DUB is a topic of midwifery nursing.

1. GOOD AFTERNOON

2. DYSFUNCTIONAL
UTERINE BLEEDING

3. DYSFUNCTIONAL UTERINE
BLEEDING
State of abnormal uterine bleeding
without any clinically detectable organic
pelvic pathology-tumour , inflammation
or pregnancy.
Incidence :10% amongest new patients
attending OPD

4. HORMONAL CYCLE

5. TYPES OF DUB
 Regular bleeding or
ovular bleeding
 Irregular bleeding or
anovular bleeding

6. OVULAR BLEEDING
OVULAR BLEEDING CONDITIONS:
-Childbirth
-Abortion
-During adolescent
-Premenopausal period
-PID

7. CAUSES OF REGULAR BLEEDING
1. Menorrhagia:
Cyclic bleeding at excessive in
amount >80 ml or duration or both.
Two varieties are found:
 Irregular shedding of the
endometrium
 Irregular ripening of the endometrium

8. IRREGULAR SHEDDING OF THE
ENDOMETRIUM
 Incomplete withdrawal of LH even on
26th day of cycle - incomplete atrophy
of the corpus luteum- persistent
secretion of progesterone.
 Persistent LH- inhibition of FSH-
supresses ripening of the follicle in the
next cycle- less oestrogen- less
regeneration
 Variation of the endometrial receptors-
influence of oestrogen & progesterone

9. IRREGULAR RIPENING OF THE
ENDOMETRIUM
 Poor formation and inadequate function
of the corpus luteum- inadequate
secretion of both oestrogen and
progesterone – inadequate support to
endometrial growth- slight bleeding
before menses.

10. 2.EPIMENORRHOEA: Cyclic bleeding where the
cycle is reduced to an arbitrary limit of 21 days
or less and remains constant at that frequency .
OR
EPIMENORRHAGIA: If the frequent cycle is
associated with excessive and prolonged
bleeding, it is called epimenorrhagia.

11. 3. OLIGOMENORRHOEA:
Menstrual bleeding occurring more than
35 days apart and which remains
constant at that frequency.
Causes:
-Ovarian unresponsiveness to FSH
-Secondary to pituitary dysfunction

12. PATHOLOGY OF DUB
 The uterus: Uniformly enlarged due to
myohyperplasia
 The endometrium: Overgrown, thick,
vascular, hyperplasia, swiss cheese
pattern.
 The ovary: Cystic changes seen in one
or both the ovaries.

13. ANOVULAR BLEEDING
 MENORRHAGIA:
-The endometrial growth is under the
influence of oestrogen and
progesterone throughout the cycle.
Due to anovulation endometrium
become fragile.

14. CYSTIC GLANDULAR HYPERPLASIA
OR METROPATHIA HAEMORRAGE:
 After period of amenorrhoea for a
month or two months bleeding is
present which is painless.
 Premenopause and adolescence
commonly seen.
 Overion dysfunction- failure of LH
effect.

15. PATHOPHYSIOLOGY OF DUB
Local causes in the endometrium
Incordination in the hypothalamopituitory-
overian axis
Disturb normal hormonal balance
Disturb endometrial blood vessels and
capillaries
Abnormal uterine bleeding

16. CLINICAL FEATURES OF DUB
 Menorrhagia
 Polymenorrhoea
 Menometrorrhagia
 Prolonged painless bleeding
 Sever anaemia
 Enlarged cystic ovary felt on one or both
sides of the uterus

17. SYMPTOMS

18. Investigations of DUB
AIM:
 To confirm the menstrual abnormality.
 To exclude the organic pelvic pathology.
 To identify the etiology of DUB.
 To workout the definite therapy
protocol.

19. Investigations of DUB
 History taking
 General and systemic examination
 Internal examination
 Plan of special investigations
 Blood values
 Diagnostic uterine curettage
 USG
 Hysteroscopy, hysterography
 Laproscopy

20. DIFFERENTIAL DIAGNOSIS
A) Pelvic condition :Abortion, disturbed tubal
gestation, endometrial TB and polyp, small
fibriod, endometrial carcinoma, IUCD.
B) Endocrinopathy : Granulosa cell tumour,
hypothyroidism causes anovulation
C) Haematological : Idiopathic thrombocytopenic
purpura, lukaemias, Von willebrand disease

21. MANAGEMENT OF DUB
Different phases:
 Pubertal and adolescent menorrhagia < 20
yrs
 Reproductive period (20-40 yrs.)
 Premenopausal (> 40 yrs.)
 Postmenopausal

22. M/N :PUBERTY MENORRHAGIA
•Rest , assurance
•Haematinics
Fails heavy bleeding
Admit for investigation
PRIMARY DUB SECONDARY DUB

23. PRIMARY DUB
PROGESTIN THERAPY(Metroxy
progesterone acetate10-20 mg/day)
Responsive
continue 2-3 cycles
Unresponsive conjugated
oestrogen 20-40 mg IV
every 6-8 hrs

24. M/N IN REPRODUCTIVE PERIOD
RESPO
NSIVE –
FOLLO
W UP
UNRESP
ONSIVE
REGULAR
CYCLE
IRREGULAR
CYCLE
INVESTIGATIONS
PATHOLOGY
DETECTED,
TREAT
ACCORDING
NEGATIVE
FINDINGS
USG,D+C
LAPEROSCO
PY, BIOPSY
FAMILY COMPLETED
HYSTERECTOMY
MEDICAL M/N,
FOLLOW UP

25. MEDICAL MANAGEMENT
 PROGESTERON
 COMBINED OESTROGEN –PROGESTERON
 OESTROGEN
 PROGESTIN RELEASING IUD
 DANAZOL
 CLOMIPHANE CITRATE
 GnRH ANALOGUES
 ANTIFIBRINOLYTIC DRUGS

26. SURGICAL MANAGEMENT

27. SURGICAL MANAGEMENT
 UTERINE CURRETTAGE
 ENDOMETRIAL ABLATION OR
RESECTION
 HYSTERECTOMY

28. PREMENOPAUSAL M/N
MALIGNANCY EXCLUDED
ENDOMETRIUM
PROLIFERATIVE
ENDOMETRIUM HYPERPLASIA,
ATYPICAL HYPERPLASTIC
HYSTERECTOMY
PROGESTINS
RESPONSIVE
FOLLOW UP
UNRESPONSIVE
HYSTERECTOMY

29. M/N OF POSTMENOPAUSAL DUB
Exclude genital malignancy as in the
perimenopausal group
Bleeding stops •Bleeding continues
•Recurs
Follow up
Recurs Hysterectomy

30. NURSING MANAGEMENT

31. NURSING MANAGEMENT
 ASSESSMENT
 GENERAL AND SYSTEMIC
EXAMINATION
 NURSING CARE

32. NURSING DIAGNOSIS
 ALTERED NUTRITION LESS THAN BODY
REQUIREMENT RELATED TO LOSS OF BLOOD
 ANXIETY RELATED TO LOSS OF BLOOD
 KNOWLEDGE DEFICIT REGARDING
MANAGEMENT AND DISEASE CONDITION
 ACTIVITY INTOLERANCE RELATED TO
WEAKNESS
 HIGH RISK FOR INFECTION RELATED TO
UNMET HYGIENE

33. DISCHAGE PLANNING
 DIET
 REST AND SLEEP
 DRUGS
 FOLLOW UP
 PERSONAL HYGIENE

34. GREEN LEAFY
VEGETABLES

35. CEREALS AND PULSES

36. ALL YELLOW AND RED
VEGETABLES