Dysfunctional Uterine Bleeding (DUB)

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Dysfunctional Uterine Bleeding is defined as abnormal vaginal bleeding in women during their reproductive years and is found in the absence of demonstrable structural or organic pathology. Although it can occur any time throughout woman’s reproductive years, it generally occurs at the menarche or the menopause. Abnormal uterine bleeding is one of the most common gynecologic problems. It may be heavier or longer than usual or occur at unexpected times. Sometimes, it may be the result of thyroid disease, liver disease, or problems with blood clotting; other common causes of abnormal uterine bleeding include problems of the reproductive organs, such as pregnancy, cancer, fibroids, ovarian cysts, or the use of birth control devices or hormone replacement therapy.

When an underlying cause is not diagnosed, the term dysfunctional uterine bleeding is used. Normally women lose about 40-155 ml blood during their menstrual cycle which occurs every 21 to 35 days. Estrogen is a hormone that stimulates growth of the uterine lining. Usually, patients with DUB have menstrual cycles that are longer than usual, which allows the lining of the uterus to be exposed to estrogen for long periods of time. After ovulation has occurred, another hormone called progesterone is produced by the ovary. Progesterone causes changes that prepare the uterine lining for menstruation, so that the entire surface layer can fall off neatly, all within a few days. DUB occurs when there is an imbalance of hormones so that there is no regular monthly release of an egg. In this situation, without the action of progesterone, steady estrogen exposure allows the lining of the uterus to overgrow, with no orderly preparation for menstruation so that bleeding can begin from one area, followed a few days later by bleeding from another area. Steady estrogen exposure results in growth of the lining, but some areas may be thicker than others, or out of synchrony, so that bleeding can begin from one area, followed a few days later by bleeding from another area.

Types of Dysfunctional Uterine Bleeding: 1) Metrorrhagia 2) Menorrhagia 3) Menometrorrhagia 4) Postcoital Bleeding 5) Polymenorrhea 6) Amenorrhea 7) Intermenstrual Uterine Bleeding (also known as Spotting) 8) Oligomenorrhea

Causes of DUB:

1. Imbalance between Estrogen and Progesterone is the first and important cause of abnormal vaginal bleeding. A prolonged bleeding may result due to improper built up of endometrial lining caused by low level of estrogen. Women who consume oral contraceptive pills (OCPs) may have such imbalance.

2. Anovulatory Cycle in which high estrogen are produced with no progesterone. The endometrium keeps on developing until feedback causes a drop in Follicle Stimulating Hormone (FSH). During this, the blood supply outgrows leading the condition in parting of endometrium slough. The type of DUB resulting is known as Menometrorrhagia.

3. Absence of Luteal phase is another cause of DUB. Luteal phase is shortened due to the insufficient progesterone availability accompanied by the low, high or normal level of estrogen.

4. Menopause: DUB usually occurs  in women above age 38. In this, the quality and quantity of ovarian follicles produced fall to a very low level. Due to this, the developed follicles are unable to produce enough/sufficient estrogen to cause ovulation. The estrogen production does not stop but late production results in late cycle and breakthrough bleeding.

5. Endocrine disorder such as thyroid Gland Disorder, PCOS, hyperprolactinemia, Cushing’s disease, premature ovarian failure, any lesion of vagina/cervix (Postcoital bleeding ) are another causes, Uterine Polyps and enlarged uterus are also considered to be associated with the development of DUB in women.

Symptoms of Dysfunctional Uterine Bleeding: In some cases, bleeding is light, although unpredictable and possibly prolonged. Moderate to heavy bleeding persistent enough to cause anemia is not uncommon. In some cases, hemorrhage can be severe enough to require hospitalization and even blood transfusion.

Diagnosis: Some Tests should be done to confirm DUB such as:

1. Urine pregnancy test

2. Complete Blood Count

3. FSH, PT/PTT, PAP SMEAR test, TSH, DHEAS, prolactin level test. Endometrial biopsy, uterine ultrasound (including transvaginal ultrasonography), dilatation and curettage, hysteroscopy, etc. to help confirm if the patient is not pregnant and not suffering from other diseases but DUB.

Treatment of Dysfunctional Uterine Bleeding: Treatment of DUB depends upon the severity of bleeding and the age of the patient. In teenagers and young women with light irregular bleeding, most will begin to have improvement in their symptoms within a few years, so only careful record keeping may be necessary. For other young women whose bleeding is heavier and more irregular, hormonal contraceptives may make bleeding more regular and provide birth control at the same time. Patients who can’t take birth control pills or who do not need birth control may be treated with a monthly dose of progesterone to bring on a regular period.

Several months of therapy may be necessary to regulate cycles with this method. Women with anemia should also receive oral iron supplements. In cases of acute, severe bleeding, the first goal is to make sure that the patient is stable. Blood transfusion may occasionally be necessary to treat critical anemia. To control the bleeding, hormonal therapy is almost always effective, though the patient must recognize that bleeding must eventually occur. When hormonal therapy is not able to control bleeding, endometrial biopsy or D&C should be performed to exclude other causes of bleeding. For women over the age of 35, DUB is less common, and other causes such as fibroids, polyps should be investigated. Once the diagnosis of DUB is made, oral contraceptive pills are often very successful in managing symptoms.

Surgical methods: 1. D&C may be successful to help manage acute bleeding that is not helped by medications. When D&C is necessary for severe bleeding, estrogen and progestins should be started immediately to help with control of future menstrual cycles.

2. Endometrial ablation is a method to destroy the lining of the uterus in order to stop or drastically decrease bleeding. This may be done by putting a hot balloon placed in the endometrial cavity to burn the lining, or by a procedure to burn or cut out the endometrium with other instruments. About 50-75% of patients may stop having periods after endometrial ablation, at least initially, and 20-30% of patients note an acceptable decrease in the amount of bleeding.

3. Occasionally, women who have finished having children may also consider hysterectomy, especially if anemia is severe, symptoms are not helped by medication, or if patients can’t tolerate the side effects of hormonal medications.

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