Dysfunctional uterine bleeding
Encyclopedia
Dysfunctional Uterine Bleeding (DUB) is abnormal genital tract bleeding
based in the uterus
and found in the absence of demonstrable structural or organic pathology
.usually due to hormonal disturbances.
AGE: extrmes of reproductive life i.e at puberty and menopause.
Diagnosis must be made by exclusion, since organic pathology must first be ruled out.
It can be classified as ovulatory or anovulatory, depending on whether ovulation
is occurring or not.
Some sources state that the term implies a hormonal mechanism.
It may represent a possible endocrine dysfunction, resulting in menorrhagia
or metrorrhagia
.
Mid-cycle bleeding may indicate a transient estrogen
decline, while late-cycle bleeding may indicate progesterone
deficiency.
The etiology can be psychological stress, weight (obesity
, anorexia
, or a rapid change), exercise, endocrinopathy, neoplasm, drugs
, or it may be otherwise idiopathic
.
Assessment of anovulatory DUB should always start with a good medical history
and physical examination
.
Laboratory assessment of hemoglobin
, luteinizing hormone
(LH), follicle stimulating hormone (FSH), prolactin
, T4, thyroid stimulating hormone (TSH), pregnancy
(by βhCG
), and androgen
profile should also happen.
More extensive testing might include an ultrasound
and endometrial
sampling.
Management of dysfunctional uterine bleeding predominantly consists of reassurance, though mid-cycle estrogen
and late-cycle progestin
can be used for mid- and late-cycle bleeding respectively.
Also, non-specific hormonal
therapy such as combined high-dose estrogen and high-dose progestin can be given.
The goal of therapy should be to arrest bleeding, replace lost iron
to avoid anemia
, and prevent future bleeding.
A hysterectomy
may be performed in some cases.
Vaginal bleeding
Vaginal bleeding refers to bleeding in females that is either a physiologic response during the non-conceptional menstrual cycle or caused by hormonal or organic problems of the reproductive system. Vaginal bleeding may occur at any age, but always needs investigation when encountered in female...
based in the uterus
Uterus
The uterus or womb is a major female hormone-responsive reproductive sex organ of most mammals including humans. One end, the cervix, opens into the vagina, while the other is connected to one or both fallopian tubes, depending on the species...
and found in the absence of demonstrable structural or organic pathology
Pathology
Pathology is the precise study and diagnosis of disease. The word pathology is from Ancient Greek , pathos, "feeling, suffering"; and , -logia, "the study of". Pathologization, to pathologize, refers to the process of defining a condition or behavior as pathological, e.g. pathological gambling....
.usually due to hormonal disturbances.
AGE: extrmes of reproductive life i.e at puberty and menopause.
Diagnosis must be made by exclusion, since organic pathology must first be ruled out.
It can be classified as ovulatory or anovulatory, depending on whether ovulation
Ovulation
Ovulation is the process in a female's menstrual cycle by which a mature ovarian follicle ruptures and discharges an ovum . Ovulation also occurs in the estrous cycle of other female mammals, which differs in many fundamental ways from the menstrual cycle...
is occurring or not.
Some sources state that the term implies a hormonal mechanism.
Ovulatory DUB
10% of cases occur in women who are ovulating, but progesterone secretion is prolonged because estrogen levels are low. This causes irregular shedding of the uterine lining and break-through bleeding. Some evidence has associated Ovulatory DUB with more fragile blood vessels in the uterus.It may represent a possible endocrine dysfunction, resulting in menorrhagia
Menorrhagia
Menorrhagia is an abnormally heavy and prolonged menstrual period at regular intervals. Causes may be due to abnormal blood clotting, disruption of normal hormonal regulation of periods or disorders of the endometrial lining of the uterus...
or metrorrhagia
Metrorrhagia
Metrorrhagia, also known as breakthrough bleeding or spotting, is uterine bleeding at irregular intervals, particularly between the expected menstrual periods.In some women, menstrual spotting between periods occurs as a normal and harmless part of ovulation...
.
Mid-cycle bleeding may indicate a transient estrogen
Estrogen
Estrogens , oestrogens , or œstrogens, are a group of compounds named for their importance in the estrous cycle of humans and other animals. They are the primary female sex hormones. Natural estrogens are steroid hormones, while some synthetic ones are non-steroidal...
decline, while late-cycle bleeding may indicate progesterone
Progesterone
Progesterone also known as P4 is a C-21 steroid hormone involved in the female menstrual cycle, pregnancy and embryogenesis of humans and other species...
deficiency.
Anovulatory DUB
About 90% of DUB events occur when ovulation is not occurring (Anovulatory DUB). Anovulatory menstrual cycles are common at the extremes of reproductive age, such as early puberty and perimenopause (period around menopause). In such cases, women do not properly develop and release a mature egg. When this happens, the corpus luteum, which is a mound of tissue that produces progesterone, does not form. As a result, estrogen is produced continuously, causing an overgrowth of the uterus lining. The period is delayed in such cases, and when it occurs menstruation can be very heavy and prolonged. Sometimes anovulatory DUB is due to a delay in the full maturation of the reproductive system in teenagers. Usually, however, the mechanisms are unknown.The etiology can be psychological stress, weight (obesity
Obesity
Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems...
