Dysfunctional uterine bleeding

Definition

Also known as abnormal uterine bleeding.

It's an irregular uterine bleeding, caused by disruption of normal cyclical pattern of ovarian hormonal stimulation of the endometrial lining.


DUB is a diagnosis of exclusion, after excluding medical, pelvic pathology and pregnancy.

Commonly associated with anovulatory cycles, and occasionally oligo-ovulation.
DUB is unpredictable for many, where it can be heavy, light, frequent, prolonged, random, etc.

Pathophysiology

When there is lost of normal cyclical pattern of hormonal stimulation, the estrogen stimulation over endometrial lining is constant and non-cyclical.
In other words, the estrogen stimulation is unopposed.

The endometrial lining will continue proliferating till it outgrowth it's blood supply. Hence, shedding of endometrium becomes irregular and dysynchronus.

Chronic, low level estrogenic stimulation -> infrequent, light bleeding
Chronic, high level estrogenic stimulation -> heavy, frequent bleeding

Epidemiology 

20% of the cases of DUB is seen among adolescence.
About 50% of the cases is seen in women within age group of 40-50 years old.

Cause

a) Estrogen break-through bleeding

This occurs in anovulatory cycles, where there's no corpus luteum formation, hence progesterone is not being produced.
Endometrial proliferation will continues until it outgrowths the blood supply, and eventually causing DUB.

This can be seen in peri-menopausal women, as their cycles gradually becomes anovulatory.


b) Estrogen withdrawal bleeding

This is seen more commonly among peri-menopausal women, as the production of estrogen from ovary reduces. Hence, endometrial lining is inadequately formed, hence irregular shedding takes place causing either :

Spotting in between periods
Light, frequent, short menstruation

c) In Adolescent

There is delayed maturation of hypothalamic-pituitary axis (HPA).
Hence, LH surge does not occur in response towards high estrogen levels.
Hence, DUB occurs similarly as in Estrogen Breakthrough bleeding.

d) Bleeding disorders

Consequences

1) Iron deficiency anaemia, or sometimes bleeding can be so severe that patients requires hospitalisation, fluid management, blood transfusion and IV hormonal therapy.

2) Endometrial hyperplasia/Carcinoma as a result of un-opposed estrogen stimulation.

3) Infertility, since DUB is commonly associated with anovulation.

History taking

1) Full history about the patient's menstrual cycle

Age of menarche
Regularity of cycles
History of Dysmenorrhoea and Menorrhagia
Days of menstrual bleed (significant if >7 days)
Any sleep disturbances?
Any passage of clot?
Number of pad changes/day

2) Symptoms of anaemia
3) Symptoms suggestive of pregnancy (amenorrhoea)
4) Symptoms suggestive of hyper/hypothyroidism
5) Symptoms suggestive of hyperprolactinemia

Amenorrhoea, Infertility, Reduced libido, Lactation (even without pregnancy)

6) Is there h/o of PID?

Sexual history
5D's -> Dyspareunia, Dysuria, Dyschezia, Dysmenorrhoea, Discharge
Abdominal/Back-ache

7) Could it be Polycystic Ovarian Syndrome?

Menses are irregular since menarche
Hirsutism, Obesity and Infertility

8) Could it be a bleeding disorder? OR other causes of coagulopathy?

Menorrhagia since menarche
Family history of bleeding disorders
One of the following present :

a) Bruising without injury
b) Bleeding from oral cavity/GI tract without obvious lesion
c) Epitaxis >10 minutes (which may require nasal packing/cauterisation)

History of liver/renal disease

9) Could it be due to drug intake?

OCP, Progestin pills, Hormonal-replacement therapy
Aspirin, Anticoagulants

10) Abdomino-pelvic masses?

Uterine fibroids
Endometrial CA/Cervical CA

Criteria for rulling out Endometrial CA :

1) Age > 35 years old
2) Morbid obesity
3) Diabetic and long-standing hypertensive
4) Chornic anovulation

Physical Exmination

1) General

Vital sign measurement - patient might have lost significant amount of blood
BMI - is the patient obese?
Signs of hyperandrogenism (Hirsutism)
Signs of Anemia
Visual field defects (might be caused by a pituitary lesion)
Look for ecchymosis/bruises
Goitre and/or other signs of hyper/hypothyroidism
Galactorrhoea
Abdominal examination - Masses palpable

2) Local examination

Sperculum examination - Growths, erosions, ulcers
Per vaginal examination - Cervical motion tenderness
High vaginal swabs, and Endocervical swabs (For sexually transmitted disease)
Pap smear taken
Bimanual pelvic examination - adnexal masses, abdomino-pelvic masses

Differential diagnosis

1) Gynaecological causes

Endometriosis/Adenomyosis
Endometrial polyp
Uterine Fibroid
Local genital tract lesions
Ectopic pregnancy
Polycystic Ovarian Syndrome
Endometrial CA
Cervical CA

2) Medical causes

Hyper/Hypothyroidism
Hyperprolactinemia

Investigation

1) Full blood count - to know the degree of anaemia
2) BUSE - baseline routine
3) Coagulation profile

PT/APTT/INR - in case abnormal, follow-up with further coagulation studies
Commonest cause is Von-Willebrand's disease

4) Thyroid function test

TSH, T4

5) Serum prolactin level
6) Pap Smear -> Histopathologist
7) Vaginal/Endocervical swabs -> Culture (STD screening)
8) Ultrasound scan
9) If TVS reveals abnormal endometrium or criteria TRO Endometrial CA in a patient is full-filled, perform endometrial sampling (D & C, aspiration)

Category: Gynecology Notes