Dysfunctional Uterine Bleeding in Reproductive Age
What is dysfunctional uterine bleeding in reproductive age?
Dysfunctional uterine bleeding in reproductive age (DUB) is the most common cause of abnormal uterine bleeding in women with polycystic ovary syndrome (PCOS) or endometriosis. In most cases, dysfunctional uterine bleeding in reproductive age is not associated with inflammation, pregnancy or tumors.
It occurs most commonly in women older than 45 years at the end of their reproductive life. It may occur in anovulatory women as a result of endometrial proliferation under estrogenic stimulation among unopposed estrogen users, especially in women taking exogenous estrogen or in women with normogonadotropic anovulation. Long-term unopposed estrogen production or chronic exposure to unopposed estrogen may result in endometrial thickness (endometrial hyperplasia) and polyps, as it results in continuous endometrial proliferation and overgrowth of the endometrial lining. Abnormally thickened endometrium sloughs off during menstrual flow resulting in irregular, heavy and unpredictable bleeding with clots. In anovulatory women, abnormal bleeding generally occurs in ovulatory cycles due to luteal phase abnormalities.
What are the symptoms of dysfunctional uterine bleeding in reproductive age?
Symptoms and signs of dysfunctional uterine bleeding include:
- Irregular periods (cycles that are shorter than 21 days or longer than 35 days), variations in the number of days between each cycle, and prolonged excessive menstrual bleeding that goes beyond a week (normally it lasts 4-6 days)
- Irregular vaginal bleeding and spotting in between periods
- Pale skin
- Generalized weakness and bad appetite
- Symptoms of anemia
What are the causes of dysfunctional uterine bleeding in reproductive age?
Anovulation is one of the most common causes of dysfunctional uterine bleeding in reproductive age women. In most women, menstrual cycles become ovulatory 2 years after menarche. However, hormone imbalance is the main cause of abnormal uterine bleeding in most women.
Other causes of DUB in reproductive age women include follicular atresia, impaired hypothalamic-pituitary-gonadal axis function, pregnancy, polyps (endometrial or cervical) or uterine fibroids. Rarely, cervical infection, uterine cancer, an IUD implant, adenomyosis, thyroid problems (hypothyroidism or hyperthyroidism), pituitary disorders, endometrial hyperplasia, polycystic ovary syndrome (PCOS), cervical dysplasia, or bleeding disorders can cause abnormal uterine bleeding.
What is the treatment for dysfunctional uterine bleeding?
Dysfunctional uterine bleeding (DUB) may be acute or chronic: however, the treatment is directed at providing enough hormones to stop or reduce the acute bleeding. Once the acute episode of DUB has been treated, attention is directed toward the underlying pathology.
High-dose estrogen therapy is used to control hemorrhagic uterine bleeding and can be helpful for patients with an extremely heavy menstrual flow
High dose combined oral contraceptives provide both estrogen and progesterone, which will stimulate the regrowth of the endometrium. After a negative pregnancy test, the patient should be give a 21 day pack of 50 mcg estrogen pills, such as ethinyl estradiol, mestranol, or OVCON® 35 (Norethindrone and Ethinyl Estradiol) and should be instructed to take four pills a day until they are gone. Bleeding should stop within 1– 2 days. Patients with light vaginal bleeding should take Provera 10 mg for 5 days; However, if bleeding is heavy enough the patient should take Premarin 25 mg IV q4 hours × 24 hours until the bleeding is reduced. At that point the patient should be put on a high-dose oral contraceptive regimen. A D&C procedure is indicated if bleeding is not controlled within a day. Once the bleeding episode is under control, the patient should start a monthly regimen that involves taking Provera 10 mg daily on days 1-5 each month. Hypoestrogenic patients should receive Premarin 0.625 mg daily on days 1-25 each month along with Provera 10 mg daily on days 16-25 each month for the long term prevention of osteoporosis and because estrogen stimulation is important for the development of secondary sex characteristics.
Hormone therapy, such as contraceptive pills or hormonal IUDs can be used to regulate the menstrual cycle
Progestin therapy should be initiated after initiating estrogen therapy to prevent potential bleeding episodes from treatment with prolonged unopposed estrogen. The levonorgestrel intrauterine device (LNG-IUD, or Mirena® IUD) is a device that slowly releases small amounts of levonorgestrel each day (releasing 30 μg/day of levonorgestrel), or cyclic progestin therapy (oral micronized progesterone, or Prometrium®) is recommended for women aged 40 years or older
The most potent progestins include: norkolut, norgestimate, levonorgestrel, desogestrel and gestodene, and other norsteroids.
Levonorgestrel prevents pregnancy if taken within the 72 hours after unprotected sexual intercourse
Surgery or Endometrial ablation should be considered only in patients in whom medical treatment has failed
- Alternative treatment
Next steps management
How to diagnose dysfunctional uterine bleeding in reproductive age?
A general health check-up, your doctor will review your menstrual bleeding history and will conduct a pelvic exam
A progesterone test to determine whether ovulation is occurring, low progesterone levels during the third week of a menstrual cycle suggest an ovulation problem. Alternatively, you can learn to chart your basal body temperature or BBT (the temperature at which your body rests, at rest, your BBT would usually be 97 °F or 36 °C) to help you determine when you’re fertile, As you chart your basal body temperature each morning throughout your cycle, you will notice your chart will become biphasic, it will show relatively low temperatures before ovulation and slightly elevated temperatures (a temperature shift of approximately 4 °F) that occur just after ovulation due to the hormone progesterone. BBT can be measured using a basal thermometer, take your temperature orally (although it can be taken vaginally or rectally) first thing in the morning straight after waking up, and before jumping out of bed. Take your BBT at the same time each day
Blood tests, such as a hCG pregnancy test, serum prolactin test to check for a pituitary problem, CBC and serum ferritin test to check for anemia, TSH test to check for a thyroid gland problem
Pap smear to detect cervical dysplasia and cancer
Urine test (urinalysis and culture test) to screen for infections, such as chlamydia and gonorrhea
Transvaginal pelvic ultrasound is an ultrasound procedure used to check for pelvic abnormalities
Saline sonohysterogram is an ultrasound procedure used to investigate uterine abnormalities, such as polyps or fibroids
Endometrial biopsy, usually for postmenopausal women to find out whether endometrial hyperplasia or endometrial cancer is present
Hysteroscopy is a procedure in which a hysteroscope is used to examine the endometrial lining, it is performed to diagnose and treat causes of abnormal bleeding and is usually recommended if bleeding continues despite treatment, it is the last choice in the treatment of patients with uterine fibroids. Hysteroscopy should be performed with caution as it increases the risk of uterine perforation and /or embolism.