Definition

Dysfunctional Uterine Bleeding (DUB) refers to abnormal bleeding caused by hormonal abnormalities in the absence of pregnancy, tumor, infection, and coagulopathy.
It is often associated with anovulation, continuous ovarian estrogen production, and a non-secretory endometrium.

Causes

DUB may result from disorders of:

• The central nervous system.
• Pituitary gland.
• Ovary.
• From the effects of exogenous or endogenous steroids.
• Systemic metabolic disorders (hyper- or hypothyroidism, hepatic dysfunction, and various chronic diseases).

Signs and Symptoms

• Continuous uterine bleeding (may last for many weeks).
• Secondary anaemia.
• Infertility.
• Amenorrhoea.

Diagnosis

The diagnostic process includes:

• History.
• A full general examination.
• Pelvic Exam.
• Papanicolaou smear test.
• US exam (endometrium, ovaries).
• A diagnostic curettage.
• Hystero-salpingography.
• Hysteroscopy.
• Hematologic studies.

Differential Diagnosis

1. Complications of pregnancy: abortion, ectopic gestation, bleeding corpus luteum, hydatidiform mole, choriocarcinoma.
2. Organic lesions of:

The corpus: myoma, carcinoma, polyps, hyperplasia of endometrium.
Cervix: chronic cervicitis, carcinoma, polyps.
Ovary: functional ovarian cysts and functioning neoplasms.
Oviducts: carcinoma.
Vagina: carcinoma.

Treatment: Overall Approach

Treatment depends on:

• The age of the patient, her fertility, and her desire for children.
• The degree of anaemia.
• The response to curettage, which is performed primarily as an aid to diagnosis, and may be therapeutically beneficial.

Medical Treatments

The medical treatments include:
Continuous OCPs (Oral Contraceptive Pills).

Progestins:

• May be as effective as GnRH-a for pain control.
• Doses mentioned: MPA 10 mg/day, DP 150 mg Semi-Monthly.
• May be taken long-term.
• Relatively inexpensive.
• Side-Effects: AUB (Abnormal Uterine Bleeding), Mood Swings, Weight Gain, Amenorrhoea.

Danazol:

Weak Androgen

•Suppresses LH / FSH

•200 mg daily for 4-6 months

•Causes Endometrial Regression, Atrophy

•Expensive

•Not recommended in young women

•Side-Effects: Weight Gain, Masculinization, Occ. Permanent Vocal Changes

Oestrogen.

• Suppresses LH / FSH.
• Causes Endometrial Regression, Atrophy.

Clomiphen:

• Used to induce ovulation.
• Dose: 50-150 mg daily from 5 to 9 day of menstrual cycle.
• Complications: multiple pregnancy, hyperstimulation of ovaries.

Ethamsylate:

• Reduces the capillary fragility.
• Reduces menorrhagia by 50%.
• Dose: 500 mg 4 times a day started from 5 day prior to the anticipated start of the period to 10 days after.

Nonsteroidal anti-inflammatory drugs (NSAID):

• Mefenamic acid 500 mg for 5-6 days controls menorrhagia in 70% cases of ovulatory cycles.
• Side effects: nausea, vomiting, dyspepsia, diarrhoea, headache, auto-haemolytic anaemia.

Combined oral contraceptive pills:

• More effective than oestrogen and progesterone alone.
• Reduces blood loss by 50% and eliminates dysmenorrhoea.
• Not expensive.

Antifibrinolytic agents:

• Tranexamic acid, epsilon-amino-caproic acid.
• Dose: 1-2 g 4 times a day for 6-7 days during menstruation.
• Success rate: 50%.
• Side effects: nausea, vomiting, diarrhoea, headache, visual disturbances, intracranial thrombosis.
• Not expensive.

GnRH (Gonadotropin-releasing hormone):

• Used as a last drug when others fail.
• Dose: Depot injection 3.6 mg monthly for 4-6 month.
• Success rate: nearly 100%.
• Expensive.
• Side effects: anti-oestrogenic effect for more than 6 months can cause menopausal symptoms and osteoporosis.

Surgical Treatment

1.D&C-removal of endometrium’s hyperplasia

•D&C will be required in young women, if hormonal therapy failed.

•30-40% may be cured by curettage alone.

2. Hysterectomy-in older women with severe menorrhagia; recurrent irregular uterine bleeding that is unresponsive to progestin therapy.

•The ovaries should be conserved in women below the age of 50 yrs.

3. Hysteroscopic endometrial ablationby

•Nd:YAG laser

•electro-cautery

•resection (TCRE)

•roller-ball electrocoagulation

•radio-frequency induced ablation (RITEA) -thermal destruction of endometrium at 66°C. 85% get cured.

•balloon therapy -hot fluid is used which causes superficial burn.