Do not forget to add iron (Fe) to the treatment regimen of dysfunctional uterine bleeding (DUB)

Author: Anjali Subbaswamy, MD

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DUB is defined as abnormal vaginal bleeding without an identifiable pathologic condition. This is in contrast to abnormal uterine bleeding (AUB), which results from a broad spectrum of conditions. In adolescents, DUB is most often due to the anovulatory cycles that result from an immature hypothalamic-pituitary-ovarian axis. Etiologies of AUB, which must be excluded, are numerous and include genital tract abnormalities (ovarian, fallopian tube, uterine, cervical, vaginal, and vulval), trauma, drugs (oral contraceptives, corticosteroids, chemotherapy, phenytoin [Dilantin], antipsychotics) and systemic diseases (Table 196.1). Optimal management of DUB requires a systematic diagnostic and therapeutic approach.

By definition, other causes of irregular menses must be excluded before a diagnosis of DUB can be made. In girls in whom a diagnosis of DUB is considered, additional evaluation may include follicle-stimulating hormone, luteinizing hormone, thyroid-stimulating hormone, and prolactin on day 3 of the menstrual cycle (by convention, the first day of menses is day 1 of the cycle, even in girls with irregular cycles). A complete blood count and coagulation tests are standard.

It is important to first exclude pregnancy, and next, to distinguish between ovulatory (cyclic) and anovulatory (acyclic) DUB. The differential diagnosis varies accordingly. For example, DUB is the most common cause of excessive menstrual flow in adolescents with anovulatory bleeding, whereas blood dyscrasias and structural anomalies (e.g., polyps, fibroids) are more common in those with ovulatory bleeding.

Ovulatory AUB is typically cyclic, but heavy or prolonged. Bleeding in these women is usually due to an anatomic lesion (polyp, fibroid, adenomyosis, neoplasm, foreign body), hemostatic defect, infection, trauma, or local disturbances in prostaglandins. Gonadotropin and sex steroid levels, if checked, are normal. Anovulatory uterine bleeding, the most common cause of DUB, refers to unpredictable endometrial bleeding of variable flow and duration. In these patients, sex steroids are produced, but not cyclically, so bleeding is irregular. Anovulation is most common at menarche or menopause but can occur at any time. Polycystic ovary syndrome is the most common endocrine disorder associated with anovulation, affecting 6% of reproductive-aged women. Signs include obesity, hirsutism, acanthosis nigricans, and irregular menstrual cycles. Thyroid dysfunction and elevated prolactinlevelsareothercommonendocrinedisordersrelatedtoanovulation.

Table 196.1 The Causes of Abnormal Uterine Bleeding in Children Vary with Age
Neonates
Estrogen withdrawal
Premenarchal
Foreign body
Trauma, including sexual abuse
Infection
Urethral prolapse
Sarcoma botryoides
Ovarian tumor
Precocious puberty
Early postmenarche
Anovulation (hypothalamic immaturity)
Bleeding diathesis
Stress (psychogenic, exercise-induced)
Pregnancy
Infection

Treatment of mild DUB (slightly prolonged cycles) may be limited to iron supplementation. Moderate DUB (menses every 1–3 weeks) requires iron and folate supplementation and hormonal therapy. Estrogen is the treatment of choice and 90% of adolescents respond well. Combination estrogen/progesterone therapy is also an option; the estrogen promotes hemostasis, whereas the progesterone promotes endometrial proliferation and stability. Actively bleeding patients require hemodynamic stabilization (hospital admission and blood transfusion may be necessary) and aggressive combination hormonal therapy. Some suggest oral contraceptives three times a day until bleeding stops and then a 1-week taper to daily dosing. In recurrent or debilitating cases, a dilation and curettage may be considered. Potential sequelae of AUB include anemia and endometrial cancer. Timely evaluation and treatment can prevent these problems.

Suggested Readings

Lavin C. Dysfunctional uterine bleeding in adolescents. Curr Opin Pediatr. 1996;8(4):328–332.
Matytsina LA, Zoloto EV, Sinenko LV, et al. Dysfunctional uterine bleeding in adolescents: concepts of pathophysiology and management. Prim Care. 2006;33(2):503–515.
Minjarez D. Abnormal bleeding in adolescents. Semin Reprod Med. 2003;21(4):363–373.

Book Source Details

• Book Title: Avoiding Common Pediatric Errors
• Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
• Year of Publication: 2008
• Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.

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Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Williams & Wilkins.

More About Causes of Vaginal bleeding

• Back to symptom: Vaginal bleeding: Introduction (review 134 causes)
• Next Book Extract About Vaginal bleeding: Do not prescribe oral contraceptivepills (OCPs) to females with undiagnosed vaginal bleeding (Avoiding Common Pediatric Errors)
• All Book Extracts: All Online Book Extracts for Vaginal bleeding

More About This Book: Title: Avoiding Common Pediatric Errors Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7489-6

 » Next page: Do not prescribe oral contraceptivepills (OCPs) to females with undiagnosed vaginal bleeding (Avoiding Common Pediatric Errors)

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