Causes of dysfunctional uterine bleeding : 

Causes of primary Dysfunctional uterine bleeding (DUB) : 

Primary DUB may result from a number of factors : 

1. Psychological factors like stress, emotion.
2. Endometrial changes.

• Disturbances in ecosanoid metabolism.
• Disturbances in fibrinolytic and lysosomal enzyme system  of endometrium.

   3. Defect in vascular morphology.

   4. Increased heparin synthesis.

Main cause of dysfunctional Uterine Bleeding.

1.. Anovulatory (80%)

• .Menorrhagia
• Cyclical glandular hyperplasia / metropathia haemorrhagica / Schroeder’s disease.

2.. Ovulatory (20)%

• Polymenorrhea or polymenorrhagia
• Oligomenorrhoea
• Functional menorrhagia :
        .Irregular ripening of endometrium.

             .Irregular shedding of endometrium.

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Medical conditions are associated with Dysfunctional Uterine Bleeding (DUB) :

The following medical conditions are associated with DUB : 

1. Polycystic ovarian disease (PCOD).
2. Obesity.
3. Hyperandrogenism.
4. Adrenal disease.
5. Thyroid disease.
6. Anorexia nervosa

Anovulation Causes excessive bleeding :

.The lack of progesterone causes asynchronous, excessive endometrial proliferation. This tissue layers lack structural rigidity and is fragile. When sloughing occurs, opens multiple vascular channels. The haemostatic mechanism of normal shedding appears to be altered in oestrogen dominant environment.

Obesity is associated with Dysfunctional uterine Bleeding (DUB) :

.In obese women there is high level of oestrogen due to increased peripheral conversion of androstenidione to oestrogen. LH surge fails to occur due to lack of appropriate concentration of oestrogen results in anovulation and DUB.

Management of Dysfunctional Uterine Bleeding (DUB) : 

History : 

1. Age of the patient : Common in two extremes of life.
2. Parity : Nulipara sometime associated with anovular DUB.
3. The statement of the excessive bleeding is assessed by 

•   No of pads used.
•   Passage of clots (size and number).
•   Duration of bleeding.

4. Menstrual history : 

•  Menstrual cycle : In DUB cycles may be frequent shorter than  21 days or longer than 35 days.
•  Menstrual flow.
•  Spasmodic dysmenorrhea.

 5. Contraceptive history : Any oral or injectable contraceptives or IUCD.

 6. Drug history like anticoagulant

 7. History of weight change, cold or heat intolerance indicates thyroid disorder.

 8. Family history like tuberculosis.

 9. History of abnormal bleeding from the injury site, epistaxis, gum bleeding should be enquired.

 10. Medical disease like liver or renal disease.

 11. Any emotional upset or psychosexual problem should be elicited tactfully.

Examination of Dysfunctional Uterine Bleeding : 

1. On general examination : 

•  Appearance : Pale/normal depending on blood  loss.
•  Build and nutrition : Obesity/average/under nutrition
•  Anaemia : May or may not present depending on blood loss.
•  Thyroid enlargement

  2. On per- abdominal examination :  No mass or tenderness in the abdomen.

  3. On Pelvic Examination : 

• Per speculum examination : Cervix is usually health looking.
• Bimanual examination : Normal or slightly bulky uterus but not larger than 12 Weeks, non- tender, mobile, fornices are free but  ovaries may be palpably 
• Per – rectal examination : Rectal mucosa free.

Investigation of Dysfunctional Uterine Bleeding (DUB) : 

General investigations : 

=Blood for : 

• Tc, DC,ESR, HB%
• Platelet count
• BT, CT, PT, APTT

=Hormones : 

• T3,T4 AND TSH
• FSH, LH, Prolactin

= Blood urea, serum creatinine.

= Diabetes screening.

= Tuberculin test.

= Chest X-Ray P/A view

= USG of lower abdomen and pelvis

Special investigations : 

• Diagnostic D & C (Endometrial biopsy).
• Hysteroscopy
• Pap’s smear
• Colposcopy
• Cervical biopsy.
• Laparoscopy

Principles of treatment  of Dysfunctional Uterine Bleeding (DUB) : 

.General treatment : 

• Assurance and bed rest.
• Correction of anaemia by diet, haematinics and even by blood transfusion.
• Any systemic or endocrine abnormality should be investigated and treated accordingly.

Medical management : 

.Non hormonal : 

• Prostaglandin synthetase inhibitors : Mefenamic acid (Fenamates)
• Antifibrinolytic agents : Tranexamic acid (TA).

Hormonal : 

1. Noretisterone acetate.
2. Medroxyprogesterone acetate
3. Progestin releasing IUCD : LNG- IUS.
4. Dydrogesterone.
5. Equine conjugated estrogen.
6. Combined estrogen and progestogen
7. 19 norsteroid derivative (Gestrinone).
8. Danazol (17 alpha – ethinyl testosterone).
9. Mifepristone (RU-486).
10. GnRH analogs.
11. Desmopressin

Surgical management of DUB : 

1. Uterine curettage.
2. Endometrial ablation/resection
3. Hysterectomy.