, anorexia
Anorexia nervosa
Anorexia nervosa is an eating disorder characterized by refusal to maintain a healthy body weight and an obsessive fear of gaining weight. Although commonly called "anorexia", that term on its own denotes any symptomatic loss of appetite and is not strictly accurate...
, or a rapid change), exercise, endocrinopathy, neoplasm, drugs
Medication
A pharmaceutical drug, also referred to as medicine, medication or medicament, can be loosely defined as any chemical substance intended for use in the medical diagnosis, cure, treatment, or prevention of disease.- Classification :...
, or it may be otherwise idiopathic
Idiopathic
Idiopathic is an adjective used primarily in medicine meaning arising spontaneously or from an obscure or unknown cause. From Greek ἴδιος, idios + πάθος, pathos , it means approximately "a disease of its own kind". It is technically a term from nosology, the classification of disease...
.
Assessment of anovulatory DUB should always start with a good medical history
Medical history
The medical history or anamnesis of a patient is information gained by a physician by asking specific questions, either of the patient or of other people who know the person and can give suitable information , with the aim of obtaining information useful in formulating a diagnosis and providing...
and physical examination
Physical examination
Physical examination or clinical examination is the process by which a doctor investigates the body of a patient for signs of disease. It generally follows the taking of the medical history — an account of the symptoms as experienced by the patient...
.
Laboratory assessment of hemoglobin
Hemoglobin
Hemoglobin is the iron-containing oxygen-transport metalloprotein in the red blood cells of all vertebrates, with the exception of the fish family Channichthyidae, as well as the tissues of some invertebrates...
, luteinizing hormone
Luteinizing hormone
Luteinizing hormone is a hormone produced by the anterior pituitary gland. In females, an acute rise of LH called the LH surge triggers ovulation and development of the corpus luteum. In males, where LH had also been called interstitial cell-stimulating hormone , it stimulates Leydig cell...
(LH), follicle stimulating hormone (FSH), prolactin
Prolactin
Prolactin also known as luteotropic hormone is a protein that in humans is encoded by the PRL gene.Prolactin is a peptide hormone discovered by Henry Friesen...
, T4, thyroid stimulating hormone (TSH), pregnancy
Pregnancy
Pregnancy refers to the fertilization and development of one or more offspring, known as a fetus or embryo, in a woman's uterus. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets...
(by βhCG
Human chorionic gonadotropin
Human chorionic gonadotropin or human chorionic gonadotrophin is a glycoprotein hormone produced during pregnancy that is made by the developing embryo after conception and later by the syncytiotrophoblast .. Some tumors make this hormone; measured elevated levels when the patient is not...
), and androgen
Androgen
Androgen, also called androgenic hormone or testoid, is the generic term for any natural or synthetic compound, usually a steroid hormone, that stimulates or controls the development and maintenance of male characteristics in vertebrates by binding to androgen receptors...
profile should also happen.
More extensive testing might include an ultrasound
Ultrasound
Ultrasound is cyclic sound pressure with a frequency greater than the upper limit of human hearing. Ultrasound is thus not separated from "normal" sound based on differences in physical properties, only the fact that humans cannot hear it. Although this limit varies from person to person, it is...
and endometrial
Endometrium
-Function:The endometrium is the innermost glandular layer and functions as a lining for the uterus, preventing adhesions between the opposed walls of the myometrium, thereby maintaining the patency of the uterine cavity. During the menstrual cycle or estrous cycle, the endometrium grows to a...
sampling.
Management
Drug of choice is progesterone.Management of dysfunctional uterine bleeding predominantly consists of reassurance, though mid-cycle estrogen
Estrogen
Estrogens , oestrogens , or œstrogens, are a group of compounds named for their importance in the estrous cycle of humans and other animals. They are the primary female sex hormones. Natural estrogens are steroid hormones, while some synthetic ones are non-steroidal...
and late-cycle progestin
Progestin
A progestin is a synthetic progestogen that has progestinic effects similar to progesterone. The two most common uses of progestins are for hormonal contraception , and to prevent endometrial hyperplasia from unopposed estrogen in hormone replacement therapy...
can be used for mid- and late-cycle bleeding respectively.
Also, non-specific hormonal
Hormone
A hormone is a chemical released by a cell or a gland in one part of the body that sends out messages that affect cells in other parts of the organism. Only a small amount of hormone is required to alter cell metabolism. In essence, it is a chemical messenger that transports a signal from one...
therapy such as combined high-dose estrogen and high-dose progestin can be given.
The goal of therapy should be to arrest bleeding, replace lost iron
Iron
Iron is a chemical element with the symbol Fe and atomic number 26. It is a metal in the first transition series. It is the most common element forming the planet Earth as a whole, forming much of Earth's outer and inner core. It is the fourth most common element in the Earth's crust...
to avoid anemia
Anemia
Anemia is a decrease in number of red blood cells or less than the normal quantity of hemoglobin in the blood. However, it can include decreased oxygen-binding ability of each hemoglobin molecule due to deformity or lack in numerical development as in some other types of hemoglobin...
, and prevent future bleeding.
A hysterectomy
Hysterectomy
A hysterectomy is the surgical removal of the uterus, usually performed by a gynecologist. Hysterectomy may be total or partial...
may be performed in some cases.