Dysfunctional uterine bleeding

Dysfunctional uterine bleeding (DUB) refers to abnormal endometrial bleeding without recognizable organic lesions. The prognosis varies with the cause. DUB is the indication for almost 25% of gynecologic surgical procedures.

Causes and incidence

DUB usually results from an imbalance in the hormonal-endometrial relationship, where persistent and unopposed stimulation of the endometrium by estrogen occurs. Disorders that cause sustained high estrogen levels are polycystic ovary syndrome, obesity, immaturity of the hypothalamic-pituitary-ovarian mechanism (in postpubertal teenagers), and anovulation (in women in their late 30s or early 40s).

In most cases of DUB, the endometrium shows no pathologic changes. However, in chronic unopposed estrogen stimulation (as from a hormone-producing ovarian tumor), the endometrium may show hyperplastic or malignant changes. DUB occurs in 20% of adolescents and in 40% of women older than age 40.

Signs and symptoms

DUB usually occurs as metrorrhagia (episodes of vaginal bleeding between menses); it may also occur as hypermenorrhea (heavy or prolonged menses, longer than 8 days) or chronic polymenorrhea (menstrual cycle of less than 18 days). Such bleeding is unpredictable and can cause anemia.

Diagnosis

Diagnostic studies must rule out other causes of excessive vaginal bleeding, such as organic, systemic, psychogenic, and endocrine causes, including certain cancers, polyps, incomplete abortion, pregnancy, and infection.

Confirming diagnosis  Dilatation and curettage (D & C) and biopsy results confirm the diagnosis by revealing endometrial hyperplasia.

Hemoglobin levels and hematocrit determine the need for blood or iron replacement.

Treatment

High-dose estrogen-progestogen combination therapy (hormonal contraceptives), the primary treatment, is designed to control endometrial growth and re-establish a normal cyclic pattern of menstruation. (The patient’s age and the cause of bleeding help determine the drug choice and dosage.) In patients older than age 35, endometrial biopsy is necessary before the start of estrogen therapy to rule out endometrial adenocarcinoma. Progestogen therapy is a necessary alternative in some women such as those susceptible to estrogen’s adverse effects (thrombophlebitis, for example).

If drug therapy is ineffective, D & C serves as a supplementary treatment, through removal of a large portion of the bleeding endometrium. Also, D & C can help determine the original cause of hormonal imbalance and can aid in planning further therapy. Regardless of the primary treatment, the patient may need iron replacement or transfusions of packed cells or whole blood, as indicated, because of anemia caused by recurrent bleeding.

Special considerations

❑ Explain the importance of adhering to the prescribed hormonal therapy. If D & C is ordered, explain this procedure and its purpose.

❑ Stress the need for regular checkups to assess the effectiveness of treatment.

Book Source Details

• Book Title: Professional Guide to Diseases (Eighth Edition)
• Author(s): Springhouse
• Year of Publication: 2005
• Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.

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Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Professional Guide to Diseases (Eighth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2005 ISBN: 1-58255-370-X

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