Ovulatory and anovulatory DUB: Causes, diagnosis and treatment
Dr N P Vijayalakshmy, MD, DGO
Dysfunctional uterine bleeding (DUB) is defined as abnormal vaginal bleeding in women with no clear etiological factor. It can occur at any time of the age between menarche and menopause in ovulatory and anovulatory women. It is commonly seen at puberty and after the age of 35 years, and, in most of these patients, irregular ovulation is seen.
In normal menstrual cycle, woman loses around 35 ml of blood, which she bleeds within 3-5 days at interval of 28-30 days. In DUB, as much as 80 ml of blood can be lost in each cycle wherein the regularity of the cycle may not be altered but bleeds for more number of days heavily. In some women, periods become vey irregular and the bleeding is profuse and prolonged where she passes plenty of clots leaving behind the women very anemic. Most of these women suffer from iron deficiency .Sometimes, interval between cycles is reduced to less than 21days.
The diagnosis of DUB is done by excluding many causes. Pregnancy or abortion is the first one. The other main causes are pelvic pathology, systemic diseases and iatrogenic causes. Fibroids contribute to menorrhagia, depending on its location in the uterus. The other conditions which can be treated are endometrial polyp, cervical polyp, endometriosis and adenomyosis. Pre-malignant conditions like endometrial hyperplasia and carcinoma have o be ruled out. Some of the systemic disorders are hypothyroidism, systemic lupus and erythematosus. Iatrogenic causes are hormones, contraceptives, intrauterine contraceptive devices and anticoagulants.
When the above are ruled out, DUB can be diagnosed. An anovulatory DUB is mainly due to unopposed estrogen effect on endometrium, sometimes leading to hyperplasic and neoplastic changes. Ovulatory DUB is mainly due to local factors like defect in endometrial process. Treatment can be medical or surgical. Endometrial curettage and histopathology report will help in deciding the treatment. There are different varieties of medicines. Mainly hormones like oral contraceptives, and progestins in the second half of cycles. Dianazole is a hormone with mild androgenic property. Anti-fibroneltic agents like tranexamic acids prevent the activation of plasiminogen and decrease the menstrual loss.
Surgical management is to stop acute episode by D&C (dilation and curettage). Endometrial ablation is an alternative for hysterectomy. There are different types of energy modalities used. Ablation does not involve the removal of uterus. When there is no pathology, endometrial ablation is a good alternative to hysterectomy. This results in short hospital stay, low cost, and early resumption of duties. Hysterectomy, the removal of uterus, can be done through laprotomy or laparoscopy.
In conclusion, women at any age having irregular excessive bleeding with no particular etiology have to undergo investigation and choose proper treatment. Women have to undergo medical and surgical treatment as per the test result.
(Dr N P Vijayalakshmy MD, DGO, is the Chief Medical Officer of Vijaya Institute of Medical Sciences, Kadavanthra, Kochi, Kerala.).