Dysfunctional Uterine Bleeding

Alternative names :- Anovulatory bleeding; Bleeding - dysfunctional uterine; DUB

Dysfunctional uterine bleeding (DUB) refers to any abnormal endometrial bleeding without recognizable organic lesions. It's a diagnosis of exclusion and, therefore, is used broadly. DUB is most common during postmenarchal and perimenopausal periods in a woman's reproductive life. The prognosis varies with the cause. DUB is the indication for almost 25% of gynecologic surgical procedures.

What causes dysfunctional uterine bleeding?

DUB usually results from an imbalance in the hormonal-endometrial relationship, where persistent and unopposed stimulation of the endometrium by estrogen occurs. Disorders that cause sustained high estrogen levels are polycystic ovary syndrome, obesity, immaturity of the hypothalamic-pituitary-ovarian mechanism (in postpubertal teenagers), and an ovulation (in women in their late 30s or early 40s). In most cases of DUB, the endometrium shows no pathologic changes. However. in chronic unopposed estrogen stimulation (as from a hormone-producing ovarian tumor),the endometrium may show hyperplastic or malignant changes.

Symptoms of dysfunctional uterine bleeding

DUB usually occurs as metrorrhagia (irregular episodes of vaginal bleeding between menses); it may also occur as hypennenorrhea (heavy or prolonged menses, longer than 8 days) or chronic polymenorrhea (menstrual cycle of less than 18 days). Such bleeding is unpredictable and can cause anemia.

Diagnosis information

Diagnostic studies must rule out other causes of excessive vaginal bleeding, such as organic, systemic, psychogenic, and endocrine causes, including certain cancers, polyps, incomplete abortion, pregnancy, and infection. Dilatation and curettage (D&C) and biopsy results confirm the diagnosis by revealing endometrial hyperplasia

Less invasive diagnostic tools such as sonographic uterine imaging may help evaluate the cause. Hemoglobin levels and hematocrit determine the need for blood or iron replacement.

Differential diagnosis must rule out:

• pregnancy
• hematologic abnormalities, such as idiopathic thrombocytopenic purpura (lTP), von Willebrand's disease, and leukemia
• exogenous hormones such as hormonal contraceptives
• infections, such as sexually transmitted diseases and pelvic inflammatory disease
• underlying medical conditions such as thyroid disease
• genital tract neoplasia.

Treatment of dysfunctional uterine bleeding

High-dose estrogen-progestogen combination therapy (hormonal contraceptives), the primary treatment, is designed to control endometrial growth and reestablish a normal cyclic pattern of menstruation. These drugs are usually administered four times daily for 5 to 7 days, although bleeding usually stops in 12 to 24 hours. The patient's age and the cause of bleeding help determine the drug choice and dosage. In patients over age 35, endometrial biopsy is necessary before the start of estrogen therapy to rule out endometrial adenocarcinoma. Progestogen therapy is a necessary alternative in some women such as those susceptible to the adverse effects of estrogen (thrombophlebitis, for example). Progestins may be delivered locally via intrauterine devices without systemic adverse effects.

If drug therapy is ineffective, a D&C serves as a supplementary treatment through removal of a large portion of the bleeding endometrium. D&C can also help determine the original cause of hormonal imbalance and aid in planning further therapy. If fertility isn't an issue, endometrial ablation may be a treatment option. Regardless of the primary treatment, the patient may need iron replacement or transfusions of packed cells or whole blood, as indicated, because of anemia caused by recurrent bleeding.

Complications

• Infertility resulting from lack of ovulation
• Severe anemia as a result of prolonged or heavy menstrual bleeding
• Prolonged buildup of the uterine lining without adequate menstrual bleeding (a possible factor in the development of endometrial cancer )

Special considerations or prevention

• Explain the importance of adhering to the prescribed hormonal therapy. If a D&C or endometrial ablation is ordered, explain this procedure and its purpose.
• Stress the need for regular checkups to assess the effectiveness of treatment.