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Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
Dysfunctional Uterine Bleeding (DUB)
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Dysfunctional Uterine Bleeding (DUB)

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Dysfunctional Uterine Bleeding

Dysfunctional Uterine Bleeding

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  • 1. DYSFUNCTIONAL UTERINE BLEEDING ‘PATHO – PHYSIOLOGY’ Dr Sonali Ingole Asst Professor OBGY
  • 2. DUB : Definition • Abnormal uterine bleeding, in the absence of any demonstrable organic disease of the genital tract – Neoplasm – Infection – Pregnancy related complication • Abnormal uterine bleeding in the absence of genital tract pathology or medical illness • Abnormal uterine bleeding for which no specific cause has been found
  • 3. DUB : Classification • Primary • Secondary – Thyroid dysfunction – Haematologic disorders • Thrombocytopenia • Von Willebrands disease • Leukemias – Hepatic dysfunction • Iatrogenic – IUCD – Progesterone only contraception – Low dose Combined OC pills
  • 4. DUB • DUB occurs most often shortly after menarche and at the end of the reproductive years. –20% of cases are adolescents –50% of cases in 40-50 year olds • Diagnosis of EXCLUSION
  • 5. DUB • Patients present with “Abnormal uterine bleeding”
  • 6. NORMAL MENSTRUATION • Duration of flow : 2 – 7 days – Average duration : 4 – 6 days • Volume of flow : 20 – 70 ml – Average flow : 30 ml • Cycle length : 24 – 35 days* – Average cycle length : 28 – 30 days *Speroff L, Glass RH, Kase NG (Eds). Clinical Gynaecologic Endocrinology & Infertility. 7th Edn. Baltimore, 2005; 549 - 554
  • 7. MENORRHAGIA • Volume of flow ≥ 80 ml • Duration of flow > 7 days • Bleeding occurs at regular intervals • Common causes – Fibroids – DUB – IUCD – Adenomyosis – Thyroid dysfunction – Pregnancy related bleeding
  • 8. HYPOMENORRHOEA • Volume of flow < 10 ml • Duration of flow < 2 days • Common causes – Endometrial tuberculosis – Combined OC pill use – Ashermann’s syndrome – PCOD – Hyperprolactinemia
  • 9. POLYMENORRHOEA • Frequent menses • Bleeding intervals < 24 days* • Common causes – PID – Endometriosis – DUB * Speroff L, Glass RH, Kase NG (Eds). Clinical Gynaecologic Endocrinology & Infertility. 7th Edn. Baltimore, 2005; 549 - 554
  • 10. POLYMENORRHAGIA • Frequent & heavy / prolonged menses • Common causes – Fibroids uterus – PID – DUB – Endometriosis – Ovarian cysts
  • 11. OLIGOMENORRHOEA • Infrequent menses • Bleeding intervals > 35 days, upto 6 months • Common causes – PCOD – DUB – Hyperprolactinemia – Ovarian cysts – Thyroid dysfunction – Stress & Exercise related ( Hypothalamic)
  • 12. METRORRHAGIA / MENO- METRORRHAGIA • Irregular, acyclical bleeding / Heavy or prolonged irregular, acyclical bleeding • Common causes – Improper hormonal contraceptive use – DUB – Pregnancy related bleeding – Submucous fibroids & Fibroid polyps – Carcinoma cervix – Carcinoma endometrium – Progesterone only contraception
  • 13. Genesis of normal menstruation
  • 14. Alternatives for estrogen – progesterone primed endometrium
  • 15. Genesis of normal menstrual flow • Estrogen – progesterone withdrawal due to luteolysis results in enzymatic auto-digestion of non-gestational hormonally primed endometrium which is then discharged as menstrual flow
  • 16. Genesis of normal menstrual flow : Role of vascular endothelium • Synthetic activity – Paracrine factors – Angiogenic factors – Vasoactive factors – Haemostatic factors • Modulation of – Vasoactivity – Haemostasis – Thrombolysis – Angiogenesis
  • 17. Autocrine / paracrine regulation of gene transcription affecting vascular function
  • 18. Effects of progesterone withdrawal
  • 19. Genesis of normal menstrual flow • Cyclic vasomotor response of spiral arterioles (end arteries) in the endometrium
  • 20. Genesis of normal menstrual flow • Increasing duration and intensity of vasospasm results in ischaemic damage to endometrium and breakdown of tissue
