MedEd by Virtual clinics
DUB / AUB Masterclass
Complete Clinical Approach to Abnormal Uterine Bleeding
Created by Dr. Sharad Maheshwari MD
imagingsimplified@gmail.com👨⚕️ Mentor Note
Welcome to the module. Dysfunctional Uterine Bleeding (DUB) is an older term, but it is deeply ingrained in exams and clinical vernacular. Today, we classify it under the non-structural causes of Abnormal Uterine Bleeding (AUB) using the PALM-COEIN system.
Your goal here is to master the concept of unopposed estrogen and how it destabilizes the endometrium. We will bridge the gap between classic DUB physiology and modern AUB management. Utilize the calculators to build your diagnostic reflexes. Let us begin.
🧠 Pathophysiology: The Core Concept
Why does bleeding occur if there is no structural lesion? The answer is Hormonal Imbalance leading to Endometrial Instability.
1. Anovulatory AUB (Most Common)
- ➡️ No ovulation means no corpus luteum forms.
- ➡️ No corpus luteum means no progesterone is produced.
- ➡️ The endometrium is subjected to unopposed estrogen.
- ➡️ It undergoes continuous proliferation, becoming thick and fragile.
- ➡️ Result: Irregular, heavy, unpredictable shedding.
2. Ovulatory AUB
- ➡️ Ovulation occurs normally, but there is a luteal phase imbalance.
- ➡️ Often involves altered prostaglandin ratios or vascular tone in the endometrium.
- ➡️ Result: Regular cycles, but excessively heavy bleeding (Menorrhagia).
Hormonal Profile Visualization
Showing normal cyclical hormone fluctuations. Note the progesterone peak.
🔍 Clinical Presentation & Etiology
👩⚕️ Think in Age Groups
Adolescents
Cause: Anovulation due to immature HPO axis.
Presentation: Irregular bleeding after menarche.
Reproductive Age
Cause: PCOS, Ovulatory dysfunction, Stress, Weight changes.
Presentation: Regular heavy or unpredictable bleeding.
Perimenopause (over 45 yrs)
Cause: Anovulation (failing ovaries) + Malignancy Risk.
⚠️ Always think malignancy until ruled out via biopsy.
Pattern Recognition
Clinical Core Rule:
DUB/AUB is a Diagnosis of Exclusion. You must exclude structural causes (Fibroids, Polyps, Adenomyosis, Malignancy) and Pregnancy before making this diagnosis.
⚙️ Clinical Calculators
Differential Diagnosis Generator
🗂️ Active Recall Flashcards
Test your high-yield knowledge. Click cards to reveal answers.
Why is progesterone absent in anovulatory cycles?
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No Corpus Luteum
Because ovulation fails to occur, the follicle never transforms into a corpus luteum, which is the sole producer of progesterone in the luteal phase.
Why is DUB extremely common in adolescents shortly after menarche?
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Immature HPO Axis
The Hypothalamic-Pituitary-Ovarian axis takes time to mature. This leads to frequent anovulatory cycles and unopposed estrogen stimulation.
Why must an endometrial biopsy be performed in a 48-year-old with heavy bleeding?
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To Rule Out Endometrial Cancer
AUB is a diagnosis of exclusion. Women over 45 are at higher risk for hyperplasia and malignancy. You cannot blindly prescribe hormones without tissue sampling.
What is the core mechanism of action for prescribing Progestins in Anovulatory AUB?
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Endometrial Stabilization
It converts the thick, fragile proliferative endometrium into a stable secretory endometrium, halting the overgrowth and allowing for controlled withdrawal bleeding.
📝 Self-Assessment Quiz
📚 Further Readings & Guidelines
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📖 FIGO PALM-COEIN Classification for AUB
The modern structural and non-structural classification system that replaced the term DUB globally.
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📘 ACOG Practice Bulletin: Management of Acute AUB
Evidence-based guidelines for handling acute severe bleeding, including high-dose estrogens and tranexamic acid protocols.
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📗 NICE Guidelines: Heavy Menstrual Bleeding
Comprehensive pathways detailing the role of the Levonorgestrel Intrauterine System (LNG-IUS) as first-line medical therapy.
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