INTRODUCTION
DUB is abnormal vaginal bleeding reflecting a deviation from a client’s regular flow where there is no medical pathology. The bleeding may be heavy, prolonged or lighter than normal. DUB reflects a disturbance in the normal pattern of menses which follows a regular pattern.
It is a common diagnosis and about 10 % or more of women will present with it at some time. Adolescents and women about to enter menopause are more at risk because they have more episodes of anovulatory cycles.
SYMPTOMS
A lady with DUB may present with the following:
- Heavy or light vaginal bleeding
- Prolonged menstrual flow
- Short intervals between menses
CAUSES
Every month, after a lady’s menses the follicles begin to grow [under the influence of FSH from the pituitary gland] and produce estrogen. Estrogen acts on the lining of the uterus to become proliferative and grow. After ovulation, the corpus luteum secretes progesterone which converts the proliferative endometrium to secretory. If no pregnancy occurs this secretory endometrium sloughs off as menstrual blood.
In menstrual cycles where ovulation does not occur, women could suffer from a variety of bleeding disorders including:
- Estrogen breakthrough bleeding
In these conditions, there is no ovulation hence no corpus luteum is formed to produce progesterone. The estrogen produced continues to act on the endometrial lining which keeps growing till it gets shed off unpredictably. The bleeding is usually heavy and flows for a long time because of the proliferated endometrium.
- Estrogen withdrawal bleeding
In these cases, the women are approaching menopause hence the follicles are reduced. Estrogen production is reduced and proliferation of the endometrium is minimal leading to scanty, irregular bleeding.
- Adolescent abnormal bleeding
In adolescents, because the hypothalamus and pituitary are not matured, ovulation does not occur in most of the cycles and the corpus luteum is not formed. Such ladies would have irregular flow because of a lack of progesterone to induce menses.
PREVENTION
Most cases cannot be prevented.
COMPLICATIONS
It is important to make an early diagnosis of DUB so the client can be evaluated properly to rule out more serious causes of the bleeding. Complications that could arise from the disorder include:
Anaemia
Frequent heavy bleeding could lead to anaemia, which may necessitate blood transfusions.
Infertility
Long term chronic anovulation [no ovulation] leads to infertility as the eggs are not released for fertilization.
Increased risk of endometrial carcinoma
Unopposed estrogen secretion and activity on the endometrium caused hyperplasia and increases a woman’s risk of developing endometrial cancer.
DIAGNOSIS
Diagnosing DUB could be a dilemma as it is a disease of exclusion. This means in the event an anatomic cause is not found for the abnormal bleeding we could blame it on DUB.
Diagnosis usually begins with a history of the above symptoms, physical examination to check for abnormal causes of bleeding.
Laboratory test done may include:
- Full blood count. This checks the level of blood in the client and the platelet level.
- Pregnancy Test. This is done to exclude an abnormal pregnancy such as an ongoing miscarriage or an ectopic pregnancy.
- Pap smear. This is done to exclude cervical cancer.
- Endometrial biopsy. Done to exclude endometrial cancer.
- Hormonal assay to assess the level of serum Follicle-stimulating hormone [FSH], Luteinizing hormone [LH] and estradiol on day 3 of menses. A 21-day progesterone test will be done. Levels of prolactin and testosterone may be indicated
An ultrasound scan to rule out fibroids, endometrial hyperplasia, polyps and endometrial cancers can be carried out.
TREATMENT
Medical treatment
- Oral contraceptive pills
They usually restore regular menses by ensuring a continuous supply of low dose estrogen and progesterone.
- Progestin-only
This is used when there has been long-standing DUB. It may have to be continuous to encourage monthly normal withdrawal bleeding.
Mirena, a progestin IUD could also be used to regularize menses.
- Estrogen only
This could be used in high doses in prolonged bleeding to induce a state of normal endometrial growth. Usually should be followed up with progestin administration.
Surgical Treatment
- Hysteroscopy is a mainstay of investigation and treatment of clients with DUB. If an endometrial fibroid or polyp is found it could be treated. A biopsy could be taken if an abnormal lesion is seen.
- This could be performed if medical treatment fails and the client has completed her family size. Hysterectomy could be laparoscopic or vaginal.
- Endometrial ablation could be considered.
WHEN TO SEE A DOCTOR
You are advised to see your doctor if you experience the following.
- If you have abnormally heavy or light menstrual flows
- If you have a short interval between menses
- If you have difficulty getting pregnant
