Dysfunctional Uterine Bleeding

Dysfunctional Uterine Bleeding
Dysfunctional Uterine Bleeding

Dysfunctional Uterine Bleeding

Overview

Dysfunctional uterine bleeding is abnormal bleeding resulting from changes in the normal hormonal control of the menstruation.

  • Dysfunctional uterine bleeding occurs most commonly at the beginning and end of reproductive years.
  • 20% of the cases occur in adolescent girls and more than 50% occur in women older than 45.
  • Dysfunctional uterine bleeding commonly results when the level of estrogen remains high.
  • High levels of estrogen are not balanced by appropriate levels of progesterone and release of the egg does not occur.
  • As a result, the lining of the uterus thickens.
  • This condition is called endometrial hyperplasia.
  • The lining is then shed incompletely and irregularly, which causes bleeding.
  • Bleeding is irregular, prolonged and sometimes heavy.
  • This type of bleeding is common in women who have the polycystic ovarian syndrome.

Types of Dysfunctional uterine bleeding

Ovulatory Dysfunctional Uterine Bleeding

  • This type of dysfunctional uterine bleeding occurs in 10% of the women who are ovulating.
  • In this type, since estrogen levels are low, progesterone secretion is prolonged.
    • Because of this, the uterine lining is shredded irregularly and break-through bleeding occurs.
  • Some studies related this type of dysfunctional uterine bleeding with fragile blood vessels in the uterus.

Anovulatory Dysfunctional Uterine Bleeding

  • In about 90% of the patients, Dysfunctional Uterine Bleeding occurs when a woman is not ovulating.
  • A varying degree of the interval between 2 menstruation and the absence of ovulation and a luteal phase are the characteristic features of anovulatory bleeding or menstruation.
    • This is considered as infertility since there is an absence of ovulation.
    • This is more common in women in their premenopause age or in early puberty.
    • It may also occur in teenagers due to a delay in the maturation of the reproductive system.
    • In this case, women will not develop a mature egg and release it.
    • As a result of which, corpus luteum which produces progesterone is not formed; leading to a continuous production of estrogen. This causes an overgrowth of the uterine lining.
    • When this happens, the menstruation is delayed. Also, the menstrual bleeding, when it occurs is prolonged and heavy.
  • The exact mechanism of the occurrence of dysfunctional uterine bleeding is unknown.

Causes

Ovulatory Dysfunctional Uterine Bleeding

  • Menorrhagia
    • In this condition, menstrual periods are characterized by excessively heavy bleeding.
    • This may happen due to endocrine dysfunction.
  • Metrorrhagia
    • In this condition, menstrual bleeding occurs unexpectedly between the next expected menstruation and the previous periods.
    • Just like menorrhagia, this may also happen due to endocrine dysfunction.
  • A decrease in estrogen levels.
    • This may lead to mid-cycle bleeding.
  • Surface lesions of the genital tract
  • A decrease in the levels of progesterone.
    • This may lead to late-cycle bleeding.
  • Endometriosis
    • In this condition, uterine lining (known as endometrium) grows outside the uterus; for example on the ovaries.
    • This usually leads to heavy bleeding during regular periods.
  • Polycystic Ovarian Syndrome
  • Uterine polyps
    • Polyps are small growths occurring in the uterus.
    • The cause of uterine polyps is unknown.
    • This causes spotting between the periods.
  • Uterine fibroids
    • Just like polyps, fibroids are also the small growths affecting the uterus or the uterine lining or the uterine muscles.
    • The causes of uterine fibroids are unknown.
  • Sexually Transmitted Diseases
    • In this condition, bleeding occurs after the intercourse.

Anovulatory Dysfunctional Uterine Bleeding

  • Psychological stress
  • Obesity
    • This is a medical condition in which excessive fat gets accumulated in the body leading to detrimental effects on health.
  • Anorexia
    • This is also known as Anorexia nervosa.
    • It is an eating disorder in which a patient has a strong desire to remain thin and an intense fear of gaining weight. As a result, the patient restricts the amount of food intake.
  • Exercise
  • Rapid weight loss
  • Rapid weight gain
  • Endocrinopathy
    • This is a term commonly used for the diseases of the endocrine gland.
    • Some of the endocrine disorders are listed below:
      • Adrenal insufficiency
      • Diabetes
      • Cushing’s disease
      • Hyperthyroidism
      • Hypothyroidism
      • Gigantism and other problems related to growth hormone
      • Hypopituitarism
      • Multiple Endocrine Neoplasia (Type I and II)
      • Precocious puberty
      • Polycystic Ovarian Syndrome
  • Neoplasms
  • Surface lesions of the genital tract
  • Medicines
  • Unknown causes

Symptoms

  • Unexpected and heavy menstrual bleeding
  • Other symptoms may accompany depending upon the underlying cause.

