Adolescent Gynecology Part I- Dysfunctional uterine bleeding

Dysfunctional uterine bleeding (DUB) is defined as painless endometrial bleeding that is prolonged, excessive and irregular and not attributable to any underlying structural or systemic disease. The etiology of the problem is caused by the continuing maturation of the hypothalamus.  

DUB is one of the main menstrual problems during the beginning of adolescence so it’s essential we know how to address this medically and also aid patients psychologically. A study by Deligeoroglou E et al. showed that DUB accounts for almost 50% of menstrual disorders during adolescence followed by amenorrhea (23%), Oligomenorrhea (21%) and Dysmenorrhea.

DUB has a complex pathophysiology and is linked to potential anovulation, absence of positive feedback, continuous estrogen secretion, endometrial hyperplasia, increased or abnormal neovascularisation, low progesterone secretion, unstabilised endometrial stroma, absence of periodic vasoconstriction, and angiogenesis.  A variety of pathologies of the female reproductive organs are associated with disturbances of the angiogenic process including DUB, endometrial hyperplasia, carcinoma and endometriosis. Therefore angiogenic or antiangiogenic compounds may prove to be effective therapeutic agents for treating these pathologies.

What about the endometrial vessels?

Once estrogen levels start to rise in response to follicular recruitment, the process of growth and healing begins in the endometrium. Both the glands and the spiral arterioles respond dramatically to estrogen. Over the following days, the endometrium grows from 0.5 up to 5 mm due to an increase in the number and size of the glands. In stimulated cycles, the number of glands is positively correlated to the serum estrogen levels. The glandular epithelium extends to form an epithelial lining facing the endometrial cavity whilst the spiral vessels extend through the stoma.

Estrogen has also been shown to have a significant effect on endometrial blood cells. When estrogen levels fluctuate, changes can be seen in vessel permeability and fragility. In an estrogen-primed endometrium, fluctuations in estrogen levels that are seen in the typical anovulatory cycles during adolescence lead to vessel fragility and incomplete and disorderly breakdown.

Diagnosing DUB

Whilst there are many organic causes of abnormal uterine bleeding during adolescence such as clotting abnormalities, systemic diseases and endocrine disorders, DUB is more likely to be a diagnosis of exclusion caused by anovulation. A patient evaluation needs to involved looking at their clinical history (and that of their immediate female family members), a gynaecological examination, labs tests and hormone profile evaluation, pelvic ultrasound, endocrinological examination and a hysteroscopy.

Differential Diagnosis

There are a number of potential differential diagnoses including;

-          Bleeding related to reproductive tract disease

-          Trauma and genital injury due to rape, sexual abuse or consensual sexual experience that can result in severe bleeding

-          Injury caused by attempting to use tampons or other foreign objects within the vagina

-          Infections resulting in heavy chronic bleeding

-          Endometriosis and pelvic inflammatory disease due to STDs such as chlamydia and gonorrhoea

-          Vaginitis, cervical inflammation or erosion can give rise to vaginal bleeding thought by patients to be irregular menstruation

-          Partially obstructive congenital uterine anomalies

-          Decreased renal clearance of prolactin which gives rise to hyperprolactinemia and may contribute to anovulatory DUB.

-          Bleeding disorders

 

How do we manage DUB?

Mild DUB- defined as menstruation mildly prolonged or irregular with, no evidence of anaemia and does not require specific therapy. This can be treated with:

-          Reassurance and education about normal menstrual cycles

-          A follow-up to help the adolescent feel safe

-          Encouraging use of a menstrual calendar so she can predict her bleeding

-          In rare cases, new generation E2 COCs can be prescribed

 

Moderate DUB- defined as prolonged, profuse menstruation, impending daily activities, or by a clearly shortened menstrual interval, accompanied by mild anaemia (hemoglobulin higher or equal to 10gr/dl). Treatment choices include:

-          Low dose E2 COCs (continued for 3-6 months) or cyclic progestins which is administered for the same 10 days every month in order to stabilise the endometrium preventing the action of unopposed estrogens

-          Oral iron therapy if the patient has iron deficiency anaemia  

-          NSAIDs can be prescribed if the patient is actively bleeding which can reduce flow by up to 50%

Severe DUB- defined as heavy bleeding and Hb less than 8gr/dl. Unfortunately these cases need hospitalisation, actions should include:

-          Obtaining blood samples to exclude an underlying bleeding disorder before starting therapy

-          IV administration of CEE (25 mg every 6 hours for no longer than 24 hours) can be effective in controlling uterine bleeding

-          If hypovolemic; immediate resuscitation with IV fluids for volume expansion and possible transfusion are indicated in order to restore hemodynamic balance.


DUB has a complex pathology and many potential differential diagnoses, it is important to accurately diagnose and determine level of DUB so that the appropriate treatment measure can be followed. The future of the patient’s reproductive life must be taken into consideration when providing guidance and support.