DYSFUNCTIONAL UTERINE BLEEDING (DUB)

• A state of abdominal uterine bleeding without any clinically detectable organic, systemic and iatrogenic cause
• Primary DUB - Abnormal bleeding from the uterus where there is no disease of the genital tract, no IUCD, and no history of sex hormone administration
• Secondary DUB- Abnormal bleeding from the uterus secondary to IUCD, administration of sex hormones, Organic disease outside the genital tract- e.g. hypothyroidism, bleeding disorders

• Disorders of the hypothalamic-pituitary-ovarian axis
• Effects of endogenous or exogenous steroids
• Systemic metabolic disorders
• 20% of cases occur in adolescent females; 50% of women aged 40-50 yrs experience DUB

Causes of Anovulatory DUB 

• Unopposed oestrogen stimulation of the endometrium
• Lack of progesterone mediated maturation
• Excessive and fragile endometrium

Causes of Ovulatory DUB

• Luteal phase deficiency
• Prolonged progesterone secretion

• Heavy and prolonged bleeding( with clots and flooding)
• Irregular, heavy periods
• Dysmenorrhoea
• Anaemia
• Associated with breast tenderness, nausea, fatigue, etc.

 The abnormal bleeding may be associated with or without ovulation and accordingly grouped into:

• Ovular bleeding (20%)
• Anovular bleeding (80%)

Ovulatory DUB

• More common in women of age group 21-40 yrs
• Heavy regular bleeding and painful
• Polymenorrhoea - Bleeding at regular intervals of less than 24 days. The condition occurs following childbirth and abortion, during adolescence and premenopausal period, and in PID
• Oligomenorrhoea- Intervals greater than 35 days
• Functional Menorrhagia - Duration > 7 days, Volume > 80 ml, Occurring at regular intervals

Anovulatory DUB

• Occurs after menarche and before menopause
• There is persistent proliferative endometrium in the second half of the cycle
• Menorrhagia
• Cystic glandular hyperplasia (Metropathia haemorrhagia) 

History taking in DUB 

• Age at menarche, Parity, Menstrual history, Obstetric history, associated vaginal discharge, and IUCD insertion/hormone therapy/drugs

Examination

• General physical examination – Pallor, thyroid, BMI, signs of PCOD
• Internal examination – Speculum examination, PV examination (Uterine position, size, shape, surface, etc.)

 Special investigations

• Blood values àHb, TC, DLC, BT, CT, Platelet count, ESR, FBS, T3, T4, TSH
• USG and colour Doppler – Transvaginal Sonography
• Saline Infusion Sonography (SIS) -to diagnose endometrial polyps, submucous fibroids, and uterine abnormality
• Hysteroscopy – Diagnostic as well as therapeutic in IUCD, submucous fibroid, polyps
• Laparoscopy- to exclude unsuspected pelvic pathology
• Diagnostic uterine curettage (D & C)

Non- hormonal therapy

• Non-steroidal anti-inflammatory drugs (NSAID)
• Anti-fibrinolytic drugs

 Combined oral contraceptive pills

• Low dose oestrogen-progesterone (regulate the cycle and reduce the blood loss)

 Progestogens

• Used in anovulatory cycles to reduce the blood loss

 Levonorgestrel releasing IUCD

 Surgical Management

• Uterine curettage
• Endometrial ablation/ resection
• Hysterectomy 

 Ayurvedic Treatment

Internal Medicines

Bleeding phase

• Musali Khadiradi Kashaya
• Guduchyadi Kashaya
• Dusparsakadi Kashaya
• Chandanadi Kashaya
• Pushyanuga Choorna
• Chandanaasava
• Ashokarishta
• Dhanwanthara Gutika
• Dadimaadi Gritha

Non-bleeding phase

• Varanadi Kashaya
• Kanchanara Guggulu
• Phala Sarpis
• Dhanwanthara gutika
• Mandoora Vataka

 Procedures

• Snehapana - Phala Sarpis, Sukumaram Gritha, Varanadi Gritha 
• Vamana
• Virechana
• Vasthi
• Nasya - Vasa Swarasa, Ksheerabala Taila
• Thakra Dhara
• Yoni Pichu - Chandanadi gana Kashaya