Danazol,
GnRH analogues

Failing Above surgical Mx

Therapeutic curettage, laser ablation,
hysterectomy

Perimenopausal
patients

D&C exclude underlying

endometrial malignancy (pap smear
to exclude cervical carcinoma)
If malignancy excluded,
HRT / Other medical management

Not responding,
hysterectomy

Thank you