Dysfunctional Uterine Bleeding Disease

BASICS

DESCRIPTION

Abnormal uterine bleeding, usually associated with anovulatory cycles, in the absence of other detectable organic lesions. This unit will deal only with women of reproductive age. Three major categories are:

Estrogen breakthrough bleeding
Estrogen withdrawal bleeding
Progestin breakthrough bleeding
System(s) affected: Reproductive, Endocrine/Metabolic
Genetics: Unclear; tendency to have familial characteristics
Incidence/Prevalence in USA: Exact numbers not available, widespread prevalence, without specific geographic variation
Predominant age: 12-45
Predominant sex: Female only

SIGNS AND SYMPTOMS

Uterine bleeding:
- Unrelated to menses
- In excess of normal menstrual flow
- Occurring in an irregular pattern
- Rarely painful
Absence of:
- Other systemic symptoms
- Unusual bleeding from other areas
- Urinary or gastrointestinal irregularities
- Sustained aspirin or anticoagulant use
- Use of hormonal preparations
- Evidence of thyroid disease
- Galactorrhea
- Pregnancy (especially ectopic)
- Evidence for reproductive tract malignancy

CAUSES

After Eisenberg:
- Midcycle spotting - caused by a decrease in estrogen at midcycle following ovulation
- Frequent menses - due to short follicular phase as a result of inappropriate feedback at pituitary/hypothalamic level
- Deficiency of luteal phase - associated with premenstrual spotting or polymenorrhea when luteal phase is suddenly shortened by prematurely decreased progesterone; due to corpus luteum insufficiency
- Prolonged corpus luteum activity - caused by persistent progesterone production - results in prolonged cycles or protracted episodes of bleeding
- Anovulation - production of estrogen unaccompanied by cyclic surges of luteinizing hormone (LH) or secretion of progesterone from the corpus luteum. 90% of all DUB is anovulatory. Usually seen at extremes of reproductive life.
- Other - uterine lesions, leiomyomata, polyps, carcinoma, vaginal infection, foreign body, ectopic pregnancy, hydatid mole, endocrine dysfunction (especially thyroid), blood dyscrasias

RISK FACTORS

Listed with Causes

DIAGNOSIS

LABORATORY

Rarely necessary unless clinical picture suggests other endocrine or hematological disease, or if patient is perimenopausal
Consider thyroid function tests, CBC, PT, PTT, workup for hirsutism, HCG (to rule out pregnancy and/or hydatid mole), prolactin (pituitary dysfunction)

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

Variable, depending on the disease process present. Pathological review of endometrial sampling specimens is mandatory in all patients.

SPECIAL TESTS

Basal body temperature to document anovulation

IMAGING

Ultrasound may be helpful in identifying ovarian cysts and uterine tumors
Transvaginal ultrasound (TVUS) recently developed and may be useful in many circumstances. Consider TVUS if you suspect pregnancy, anatomic problems, polycystic ovarian syndrome. The ultrasonographer should have a great deal of experience with the technique.

DIAGNOSTIC PROCEDURES

Careful history of bleeding, with graphic display of cycles often helpful
Pelvic examination
Pap smear
Endometrial biopsy in selected patients:
- All patients over 35 years of age
- Obese patients
- Patients with diabetes mellitus
- Patients with hypertension
- Patients with suspected polycystic ovary syndrome
Dilatation and curettage in those who have higher risk for endometrial hyperplasia and carcinoma (consider D&C more strongly over endometrial biopsy if the suspected diagnosis is endometritis, atypical hyperplasia, or carcinoma):
- Heavy, uncontrolled bleeding
- Histological examination is necessary, but biopsy is contraindicated
- Medical curettage fails

TREATMENT

APPROPRIATE HEALTH CARE

Almost always outpatient; may need hospitalization for profuse bleeding and hemodynamic instability

GENERAL MEASURES

See Medications

SURGICAL MEASURES

Acute (profuse bleeding, hemodynamic instability):
- Dilatation and curettage
- Hysterectomy in selected (rare) cases
Non-acute:
- Hysterectomy in selected patients if medical therapy fails
- Endometrial ablation in selected patients if medical therapy fails

ACTIVITY

As tolerated

DIET

Normal; include adequate iron

PATIENT EDUCATION

Thorough yet easily comprehended explanation of diagnostic approach and plan of treatment is important. Many questions regarding fertility, cancer, and infectious disease.
Discuss ways for patient to avoid prolonged stress or emotional turmoil
American College of Obstetricians & Gynecologists (ACOG), 409 12th St., SW, Washington, DC 20024-2188, (800)762-ACOG

FOLLOW UP

PREVENTION/AVOIDANCE

N/A

POSSIBLE COMPLICATIONS

Anemia
Adenocarcinoma of the uterus if prolonged unopposed estrogen stimulation in women with intact uterus
Significant side effects of individual preparations. See manufacturer's printed information.

EXPECTED COURSE AND PROGNOSIS

Varies with pathophysiologic process
In young women, most anovulatory cycles can be treated confidently and successfully with physiologically sound therapeutic regimens, without surgical intervention

MISCELLANEOUS

ASSOCIATED CONDITIONS

Listed with Causes

AGE-RELATED FACTORS

Pediatric: N/A
Geriatric: Uterine bleeding in a postmenopausal female must be pursued as if there were carcinoma or other significant pathology present
Others: Early postpubertal females and those in their later reproductive years most often affected

PREGNANCY

May confuse with ectopic pregnancy, hydatidiform mole

OTHER NOTES

If DUB cannot be controlled with medical treatment, options besides hysterectomy are available. Among these are the ND:YAG laser or electrocautery of the endometrium with a ball-end resectoscope.

ABBREVIATIONS

N/A

Clinical Investigations

ROLE OF HOMOEOPATHY

Holistic healing that treats the person, not just the disease. Experience gentle, lasting wellness with expert constitutional care.