Diagnosis

Evaluation of physical signs and symptoms

  • Calculation of BMI to determine whether the patient is obese or not.
  • Symptoms of androgen excess
    • Hirsutism
    • Acne
  • Symptoms of a bleeding disorder
    • Purpura – Formation of red or purple colored spots on the skin.
    • Ecchymosis – This is discoloration of the skin due to an underneath internal bleeding.
  • Signs of anemia

Other tests

  • Dysfunctional uterine bleeding is diagnosed when all other possible causes of vaginal bleeding have been excluded.
  • The first step towards the diagnosis of Dysfunctional uterine bleeding is a thorough evaluation of medical history followed by physical evaluation.
  • Ruling out of diseases or pathological conditions which causes;
    • Epistaxis
    • Bleeding gums
    • Easy bruising
    • The occurrence of excessive bleeding during childbirth
  • Bleeding due to hormonal replacement therapy, other hormonal treatments, and hormonal contraception should be ruled out.
  • Other iatrogenic causes of bleeding should also be ruled out.
  • Confirm the presence or absence of bleeding disorders.
  • The results of a blood test can help doctors estimate the extent of the blood loss.
  • Laboratory assessment of following parameters should be done.
    • Hemoglobin
    • CBC (Complete Blood Count)
    • Human Chorionic Gonadotropin
    • LH or Luteinizing hormone
    • FSH Follicle Stimulating Hormone
    • Prolactin
    • TSH (Thyroid Stimulating Hormone)
    • T3
    • T4
    • Complete androgen profile
      • Testosterone
      • Dehydroepiandrosterone (DHEA) – This hormone is produced in the adrenal cortex.
      • Androstenedione (A4) –  This hormone is produced by the testes and the ovaries.
      • Androstenediol (A5) – This hormone is an intermediate in the synthesis of testosterone from DHEA within the body.
      • Androsterone
      • Dihydrotestosterone (DHT) – This hormone is a metabolite of testosterone. Since it binds more strongly to androgen receptors, it is a more potent androgen than testosterone.
    • Coagulation factors and disorders
      • Factor XI
      • Von Willebrand disease
      • Primary thrombocytopenia
      • Secondary thrombocytopenia
  • PAP smear
  • Transvaginal sonography may be used to determine whether the uterine lining is thickened.
  • A sonography scan will also confirm the presence or absence of the formation of uterine fibroids and uterine polyps.
  • An ultrasound scan will also help to find out the cause of an internal bleeding if any.
  • If the risk of the cancer of the uterine lining is high, an endometrial biopsy is performed before drug treatment is started.
  • Endometrial biopsy is done if one or more of the following conditions are confirmed;
    • The growth of uterine polyps
    • The growth of uterine fibroids
    • Thickening of the uterine lining
  • If the cells in the uterine lining have undergone abnormal changes, a biopsy will reveal whether such changes are due to hormonal imbalance or a tumor.
  • Women at risk include those who are 35 years or older, those who are substantially overweight and those who have the polycystic ovarian syndrome, high blood pressure or diabetes.

Treatment

  • Treatment of a woman suffering from dysfunctional uterine bleeding should be approached with 4 basic goals:
    • To stop the current bleeding.
    • Treat the underlying pathological condition if any.
    • To prevent future bleeding.
    • To avoid anemia by replacing the lost iron.
  • Treatment depends on the woman’s age, how heavy the bleeding is whether the uterine lining is thickened and whether the woman wishes to become pregnant.
  • When the uterine lining is thickened but its cells are normal, hormones may be used.
  • Women who have heavy bleeding may be treated with oral contraceptives containing estrogen and progestin.
  • When bleeding is very heavy, estrogen may be given intravenously until the bleeding stops.
  • Sometimes progestin is given by mouth at the same time or started 2 or 3 days later.
  • Bleeding usually stops in 12 to 24 hours.
  • Low doses of oral contraceptives may be prescribed for at least 3 months.
  • Treatment given with oral contraceptives or intravenous estrogen may be inappropriate for some women like postmenopausal women or women with significant risk factors for heart or blood vessel disease.
  • These women may be given progestin alone by mouth for 10 to 14 days each month.
  • For women, who wish to become pregnant, clomiphene may be given by mouth.
  • Desmopressin should be employed in patients with coagulation disorders.
  • If the uterine lining remains thickened or bleeding persists despite the treatment with hormones, dilation and curettage is usually needed.
  • In this procedure, tissue from the uterine lining is removed by scraping.
  • When the uterine lining is thickened and contains abnormal cells, particularly in women who are older than 35 years and women who don’t want to become pregnant, treatment begins with a high dose of progestin.
  • If the cells continue to be abnormal after treatment, a hysterectomy is performed, because the abnormal cells may become cancerous.

Complications resulting from dysfunctional uterine bleeding

  • Anemia is a major complication arising due to dysfunctional uterine bleeding.
  • This is because, in dysfunctional uterine bleeding or DUB, heavy bleeding occurs; which may lead to blood loss and anemia.
  • This condition is usually treated by recommending the patient to use an iron supplement and eat more fruits and leafy vegetables.
  • In certain extreme cases of severe blood loss, blood transfusion should also be considered.