Tag: Dysfunctional Uterine Bleeding (Dub)

Dysfunctional Uterine Bleeding (Dub)

Dysfunctional Uterine Bleeding (Dub)


INTRODUCTION:

  • Abnormal uterine bleeding (AUB) is bleeding from the uterus that is longer than usual or that occurs at an irregular time.
  • Bleeding may be heavier or lighter than usual and occur often or randomly.
  • Irregular ripening of endometrium and Irregular shedding of endometrium leads to DUB
RISK FACTORS:
  • As spotting or bleeding between your periods
  • After sex
  • For longer days than normal
  • Heavier than normal
  • After menopause

ETIOLOGY:

Hormonal imbalance due to:

  • Thickening of the uterine wall or lining
  • Uterine fibroids
  • Uterine polyps
  • Cancers of ovaries, uterus, cervix, or vagina
  • Bleeding disorders or problems with blood clotting
  • Polycystic ovary syndrome
  • Severe weight loss
  • Hormonal birth control, such as birth control pills or intrauterine devices (IUD)
  • Excessive weight gain or loss (more than 10 pounds or 4.5 kilograms)
  • Infection of the uterus or cervix

TYPES:

DUB is of two types :          

Anovulatory (80%) : 

  • Threshold bleeding of puberty menorrhagia
  • Metropathia hemorrhagica/cystic glandular hyperplasia
  • Premenopausal DUB (Atrophy of endometrium).

Ovulatory (20%) :           

  • Irregular ripening
  • Irregular shedding
  • IUCD insertion
  • Following sterilization operation.

SYMPTOMS:

Symptoms of AUB may include:

  • Bleeding or spotting from the vagina between periods
  • Periods that occur less than 28 days apart (more common) or more than 35 days apart
  • Time between periods changes each month
  • Heavier bleeding (such as passing large clots, needing to change protection during the night, soaking through a sanitary pad or tampon every hour for 2 to 3 hours in a row)
  • Bleeding that lasts for more days than normal or for more than 7 days
  • Associated with Metropathia-haemorrhagica

Other symptoms caused by changes in hormone levels may include:

  • Excessive growth of body hair in a male pattern (hirsutism)
  • Hot flashes
  • Mood swings
  • Tenderness and dryness of the vagina

A woman may feel tired or fatigued if she loses too much blood over time. This is a symptom of anemia.

DIAGNOSIS:

  • Complete blood count (CBC)
  • Blood clotting profile
  • Liver function tests (LFT)
  • Fasting blood glucose
  • Hormone tests(Increased oestrogen) for FSH, LH, male hormone (androgen) levels, prolactin, and progesterone(decreased)
  • Pregnancy test
  • Thyroid function tests
  • Pap smear
  • D and C 
  • Culture to look for infection
  • Biopsy to check for precancer, cancer, or to help decide on hormone treatment 
  • Hysteroscopy, performed in your provider’s office to look into the uterus through the vagina
  • Ultrasound to look for problems in the uterus or pelvis
  • Histopathological findings include:Hyperplastic endometrium, Irregular shedding & ripening , Atrophic pattern & Normal secretory endometrium 

TREATMENT:

  • Treatment may include one or more of the following:
  • Low-dose birth control pills
  • Hormone therapy(Progesterone i.e. Norethisterone)
  • High-dose estrogen therapy for women with very heavy bleeding
  • Intrauterine device (IUD) that releases the hormone progestin
  • Nonsteroidal anti-inflammatory drugs (NSAID) taken just before the period starts
  • Surgery, if the cause of the bleeding is a polyp or fibroid

COMPLICATIONS:

  • Infertility (inability to get pregnant)
  • Severe anemia due to a lot of blood loss over time
  • Increased risk for endometrial cancer
Exam Question
 
  • Treatment of DUB in young female is Hormones
  • Causes of dysfunctional uterine bleeding can be Irregular ripening of endometrium
  • The most common histological finding of endometrium in DUB is  Hyperplastic
  • Treatment for 32 years old multipara with dysfunc­tional uterine bleeding (DUB) is Progesterone
  • In DUB, there is Increased oestrogen
  • Dysfunctional uterine bleeding is associated with Metropathia-haemorrhagica
  • Dysfunctional uterine bleeding is defined as abnormal bleeding due to Anovulatory cycle
  • In a case of dysfunctional uterine bleeding thehormone which is usually deficient is Progesterone
  • The progestogen with the greatest haemostatic effect used in dysfunctional uterine bleeding (DUB) is  Norethisterone
  • D and C is useful in the diagnosis of DUB
Don’t Forget to Solve all the previous Year Question asked on Dysfunctional Uterine Bleeding (Dub)

