Dysfunctional Uterine Bleeding and Related Topics

Dysfunctional Uterine Bleeding (DUB)

  • Definition: Dysfunctional uterine bleeding is any bleeding that differs in regularity, frequency, duration, or volume from a patient's usual menstrual flow.

    • Affects 3 out of 10 women during reproductive age.
    • It is socially and physically debilitating.

  • Etiologies: Most common causes

    • Anovulation (most common, accounts for 70% of cases)
    • Pregnancy
    • Trauma
    • Anatomic abnormalities
    • Infections
    • Endocrinologic disorders
    • Malignancies
    • Medications

  • Types of Bleeding:

    • Menorrhagia: Prolonged or excessive bleeding
    • Metrorrhagia: Irregular bleeding
    • Menometrorrhagia: Combination of menorrhagia and metrorrhagia
    • Polymenorrhea: More frequent periods (less than 21 days apart)
    • Oligomenorrhea: More than 35 days between periods
    • Amenorrhea: Absence of menstruation for 6 months or longer in non-menopausal women

  • Pathophysiology of Anovulation:

    • Lack of ovulation affects the hormonal balance, particularly the levels of estrogen and progesterone.
    • Without ovulation, there is constant estrogen stimulation of the endometrium leading to thickening but no stabilization (no progesterone).
    • Result: Premature shedding of the endometrium, leading to dysfunctional bleeding.

  • Diagnosis:

    • Must exclude structural or pregnancy-related causes first.
    • Medical history essential, including: gynecological history, sexual history, and medication list (includes anticoagulants, antidepressants, hormonal therapies).
    • Pelvic Examination: Important for identifying sources of bleeding (e.g., cervix, trauma, STDs, cancer).
    • Laboratory Testing:
    • Urine pregnancy test (vital)
    • Complete blood count (CBC) with platelet count
    • Cervical testing for infections
    • Additional tests for underlying causes as indicated (prolactin, TSH, testosterone for hirsutism, etc.).

  • Management of DUB:

    • Immediate Goal: Stop the bleeding. Assess the volume and impact on the patient's well-being.
    • Treatment Options in Urgent Care:
    • Severe bleeding: High doses of IV or oral estrogen.
    • Moderate bleeding: Combined oral contraceptive pills, or progestin (e.g., Medroxyprogesterone).
    • Progestin offers less risk if there's potential for endometrial hyperplasia/cancer.
    • Follow-up: Schedule an appointment with a gynecologist for further evaluation and management strategies.

  • Long-Term Management:

    • Use of IUDs releasing progestin for continual stabilization.
    • Consider NSAIDs for pain control and to reduce heavy bleeding.
    • Hormonal treatments based on further investigations by specialists (e.g., endometrial ablation, hysterectomy in extreme cases).

  • Ectopic Pregnancy:

    • Occurs in 1 in 50-80 pregnancies, major cause of maternal mortality in the first trimester.
    • Risk factors include history of ectopic pregnancies, endometriosis, PID, and smoking.
    • Presentation includes abdominal pain, spotting, or pelvic pain.
    • Diagnosis typically involves results from a beta-HCG blood test and transvaginal ultrasound.
    • Treatment may involve surgical intervention or medical treatment (e.g., Methotrexate) depending on stability of patient and size of ectopic mass.

  • Conclusion: Understanding the differential diagnoses and managing abnormal uterine bleeding is critical in urgent care settings. Always ensure that safety, comprehensive history, and appropriate follow-up with specialists are prioritized.