  • 21. Genesis of normal menstrual flow • During periods of relaxation of vasospasm, blood extravasates though damaged vessel walls, cleaving the endometrium between stratum basalis and stratum spongiosum
  • 22. Genesis of normal menstrual flow • Progesterone withdrawal induces release of matrix metalloproteinases from the endometrial cells resulting in breakdown of cell membranes and extracellular matrix
  • 23. Genesis of normal menstrual flow • Endometrial tissue and extravasated blood are shed as menstrual flow
  • 24. Haemostaisis within uterus • Vasospasm • Platelet plug • Thrombin generation in the basal endometrium • Re-epithelialization • Myometrial contractions do not play a part in controlling menstrual blood loss ( in contrast to control of post – partum hge)
  • 25. Why is Estrogen – Progesterone withdrawal menstrual bleeding not heavy ? • It is a universal event occurring simultaneously throughout the entire endometrium
  • 26. Why is Estrogen – Progesterone withdrawal menstrual bleeding not heavy ? • The endometrium primed with estrogen and progesterone is structurally stable and random breakdown due to fragility is avoided
  • 27. Why is Estrogen – Progesterone withdrawal menstrual bleeding not heavy ? • Inherent in the events (vasospasm) that start the menstrual flow are the factors involved in stopping the menstrual flow
  • 28. Why is Estrogen – Progesterone withdrawal menstrual bleeding not heavy ? • Denudation of the functional layers of the endometrium allows the reparative process of re-epithelializtion to begin from the stratum basalis
  • 29. Dysfunctional Uterine Bleeding • Hormonally imbalanced conditions can give rise to abnormal uterine bleeding –Hyper-estrogenic state / Unopposed estrogen action –Hyper-progestogenic state / Abnormal progestogen – estrogen ratio
  • 30. Dysfunctional Uterine Bleeding • Anovulatory – Estrogen withdrawal – Estrogen breakthrough • Threshold bleeding • Supra-threshold bleeding – Progesterone breakthrough • Ovulatory – Irregular ripening – Irregular shedding – Abnormal local haemostatic mechanisms
  • 31. Estrogen withdrawal • One of the mechanisms of anovulatory uterine bleeding • Occurs on withdrawal of estrogen support to the endometrium • Common following menarche. Midcycle spotting can occur due to pre-ovulatory fall in E2 levels
  • 32. Estrogen breakthrough bleeding • Threshold bleeding – The levels of E2 waver around the threshold below which endometrium cannot be supported – Results in intermittent / prolonged spotting – May occur at extremes of reproductive age
  • 33. Estrogen breakthrough bleeding • Supra-threshold bleeding –Continuous E2 production unopposed by progesterone due to anovulation –Delayed periods followed by prolonged moderate to profuse bleeding –Endometrium thick without concomitant stromal structural support –Random breakdown common
  • 34. Progesterone breakthrough bleeding • Seen in the presence of an unfavourably high ratio of progesterone to estrogen (use of progesterone only contraception) • Results in intermittent spotting of variable duration • Prolonged progestogenic exposure results in atrophic changes and altered gland –stromal ratio within the endometrium • Bleeding occurs from unsupported endometrial vessels
  • 35. Progesterone withdrawal bleeding • Medical curettage • Poor compliance with progestogen therapy
  • 36. Ovulatory DUB • Luteal phase insufficiency – Irregular ripening – Mixed proliferative - secretory patterns • Prolonged luteal function / Corpus luteum cysts – Irregular shedding / Delayed prolonged menses • Primary pathology of haemostatic processes
  • 37. Mechanisms of DUB • Hyper-estrogenic / Hyper-progestogenic state • Abnormal angiogenesis and vascular fragility • Increased / Asynchronous tissue breakdown • Impaired haemostatic mechanisms • Impaired re-epithelialization
  • 38. Thank You

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