Dysfunctional Uterine Bleeding (DUB)

Abnormal uterine bleeding not associated with tumor, inflammation, or pregnancy.

DUB, the most common cause of abnormal uterine bleeding, must be a diagnosis of exclusion.

It occurs most commonly at the extremes of reproductive life; > 50% of the cases of DUB occur in women > 45 yr, and 20% are seen in adolescents.

Although DUB may occur with either ovulatory or anovulatory cycles, > 70% of episodes are associated with anovulation.

Thus, DUB is common in women with polycystic ovary syndrome (PCO).

The bleeding in anovulatory women is generally the result of stimulation of the endometrium with unopposed estrogen and may result in endometrial hyperplasia.

The endometrium, thickened by the estrogen, then sloughs incompletely and irregularly, and bleeding becomes irregular, prolonged, and sometimes profuse.

Abnormal bleeding may also occur in women taking some form of exogenous estrogen. In ovulatory cycles the abnormal bleeding is generally due to luteal phase abnormalities.

History and physical examination cannot distinguish patients with abnormal uterine bleeding who have endometrial hyperplasia from those who do not.

¨1Women 35 yr, those with PCO and/or

¨2a prolonged history of anovulatory bleeding, and

¨3obese and

¨4nulliparous women should have an endometrial biopsy before initiation of medical therapy, because they are at increased risk for endometrial carcinoma.

A Hct and Hb should be done on each patient presenting with abnormal bleeding to evaluate the chronicity and severity of the bleeding.

Treatment

Treatment varies with the age of the patient, the extent of the bleeding, pathologic assessment of the endometrium, and the patient's wishes.

Even acute episodes of profuse bleeding in anovulatory women can generally be treated by giving 1 combination oral contraceptive agent q 6 h for 5 to 7 days.

Bleeding should stop in 12 to 24 h, but patients will have heavy bleeding, often with cramping, 2 to 4 days after stopping therapy.

Recurrence is prevented by giving combination oral contraceptive agents cyclically for at least 3 mo.

If spontaneous cyclic menses do not resume and pregnancy is not desired, or if use of oral contraceptives is contraindicated for some reason, the patient can be treated with progestin (medroxyprogesterone) acetate 5 to 10 mg/day orally for 10 to 14 days each month).

Uterine curettage is indicated in patients failing to respond to hormonal therapy (as indicated in a subsequent biopsy) and in those in whom irregular bleeding persists. If pregnancy is desired, then ovulation can be induced as discussed in treatment of PCO, above.

An alternative approach to the treatment of an acute episode of anovulatory bleeding is the administration of conjugated oestrogens 25 mg IV q 4 h up to 3 doses until bleeding abates.

Progestin therapy (medroxy-progesterone acetate 5 to 10 mg/day orally for 10 days) should be started simultaneously.

Following cessation of therapy, withdrawal bleeding will result. The patient can then be treated with oral contraceptives for at least 3 cycles.

For women with anovulatory bleeding without a profuse bleeding episode, treatment with cyclic oral contraceptives or progestin can be offered if pregnancy is not desired.

Ovulation induction with clomiphene citrate can be offered to those desiring pregnancy.

Similarly, clomiphene citrate can be used to treat luteal dysfunction. HCG 2500 to 5000 IU IM q 2nd or 3rd day beginning with the midcycle increase in basal body temperature and progesterone 12.5 mg/day IM in oil or 25 mg bid as rectal or vaginal suppositories have also been used to treat luteal dysfunction

Treatment of women with endometrial hyperplasia must be individualized, based on the pathologic findings, the age of the patient, and the patient's reproductive desires.

Women with atypical adenomatous hyperplasia are most easily treated with hysterectomy regardless of age because of the risk of subsequent adenocarcinoma of the uterus.

A fractional D & C should be performed prior to any therapy in any woman with atypical hyperplasia on biopsy to rule out coexisting carcinoma.

In women who are poor surgical risks and in those who wish to preserve future fertility, medroxyprogesterone acetate 20 to 40 mg/day orally can be given for 3 to 6 mo.

Patients can then undergo a repeat endometrial biopsy. If the biopsy indicates resolution of the hyperplasia, patients may be treated with cyclic medroxyprogesterone acetate (5 to 10 mg/day orally for 10 to 14 days each month) or with clomiphene citrate to induce ovulation if pregnancy is desired.

Women with more benign cystic hyperplasia or adenomatous hyperplasia can generally be treated cyclically with medroxyprogesterone acetate, but again should undergo a repeat biopsy in about 3 mo

Abnormal Genital Bleeding

Abnormal uterine bleeding includes

(1) Excessive duration (menorrhagia) or amount (hypermenorrhea) of menstruation or both;

(2) Too frequent menstruation (polymenorrhea);

(3) Nonmenstrual or intermenstrual bleeding (metrorrhagia); and

(4) Postmenopausal bleeding, which denotes any bleeding occurring 6 mo after the last normal menstrual period at the menopause.

Abnormal genital bleeding is due to organic causes in about 25% of patients; in the remainder there is a functional abnormality of the hypothalamic-pituitary-ovarian axis (dysfunctional uterine bleeding). In considering the individual patient, age is the most important factor.

Dysfunctional bleeding is much more common during the early reproductive years, whereas organic causes, including neoplasias of the genital tract, become more frequent with advancing age