Define Dysfunctional Uterine Bleeding (D.U.B.). How will you diagnose a case of Metropathia Haemorrhagica? Briefly write the management of Metropathia Haemorrhagica.

Defining Dysfunctional Uterine Bleeding (D.U.B.)

DUB is defined as abnormal uterine bleeding occurring in the absence of pelvic pathology, coagulation disorders, or medical systemic disease. The International Federation of Gynecology and Obstetrics (FIGO) system categorizes abnormal uterine bleeding using the PALM-COEIN system (Polyp, Adenomyosis, Leiomyoma, Malignancy and Hyperplasia; Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified). DUB falls under the ‘COEIN’ category, specifically ovulatory dysfunction or endometrial causes.

Diagnosing Metropathia Haemorrhagica

Diagnosing Metropathia Haemorrhagica requires a systematic approach to rule out other causes of abnormal uterine bleeding. The following steps are crucial:

1. History and Physical Examination

• Detailed menstrual history: cycle length, duration of bleeding, amount of blood loss (using pictorial blood loss assessment chart - PBAC).
• Assessment for signs of anemia (pallor, fatigue).
• General physical examination to rule out systemic diseases.

2. Investigations

• Complete Blood Count (CBC): To assess for anemia.
• Coagulation Studies: Prothrombin time (PT), activated partial thromboplastin time (aPTT), platelet count to rule out bleeding disorders.
• Thyroid Function Tests (T3, T4, TSH): To exclude thyroid dysfunction.
• Prolactin Level: To rule out hyperprolactinemia.
• Pelvic Ultrasound: To exclude structural abnormalities like fibroids, polyps, or adenomyosis. Transvaginal ultrasound is preferred for better visualization.
• Endometrial Biopsy: Essential to rule out endometrial hyperplasia or malignancy, especially in women over 45 years or with risk factors.
• Hormonal Assays: FSH, LH, Estradiol levels to assess ovarian function.
• Hysteroscopy: May be considered if ultrasound findings are inconclusive or to directly visualize the uterine cavity.

3. Diagnostic Criteria for Metropathia Haemorrhagica

Metropathia Haemorrhagica is diagnosed when:

• Abnormal uterine bleeding is present.
• Organic pathology, coagulation disorders, and systemic diseases have been excluded.
• The bleeding pattern is irregular, prolonged, or excessive.
• Endometrial biopsy shows proliferative endometrium without evidence of hyperplasia or malignancy.

Management of Metropathia Haemorrhagica

Management depends on the severity of bleeding, patient’s age, reproductive desires, and underlying cause (if identified).

1. Medical Management

• Progestogens: Medroxyprogesterone acetate (MPA) or Norethisterone can be used to regulate the cycle and reduce bleeding.
• Combined Oral Contraceptive Pills (COCPs): Effective in regulating the cycle and reducing bleeding.
• Tranexamic Acid: An antifibrinolytic agent that reduces menstrual blood loss.
• Nonsteroidal Anti-inflammatory Drugs (NSAIDs): Reduce prostaglandin production and can decrease bleeding.
• Danazol: A synthetic androgen that suppresses ovarian function, but has significant side effects.

2. Surgical Management

• Dilation and Curettage (D&C): Can provide temporary relief by removing the endometrial lining, but bleeding often recurs.
• Endometrial Ablation: Destroys the endometrial lining, reducing or stopping menstrual bleeding. Suitable for women who have completed childbearing.
• Hysterectomy: The definitive treatment for DUB, but is reserved for severe cases unresponsive to other treatments and in women who do not desire future fertility.

3. Management Algorithm

Initial management typically involves medical therapy. If medical therapy fails, endometrial ablation or hysterectomy may be considered. The choice of surgical procedure depends on the patient’s age, parity, and desire for future fertility.