Dysfunctional Uterine Bleeding (Dub)

DYSFUNCTIONAL UTERINE BLEEDING (DUB)

Q. 1

Treatment of DUB in young female is :

 A

Hormones

 B

Radiotherapy

 C

D & C

 D

Hysterectomy

Q. 1

Treatment of DUB in young female is :

 A

Hormones

 B

Radiotherapy

 C

D & C

 D

Hysterectomy

Ans. A

Explanation:

Ans. is a i.e. Hormones 

Common Causes of Bleeding in Reproductive Age Group are :

  • DUB
  • Pregnancy related bleeding
  • Exogenous hormone (eg. OCP)
  • Endocrine causes : – Hypothyroidism                                        – Hypothalamic dysfunction

Hyperprolactinemia                            – Premature ovarian failure Pituitary disease

  • Uterine pathology : – Lelomyomas                                             – Endometrial polyps
  • Coagulopathies
  • Infectious cause        – Chlamydial cervicitis can cause irregular bleeding and post coital bleeding
  • Neoplasia                   – Endometrial hyperplasia                      – Cervical neoplasia

– Vaginal neoplasia (uncommon)

Investigations : In Reproductive age group besides Lab investigations (as done in case of puberty menorrhagia) and USG, Endometrial sampling should be done.

Role of Endometrial sampling : Endometrial sampling has now replaced D & C which was used extensively for evaluation of abnormal bleeding (but in countries like India, D & C is still being done).

Endometrial sampling should be done in females :

  1. At risk for Endometrial polyps.
  2. At risk for Endometrial hyperplasia or carcinoma.
  3. 3.   With anovulatory bleeding and 35 — 40 years of age.
  4. 4.   With anovulatory bleeding and obesity (No age constraint).
  5. H/0 prolonged anovulation.

Hysteroscopy can be done along with endometrial sampling.

Surgical therapy :

    • It is reserved for situations in which medical therapy has been unsuccessful or is contraindicated.
    • Surgical treatment depends on the cause of bleeding.



Q. 2

Causes of dysfunctional uterine bleeding can be:

 A

Uterine polyp

 B

Fibroid

 C

Granulosa cell tumour

 D

Irregular ripening of endometrium

Q. 2

Causes of dysfunctional uterine bleeding can be:

 A

Uterine polyp

 B

Fibroid

 C

Granulosa cell tumour

 D

Irregular ripening of endometrium

Ans. D

Explanation:

Ans. is d and e i.e. Irregular ripening of endometrium; and Irregular shedding of endometrium

DUB is defined as a state of abnormal uterine bleeding without any clinically detectable organic pelvic pathology.

DUB is of two types :          

1. Anovulatory (80%)

2. Ovulatory (20%)

Anovulatory (80%) : • Threshold bleeding of puberty menorrhagia

  • Metropathia hemorrhagica°/cystic glandular hyperplasia°
  • Premenopausal DUB (Atrophy of endometrium).

Ovulatory (20%) :           

  •  Irregular ripening°
  • Irregular shedding°
  • IUCD insertion
  • Following sterilization operation.

Q. 3

The most common histological finding of endometrium in DUB is :

 A

Hypertrophic

 B

Hyperplastic

 C

Cystic glandular hyperplasia

 D

Dysplastic

Q. 3

The most common histological finding of endometrium in DUB is :

 A

Hypertrophic

 B

Hyperplastic

 C

Cystic glandular hyperplasia

 D

Dysplastic

Ans. B

Explanation:

Ans. is b i.e. Hyperplastic

Endometrial pattern in DUB

Normal secretory endometrium = 60 %

  • Hyperplastic endometrium         = 30 %
  • Irregular shedding                 1
  • Irregular ripening            = 10%
  • Atrophic pattern

Since normal secretory endometrium is not given in options so, we will see 2rld most common which is hyperplastic endometrium.



Q. 4

Treatment for 32 years old multipara with dysfunc­tional uterine bleeding (DUB) is :

 A

Progesterone

 B

Danazol

 C

Prostaglandins

 D

Endometrial ablation

Q. 4

Treatment for 32 years old multipara with dysfunc­tional uterine bleeding (DUB) is :

 A

Progesterone

 B

Danazol

 C

Prostaglandins

 D

Endometrial ablation

Ans. A

Explanation:

Ans. is a i.e. Progesterones

Guys, It is very important to clear your facts on Management of DUB and Polymenorrhea in different age groups. You must read the question very carefully as management of Polymenorrhea and DUB is different. First lets understand the basics regarding Polymenorrhea and DUB.

