Dysfunctional uterine bleeding

Dysfunctional uterine bleeding (DUB) is defined as an abnormal uterine bleeding (AUB) characterized by heavy, prolonged or frequent bleeding that is not due to pregnancy or any recognizable local or systemic disease. It is therefore a diagnosis of exclusion. 

Abnormal uterine bleeding (AUB) can be defined as any variation from the normal menstrual cycle, including changes in regularity and frequency of menses, changes in duration of flow, or changes in amount of blood loss. Abnormal uterine bleeding (AUB) can be further subcategorized into different terms with different definition/description. The terms include: 1) Heavy menstrual bleeding (HMB), 2)Irregular menstrual bleeding, 3)Infrequent uterine bleeding 4) Frequent uterine bleeding 5)Prolonged uterine bleeding 6) Shortened uterine bleeding 7) Inter-menstrual bleeding 8)Post coital bleeding 9)Pre or post menstrual bleeding 10) Post-menopausal uterine bleeding 11)Precocious uterine bleeding 12) Acute abnormal uterine bleeding 13)Chronic abnormal uterine bleeding.

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Definition of different terms under Abnormal uterine bleeding (AUB)

When a patient presented with abnormal uterine bleeding (AUB), a detail history taking and thorough physical examination should be done to look for the causes and complications of the bleeding, and to guide in term of further investigations and management.

Most common presentation of abnormal uterine bleeding is heavy menstrual bleeding (HMB). Features that suggest heavy menstrual bleeding (HMB) from the history include: 1) Need to change pad/tampon frequently (e.g 1 – 3 hourly), 2) Bleeding more than 7 days, 3) Need to use double protection i.e pad + tampon, 4) Need to change at night, 5) Flooding, 6) Clotting >3cm.

From the history, it is important to know whether the bleeding is regular or irregular. Ovulatory bleeding is regular while anovulatory bleeding is usually irregular. By identifying whether the abnormal uterine bleeding (AUB) is ovulatory or anovulatory may help us to narrow down the causes of abnormal uterine bleeding (AUB), besides guide us in term of management since the management is different between ovulatory and anovulatory bleeding.

Ovulatory bleeding usually can be successfully treated with both hormonal and non-hormonal options, while anovulatory bleeding is most effectively treated with hormonal options, by which they regulate menstrual cycle, and protect endometrium from unopposed estrogen and the risk of endometrial hyperplasia or carcinoma. In ovulatory AUB, regular ovulation and menstrual cycle do occur, however, there is excessive bleeding. This can be due to structural abnormalities such as polyp or fibroid which cause increase in endometrial surface area; or, systemic diseases like chronic liver disease, von Willebrand syndrome, or medication that cause coagulation abnormalities. Meanwhile, in anovulatory AUB, there is no ovulation occurs, thus no corpus luteum been produced result in no progesterone production. This leads to prolonged estrogenic stimulation of endometrium causing excessive endometrial proliferation. The existing blood supply is unable to provide sufficient nutritional support to the excessive tissue proliferation, and eventually tissue ischemia and necrosis occur, and lead to erratic bleeding. Examples of conditions that lead to anovulation are Polycystic ovarian syndrome (PCOS), thyroid problems, uncontrolled diabetes mellitus and so on. Some medication also can lead to ovulatory dysfunction.

Presence of associated gynaecological symptoms such as inter-menstrual spotting, post coital bleeding, dyspareunia, pelvic pain / pressure, abnormal vaginal discharge / odor may suggest toward local pelvic causes which could be benign, malignant, or infective in nature. Besides abnormal uterine bleeding, patient may complaint of other systemic symptoms which suggest systemic cause of the abnormal uterine bleeding such as hyperthyroidism, coagulation disorders and polycystic ovarian syndrome (PCOS). Patient with abnormal uterine bleeding also may suffer from complication of chronic blood loss particularly iron deficiency anemia causing them to have symptoms like giddiness, exertional shortness of breath, lethargy, and so on.

Other important information to be elicited from the history includes: 1) Comorbid condition such as tumour, thromboembolic disease or cardiovascular problems that would influence treatment option (e.g these diseases are contraindication for COCP). 2) Medication history including over the counter, herbal remedies that may lead to ovulatory dysfunction or otherwise associated with bleeding tendency. 3) Family history of inherited coagulation disorders, PCOS, endometrial or colon cancer. 4) Sexual and reproductive history including contraception, desire for future pregnancy, infertility, cervical screening and risk of sexual transmitted infection(STI). 4) Impact of the condition on social life.

A complete history taking and thorough physical examination should be able to guide further investigations to be done.

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Abnormal uterine bleeding - investigation

Once all causes of abnormal uterine bleeding (AUB) have been excluded, medication should be considered as the first line treatment. Medication used in the treatment of dysfunctional uterine bleeding can be divided into hormonal and non-hormonal.

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Causes of Abnormal uterine bleeding

Hormonal treatments include COCP, progesterone (progestin only pill, DMPA, LNG-IUS), GnRH agonist and Danazol. These medications treat dysfunctional uterine bleeding by regulating the menstrual cycle, inhibit endometrial proliferation, and promote endometrial atrophy.

Tranexamic acid is one of the non-hormonal treatments for dysfunctional bleeding. It is an antifibrinolytic agent. It reduces the endometrial fibrinolytic enzymes that are increased in dysfunctional uterine bleeding. It is the 1st line treatment for ovulatory dysfunctional uterine bleeding.

Besides tranexamic acids, NSAIDs also useful in the treatment of dysfunctional uterine bleeding. It is known that endometrial prostaglandin level is high in uterus of women with heavy menstrual bleeding. NSAIDs reduce the level of prostaglandin by inhibition of cyclo-oxygenase (enzyme that converts arachidonic acid to prostaglandin), thus reducing total production of prostaglandin.

Iron therapy should be prescribed if iron deficiency anemia is diagnosed.

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Medical treatment  for Abnormal uterine bleeding