Dysfunctional Uterine Bleeding (DUB)

Dysfunctional Uterine Bleeding Definition

Dysfunctional uterine bleeding (DUB) refers to irregular and unpredictable bleeding from the uterus. Though dysfunctional uterine bleeding is not serious in most cases, it can be severely affect a woman’s quality of life and lead to anemia if the bleeding is frequent. In the majority of patients, dysfunctional uterine bleeding results from changes in hormone levels. It occurs in the absence of other medical conditions, like miscarriage, cancer, fibroids, or blood clotting problems. Dysfunctional uterine bleeding can be light or excessively heavy, prolonged, recurrent, or unpredictable. This condition mainly affects adolescents and women undergoing menopause.

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Dysfunctional Uterine Bleeding Incidence

Dysfunctional uterine bleeding is a common problem, affecting about 1 out of 10 women. Of these DUB patients, up to 30% suffer from anemia due to abnormal blood loss with disturbed menstrual cycles. If left untreated, DUB can contribute to the development of endometrial cancer in 1% to 2% of cases.

Dysfunctional Uterine Bleeding Hormones

During menstruation in normal healthy women, the levels of the hormone estrogen increase and the wall of the uterus (endometrium) becomes thick. Due to the effect of another hormone called luteinizing hormone (LH), one of the follicles in the ovary releases an egg. After the release of the egg the levels of a hormone, progesterone, increases causing the endometrium undergoes several changes in preparation for a potential pregnancy. If there is no implantation, levels of both progesterone and estrogen drop sharply. This leads to the next round of menstruation in which the endometrium is shed and expelled via the vagina.

Dysfunctional Uterine Bleeding Pathophysiology

In patients with DUB, there is no cyclic stimulation of endometrium. The levels of estrogen are always constant. This promotes continuous endometrial growth. In the absence of regular shedding, the endometrium outgrows its blood supply. As a result, it breaks down and sheds from the uterus but does not heal properly. This results in dysfunctional uterine bleeding.

  • If estrogen levels are lower than normal, irregular and light DUB is seen.
  • If estrogen levels are higher than normal, frequent and heavy bleeding is seen.

Dysfunctional Uterine Bleeding Symptoms

The following symptoms may be present during dysfunctional uterine bleeding:

  • Getting periods before completion of 3 weeks from the date of previous menstrual flow.
  • Getting periods after completion of 5 weeks from the date of previous menstrual flow.
  • Periods lasting for more than a week,
  • Abnormally heavy bleeding.
  • Passing of blood clots.

Frequent and intense blood loss resulting from dysfunctional uterine bleeding can lead to anemia. Other symptoms such as fatigue, paleness of the skin, shortness of breath and frequent muscle cramping may therefore also be evident.

Dysfunctional Uterine Bleeding Causes

In most cases, dysfunctional uterine bleeding is associated with hormonal changes. In some cases, however, the cause of the bleeding is not known. Sometimes, the use of oral contraceptives or hormone medication might also result in dysfunctional uterine bleeding. In addition, some bleeding disorders can also cause DUB.

No ovulation

Dysfunctional uterine bleeding is not associated with any release of egg during the menstrual cycle. Such cycles are called anovulatory menstrual cycles. In few cases, however, dysfunctional uterine bleeding occurs even when women are ovulating normally. The exact cause of this type of DUB is not known.

In women with anovulatory cycles, dysfunctional uterine bleeding develops in one of the following two patterns :

  • Estrogen breakthrough bleeding: In this type, estrogen levels are not controlled and the endometrium keeps growing unchecked. Eventually, when the endometrium sheds, it results in heavy and prolonged bleeding.
  • Estrogen withdrawal bleeding: This is more common in menopausal women. In such patients, the menstrual cycle becomes short and there is less growth of endometrial tissue. The menstrual shedding pattern becomes irregular and the bleeding is light and spotted.

Dysfunctional Uterine Bleeding Diagnosis

Diagnosis of dysfunctional uterine bleeding involves ruling out other probable causes of vaginal bleeding (e.g., miscarriage, fibroids, or problems with pregnancy). A pelvic examination, urine or blood tests, and ultrasound can help in diagnosing DUB or other reasons of vaginal bleeding.

Tests for Dysfunctional Uterine Bleeding

These involve checking the levels of human chorionic gonadotropin (HCG) hormone in the urine, thyroid functions, liver functions, and the levels of coagulation factors and hormones in blood samples.

  • Complete blood count (CBC) is done to check the levels of different blood cells and to detect anemia.
  • Human chorionic gonadotropin (an indicator of pregnancy) is checked to rule out abnormal pregnancy in women of reproductive years.
  • Pap smear and endometrial sampling rule out cervical cancer.
  • Thyroid function tests and prolactin levels can indicate hypothyroidism, hyperthyroidism, and hyperprolactinemia. These conditions occur due to ovulatory dysfunction.
  • Liver function tests can identify alcoholism or hepatitis, which can affect liver metabolism of estrogen to cause abnormal uterine bleeding.
  • Levels of coagulation factors are determined to rule out factor XI deficiency and Von Willebrand disease.

Scans for Dysfunctional Uterine Bleeding

Imaging studies are recommended only in some cases.

  • Pelvic ultrasound is done in obese patients to check the status of the endometrium. Ultrasound can detect abnormal growth of the endometrium (endometrial hyperplasia), presence of tumors or polyps in endometrium and uterine fibroids.
  • Sterile salt solution can be used in an ultrasound technique called saline-infusion sonohysterography, which gives better images.

Dysfunctional Uterine Bleeding Treatment

Irregular vaginal bleeding in adolescents often resolves on its own with time. Treatment for DUB is aimed at re-establishing menstrual bleeding patterns, decreasing bleeding or stopping menstruation.

Hormone therapy

  • Progestin levels can be restored with the help of progestin pills. The contraceptive pills restore the levels of both progestin and estrogen. These hormones normalize the menstrual cycle and relieve symptoms like heavy bleeding and cramping. Oral contraceptives also lower the risk of anemia.
  • A short course of high-dose estrogen can stop prolonged bleeding, which may not respond to progestin treatment. Estrogen alone can boost the rapid growth of endometrium in such cases.
  • An intrauterine device (IUD which is placed inside the uterus) is often recommended for pregnant women. This levonorgestrel IUD releases a progesterone-like hormone into the uterus. This decreases bleeding without affecting pregnancy.
  • Hormones like gonadotropin-releasing hormones are prescribed in rare cases as they can have severe side effects.

Surgery

Surgery is recommended only to people who do not show any improvement with other treatments and to patients who do not suffer from anemia. Surgical options include endometrial ablation and hysterectomy.

  • In endometrial ablation, the endometrium is destroyed with the help of laser, heat, or electricity. Endometrium heals by scarring, which decreases or stops heavy, prolonged menstrual bleeding.
  • Alternatively, the uterus can be removed surgically in a procedure called hysterectomy.

Endometrial ablation has a shorter recovery time.

Medication

  • Non-steroidal anti-inflammatory drugs (NSAID) like ibuprofen can relieve symptoms like menstrual pain.
  • A medication called desmopressin is recommended in patients with bleeding disorders or with coagulation factor deficiency.
  • Drugs called antifibrinolytics (aminocaproic acid and tranexamic acid) are not recommended generally because of side effects like severe nausea, headache, diarrhea, and allergies. These drugs cannot be used in patients with kidney failure.

References :

http://www.sh.lsuhsc.edu/fammed/outpatientmanual/dub.htm

http://emedicine.medscape.com/article/795587-overview

http://www.nlm.nih.gov/medlineplus/ency/article/000903.htm

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