Dysfunctional uterine bleeding
- Incidence: 750.00 cases per 100,000 person-years
- Peak incidence: 30-40 years
|Dysfunctional uterine bleeding||1|
- An anovulatory woman remains in the follicular stage of the ovarian cycle, and consequently the only hormone stimulation the endometrium receives is oestrogen. This maintains the endometrium in the proliferative phase of the endometrial cycle.
- Over time, the uninterrupted oestrogen signals in the absence of periodic progesterone causes hyperplasia and structural instability of the stroma.
- Histology demonstrates proliferative endometrium, with areas of stromal breakdown and platelet/fibrin repair, associated with increased and dilated venous capillaries.
- Once initiated, the process is exacerbated by local release of lysosomal proteolytic enzymes from surrounding epithelia, migratory leukocytes, and prostaglandins.
- More common in states of increased unopposed oestrogen exposure
- Polycystic ovarian syndrome
- Peri-menopausal period
- Post-menarche adolescence
- Typically, infrequent and irregular, unpredictable menstrual bleeding
- Varies in amount, duration and character
- Not necessarily preceded by premenstrual symptoms (breast fullness/tenderness, bloating, mild mood swings)
- Ask the patient if there is any possibility she may be pregnant
- In a woman aged >40, peri-menopausal period may include DUB, and other symptoms such as:
- Hot flushes
- Night sweats
- Vaginal dryness or itching
- Mood changes
- Sleep disturbance
- In women of reproductive age, polycystic ovarian syndrome (PCOS) can cause DUB. Signs and symptoms include:
- Acanthosis nigricans
- Anaemia is be present in 20-60% women with DUB. Signs of symptoms of anaemia may include:
- Conjunctival pallor
- Systemic symptoms such as weight loss, fever, as well as dysmenorrhea are not typical and are more suggestive of other uterine pathology.
- Pregnancy test
- Essential to rule out pregnancy as differential and before any treatment is given
- Full blood count
- May show anaemia
- UTI causing bleeding may show high WCC
- Abnormalities should prompt further tests such as Factor VIII and von Willebrand factor antigen.
If indicative symptoms:
- Thyroid function tests
- If clinical history suggestive of hypo- or hyperthyroidism
- FSH and LH levels
- Peri-menopausal women (typically aged 40-60) may experience irregular bleeding
- Two levels at least 1 week apart are recommended
- Elevated levels indicates patient is perimenopausal
- Prolactin level
- If clinical history suggests hyperprolactinaemia as a cause for anovulatory bleeding
- Androgen levels
- Can aid in the diagnosis of co-existent poly-cystic ovarian syndrome (PCOS), a strong risk factor for DUB
A transvaginal ultrasound is the first-line investigation in DUB as it can delineate endometrial pathology such as polyps or fibroids which may be causing abnormal bleeding.
- Furthermore, an endometrial biopsy can be done to rule out neoplasm if ultrasound findings indicate myometrium thickness >12mm, or 5-12mm with history of unopposed oestrogen exposure (e.g. poly-cystic ovarian syndrome)
- Identification of intra-uterine pathology e.g. fibroids or endometrial cancer may require further imaging such as direct hysteroscopy or MRI.
- Pregnancy related bleeding
- Pregnancy should be excluded when departure from normal bleeding pattern occurs
- Threatened or inevitable miscarriage, and ectopic pregnancy should be excluded if positive
- Uterine fibroids (leiomyoma)
- Fibroids can cause increased menstrual bleeding
- Mass may be palpable on abdominal examination, confirmed on ultrasound imaging
- May be managed medically or surgically
- Iatrogenic uterine bleeding
- Oral combined contraceptive pill or oral anticoagulants may cause irregular bleeding
- Endometrial or cervical malignancy
- Regional lymphadenopathy and systemic symptoms such as weight loss may be present
- Screen for specific risk factors: obesity, family history, exogenous oestrogen use for endometrial cancer; HPV infection, smoking for cervical cancer
- Biopsy and histological diagnosis
- Clotting disorder
- Family history important
- May also report frequent bruising, epistaxis, bleeding from gums
- Non-uterine bleeding
- E.g. urethritis, lesions of the cervix or vulva
- May be suggested by clinical history
- UTI may present with systemic symptoms such as fever, malaise
The aim is to restore regular cyclical bleeding
- Antagonise action of oestrogen
- Intra-uterine device (IUD) e.g. Mirena most common option
- Otherwise, norethisterone 5 mg orally three times daily on days 5-25 of cycle
- Subdermal progestogen implant also available
- Combined oestrogen and progestogen therapy
- Oral combined contraceptive pill may help if progestogen therapy alone ineffective
- NSAIDS e.g. mefenamic acid or ibuprofen have anti-prostaglandin effects
- Tranexamic acid (e.g. 1g PO TDS during menstruation) reduces rate of bleeding
- Gonadotropin-releasing hormone analogues
- Expert-guided treatment following referral to specialist centre
- E.g. leuprorelin
- Ovarian suppression therapy to cease oestrogen influence on proliferating endometrium.
- Must be discussed fully with the patients taking in to account their desire for future fertility, risks and effect of current condition on their wellbeing.
- Endometrial ablation
- Hysterectomy - can be performed laparoscopically, trans-vaginal, or via laparotomy.