Polymenorrhea :

  • It is cyclical bleeding which is normal in amount but occurs at frequent intervals (< 21 days).
  • Polymenorrhea occurs in ovulatory bleeding where the ovary goes through its normal cycle but does it more quickly. The acceleration mainly affects the follicular phase of menstrual cycle.

Physiological

  • Following menarche Preceeding menopause

Pathological

Chronic congestion of ovaries as in : chronic salpingo-oophiritis

DUB :

  • DUB is defined as a state of abnormal uterine bleeding without any clinically detectable organic pelvic pathology.
  • It is mostly anovulatory (80%) i.e., there is deficeincy of progesteron,.so it can be treated successfully with progesterone,

Also know :

In anovulatory cycles : If progesterone is commenced during an episode of heavy bleeding — Progesterone of choice is Norethisterone acetate° as it has better hemostatic action whereas for cyclical maintenance therapy dydrogesterone or medroxy progesterone acetate is preferred.


Q. 5

In DUB, there is :

 A

Increased oestrogen

 B

Decreased receptors of progesterone

 C

Decreased receptors of oestrogen

 D

Pituitary imbalance of hormones

Q. 5

In DUB, there is :

 A

Increased oestrogen

 B

Decreased receptors of progesterone

 C

Decreased receptors of oestrogen

 D

Pituitary imbalance of hormones

Ans. A

Explanation:

Ans. is a i.e. Increased estrogen 

DUB is defined as a state of abnormal uterine bleeding without any clinically detectable organic pelvic pathology (viz tumor, inflammation or pregnancy).

Its etiology is purely hormonal di la the hypertrophy and hyperplasia of the endometnum are induced by a high titre of estrogen in the circulating blood.

Also know : Hormone which is deficient in DUB – Progesterone°.


Q. 6

Dysfunctional uterine bleeding is defined as abnormal bleeding due to :

 A

Thyroid dysfunction

 B

Functioning ovarian tumour

 C

Anovulatory cycle

 D

Blood dyscrasias

Q. 6

Dysfunctional uterine bleeding is defined as abnormal bleeding due to :

 A

Thyroid dysfunction

 B

Functioning ovarian tumour

 C

Anovulatory cycle

 D

Blood dyscrasias

Ans. C

Explanation:

Anovulatory cycle


Q. 7

Initial treatment of dysfunctional uterine bleeding in a young female is :

 A

Oral pills

 B

Danazol

 C

Hysterectomy

 D

Androgens

Q. 7

Initial treatment of dysfunctional uterine bleeding in a young female is :

 A

Oral pills

 B

Danazol

 C

Hysterectomy

 D

Androgens

Ans. A

Explanation:

Oral pills


Q. 8

In a case of dysfunctional uterine bleeding thehormone which is usually deficient is :

 A

Oestrogen

 B

Progesterone

 C

Thyroxin

 D

A.C.T.H.

Q. 8

In a case of dysfunctional uterine bleeding thehormone which is usually deficient is :

 A

Oestrogen

 B

Progesterone

 C

Thyroxin

 D

A.C.T.H.

Ans. B

Explanation:

Progesterone


Q. 9

Treatment of dysfunctional uterine bleeding is all except :

 A

Oral contraceptive pills

 B

Oestrogen

 C

Progesterone

 D

Ovariotomy

Q. 9

Treatment of dysfunctional uterine bleeding is all except :

 A

Oral contraceptive pills

 B

Oestrogen

 C

Progesterone

 D

Ovariotomy

Ans. D

Explanation:

Ovariotomy


Q. 10

Which of the following is an example of dysfunctional uterine bleeding :

 A

Hypothyroidsm

 B

PID

 C

Cervical erosion

 D

None

Q. 10

Which of the following is an example of dysfunctional uterine bleeding :

 A

Hypothyroidsm

 B

PID

 C

Cervical erosion

 D

None

Ans. D

Explanation:

None


Q. 11

The progestogen with the greatest haemostatic effect used in dysfunctional uterine bleeding (DUB) is :

 A

Medroxy progesterone

 B

Hydroxy progesterone

 C

Norethisterone

 D

Dydrogesterone

Q. 11

The progestogen with the greatest haemostatic effect used in dysfunctional uterine bleeding (DUB) is :

 A

Medroxy progesterone

 B

Hydroxy progesterone

 C

Norethisterone

 D

Dydrogesterone

Ans. C

Explanation:

Norethisterone


Q. 12

D and C is useful in the diagnosis of :

 A

Genital TB

 B

Endometrial carcinoma

 C

DUB

 D

All

Q. 12

D and C is useful in the diagnosis of :

 A

Genital TB

 B

Endometrial carcinoma

 C

DUB

 D

All

Ans. D

Explanation:

All


Q. 13

Which of the following condition is associated with dysfunctional uterine bleeding?

