DUB

* Defn_
 It is menorrhagia which is not associated with any structural abnormality, disease in pelvis, and general/endocrine disease with normal uterus and its appendages on bimanual pelvic exam
_ there is no extragenital cause of bleeding.

# AetiologY
_ aetiology is purely hormonal
_ there is hypertrophy and hyperplasia of endometrium due to high Estrogen

# PathogenesiS
_ reduced levels of progesteron cause low levels of PGF2 alpha and cause menorrhagia
_increased level of Tissue Plasminogen Activator(TPA) a fibrinolytic enzyme leads more fibrinolysis

# ClassificatioN
¤ Anovulatory (80%)
_ threshold bleeding of puberty menorrhagia
_ metropathia haemorrhagica
_ premenopausal dysfunctional uterine bleeding
¤ Ovulatory (20%)
_ irregular ripening
_ irregular shedding
_ IUCD insertion
_ following sterilization operation

¤¤ Puberty menorrhagia
_ it s threshold bleeding of adolesceent girls due to unapposed oestrogen and absence of progesteron in anovulatory cycles
_ it occures as excessive bleeding or normal but continuous lasting many years

¤¤ Metropathia haemorrhagica
_ it s a special type of DUB
_ in it endometrium is thick and polypoidal and one or other ovary contains a cystic follicle
_ it s more prevalent in womens over d age of 40 yr
_ continuous vainal bleeding lastin 4 many weeks s commenest symptm
_ bleeding is painles
_ bleeding is preceded by amenorrhoea of 8 to 10 wks in 50% pt.
_ sometime blding shows normal patern and occurs at d time of period
_ in pt. It is preceded by menorrhagia

¤¤ Premenopausal DUB
_ it s seen in woman with anovulatory cycles b4 menopause

# Pathological Anatomy
1) mild myohyperplasia of myometrium cause enlargement of uterus
_ d endometrium is thick, haemorrhagic, and polypoidal,
_ polypi r thin slender project downwards 2wards d internal Os
_ endometrium shows characteristic glandular hyperplasia, most of d gland show cystic dialation and large cysts can b seen by naked eye
this is called as " Swiss cheese Patern"
2) there s absence of secretory hypertrophy so that "Corkscrew shaped gland" r never seen
3) areas of necrosis r scattered over superficial layers of endometrium and histological features in these necrotic areas correspond wth those found in d menstruating endometrium

# DiagnosiS of Menorrhagia
¤ History of onset, duration and amount of bleeding, its character and cyclical features, antecedent cause such as IUCD, recent delivery, abortion, drug therapy
¤ General exm with thyroid exm, full blood count, followed by abdominal and bimanual pelvic exm
¤ Ultrasound 2 exclude pelvic pathology
¤ Diagnostic curettage 2 obtain material 4 histology
¤ Histerosalpingography
¤ Histeroscopic examination

# TREATEMENT
¤ ConserVative
_ if bleeding is not heavy and pt.Hb% is normal, observation and maintenance 4 few mnths
_ oral iron 4 anaemia
_ rest and sedation
_ bld transfusion 4 svere anaemia

¤ Hormonal therapy
_ oraly active prostaglandins, steroid, such as nor_ethindral
_ progesterone IUD also stop bleeding in 90% pt.
_ Danazol has progestogenic action on endomeptrium
_ GnRH
_ NSAID_mefenamic acid

¤ Surgical treatment
1) Dilation and curettage in genital TB
2) Hysterectomy
_ in severe menorragia
_ it is contraindicated in enlarged uterus, fibroid uterus,and scarrd uters, endometrial carcinoma, young women
_ its coplications r pul.Oedema, embolism, htn, haemorrhage, infection
3) Radiofrequency induced thermal endometrial ablation
4) Baloon therapy
5) microwave endondtrial ablation