 A

Metropathia haemorrhagica

 B

Polycystic ovary

 C

Endometrial TB

 D

Hypothyroidism

Q. 13

Which of the following condition is associated with dysfunctional uterine bleeding?

 A

Metropathia haemorrhagica

 B

Polycystic ovary

 C

Endometrial TB

 D

Hypothyroidism

Ans. A

Explanation:

Metropathia haemorrhagica is a condition associated with cyclic endometrial hyperplasia and is the best documented type of dysfunctional uterine bleeding.
In this, ovary is refractory to normal levels of pituitary gonadotropins, the follicles ripen but do not rupture and the endometrium become hyperplastic under persistent oestrogenic stimulation.
Patient develop heavy painless hemorrhage after a variable duration of amenorrhea when the exuberant endometrium is shed as relative estrogen deficiency occur.
 
Dysfunctional uterine bleeding is defined as: Abnormal vaginal bleeding not associated with any demonstrable pathology.
 
Aeitiologic classification:
Ovular:
  • Functional epimenorrhea
  • Ovulation
  • Functional menorrhagia
Anovular
  • Metropathia haemorrhagica
  • Threshold bleeding
Ref: Gynaecology and Obstetrics By Balaram Jana page 43.

Q. 14

A 38-year-old woman is seen by a gynecologist on a routine visit. A complete history is taken and is non-contributory except for the fact that the patient’s menstrual irregularities apparently developed insidiously over the preceding decade. Screening physical examination is performed. Routine serum chemistries and complete blood count are sent, as are Pap smear studies. Pelvic ultrasound studies are also performed. Pregnancy test is negative. Endometrial biopsy shows proliferative endometrium. All other results are within normal limits, except for evidence of a mild iron deficiency anemia. Which of the following is the most likely diagnosis?

 A

Cervical carcinoma

 B

Cervical dysplasia

 C

Dysfunctional uterine bleeding

 D

Endometrial carcinoma

Q. 14

A 38-year-old woman is seen by a gynecologist on a routine visit. A complete history is taken and is non-contributory except for the fact that the patient’s menstrual irregularities apparently developed insidiously over the preceding decade. Screening physical examination is performed. Routine serum chemistries and complete blood count are sent, as are Pap smear studies. Pelvic ultrasound studies are also performed. Pregnancy test is negative. Endometrial biopsy shows proliferative endometrium. All other results are within normal limits, except for evidence of a mild iron deficiency anemia. Which of the following is the most likely diagnosis?

 A

Cervical carcinoma

 B

Cervical dysplasia

 C

Dysfunctional uterine bleeding

 D

Endometrial carcinoma

Ans. C

Explanation:

This patient most likely has dysfunctional uterine bleeding (DUB). Other, potentially more serious, diseases have been mostly excluded by the patient’s extensive evaluation (more than many patients receive in this setting).

Cervical dysplasia or carcinoma usually produce abnormal pap smears, and sometimes produce an abnormal vaginal examination.

Endometrial carcinoma would usually be evident in either the endometrial biopsy or on the pelvic ultrasound examination.

Q. 15

A 48 years old female suffering from severe menorrhagia (DUB) underwent hysterectomy. She wishes to take hormone replacement therapy. Physical examination and breast are normal but X-ray shows osteoporosis. The treatment of choice is:

 A

Progesterone

 B

Estrogen progesterone

 C

Estrogen

 D

None

Q. 15

A 48 years old female suffering from severe menorrhagia (DUB) underwent hysterectomy. She wishes to take hormone replacement therapy. Physical examination and breast are normal but X-ray shows osteoporosis. The treatment of choice is:

 A

Progesterone

 B

Estrogen progesterone

 C

Estrogen

 D

None

Ans. C

Explanation:

Osteoporosis in this patient is due to estrogen deficiency. Estrogens are efficacious when administered orally or transdermally.

Various types of estrogens (conjugated equine estrogens, estradiol, estrone, esterified estrogens, ethinyl estradiol, and mestranol) reduce bone turnover, prevent bone loss, and induce small increases in bone mass of the spine, hip, and total body.

The effects of estrogen are seen in women with natural or surgical menopause and in late postmenopausal women with or without established osteoporosis.

Ref: Lindsay R., Cosman F. (2012). Chapter 354. Osteoporosis. In D.L. Longo, A.S. Fauci, D.L. Kasper, S.L. Hauser, J.L. Jameson, J. Loscalzo (Eds), Harrison’s Principles of Internal Medicine, 18e.



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