Dysfunctional Uterine Bleeding

Dysfunctional uterine bleeding

the causes and treatment of abnormal uterine bleeding vary with the patient's age and health. The evaluation can be organized according to physiologic age groups: menarche through adolescence; the childbearing period, and the perimenopausal and postmenopausal years. Dysfunctional beleeding is a diagnosis by exclusion and is related to the basic physiology of normal menstruation. Endometrial sampling, hysteroscopy, and dilatation and curettage are useful in evaluating the post-teenage patient.

Dysfunctional uterine beelding is abnormal uterine bleeding that has no organic cause, such as a tumor, inflammation or pregnancy. The diagnosis is generally made by exclusion of other disorders. This article describes the evaluation and management of both ovulatory and anovulatory causes of dysfunctional uterine bleeding.

Normal Menstruation

The evaluation of abnormal uterine bleeding requires an understanding of normal menstrual physiology. During the normal menstrual cycle, the hypothalamus secretes luteinizing hormone-releasing hormone (LHRH), which stimulates the pituitary gland to produce follicle-stimulating hormone (FSH) and luteinizing hormone (LH).

Through its production of estrogen, the dominant follice causes the pituitary gland to induce a midcycle surge of LH by increasing the level of estradiol above a critical level. This LH surge divides the menstrual cycle into two phases: (1) The follicular phase, which is characterized by the predominance of FSH, follicular growth and estradiol production, and (2) the luteal phase, which consists of the LH surge, ovulation and progesterone production.

The exact cause of the onset of menstruation is not known, but the most popular theory is that of estrogen withdrawal. According to this theory, maintenance of theendometrium requires an increase in estradiol; when sufficient estradiol is not produced,endrometial sloughing occurs.

The amount of tissue shed and blood lost at menstruation depends on the length of time that the endometrium is stimulated by estrogen. Since that time is relatively constant in normal regular menstrual cycles, the amount of tissue sloughed and blood lost also remains relatively constant.

Abnormal Bleeding

A significant portion of the time that is spent on evaluating the patient whth abnormal uterine bleeding will be devoted to ruling out organic causes, such as uterine neoplasms, pregnancy, trauma, infection and blood dyscrasias. The evaluation can be organized by physiologic age groups: menarche to age 20 (puberty and adolescence); age 20 to 40 (childbearing years), and age over 40 (premenopausal, menopausal and postmenopausal years).

MENARCHE TO AGE 20

Causes. Although the average age of menarche in the United States is 12.8 years, maturation of the hypothalamic-pituitary-ovarian axis is slow in adolescence. A regular menstrual pattern is generally not established until 20 months after menarche. Regular ovulatory periods may not occurfor for four or five years, and 80 percent of cycles are anovulatory in the first year after menarche. Anovulatory cycles with irregular bleeding and spotting are the most common cause of abnormal bleeding in teenagers, but the diagnosis is made byexclusion of other causes.

Pregnancy and its complications, including threatened abrtion, incomplete or complete abortion, ectopic pergnancy, postabortal trophoblastic disease, postpartum or postabortal endometritis, and uterine subinvolution, frequently present as irregular bleeding. Adolescent pregnancy rates remain high since 70 percent of young women have sexual intercourse before age 19 and many of them (50 percent) do not use contraception initially. Consequently, pergnancy and its complications must be considered when teenagers and younger girls present with irregular bleeding. These patients should be interviewed in private so that the physician can question them closely about sexual activity.

Trauma and foreign bodies are also common causes of dysfunctional uterine bleeding in this age group. Sexual abuse of children and young teenagers frequently presents as abnormal bleeding. Foreign bodies, particulary in younger girls, may include objects that can cause abrasions or lacerations. Abnormal bleeding may also be a complication of intrauterine devices or oral contraceptives.

Pelvic inflammatory disease should be suspected in females of any who present with abdominal pain, abnormal bleeding, low-grade fever and tenderness on pelvic examination.

Ten percent of fermales with blood dyscrasias have menorrhagia. the most common dyscrasia in adolescents is primary or secondary thrombocytopenic purpura. Hereditary bleeding disorders, such as von Willebrand's disease and Christmas disease (hemaphilia B), are usually known to exist in the family an thus are readily recognized. However, about 25 percent of patients with hereditary coagulation disorders give a negartive family history.

In a Toronto study, coagulation disorders caused 19 percent of the cases of acute menorrhagia in adolescents. Coagulation disorders were found in one-fourth of those whih severe menorrhagia (hemoglobin of less than 10 g per dL [100 g per L]), in one-third of those requiring transfusion and in one-half of those presenting at menarche with heavy bleeding. Glanzmann's disease, leukemia, iron deficiency anemia and vitamin C deficiency can also cause abnormal uterine bleeding.

Benign and malignant neoplasms of the vagina, cervix, uterus and ovaries may present as abnormal bleeding. Condylomata acuminata occasionally bleed.

Other causes of abnormal bleeding include cervicitis, polycystic ovary syndrome, persistent corpus luteum syndrome (Halban's disease), hypothyroidism, congenital adrenal hyperplasia, Addison's disease, prolactin-secreting adenomas, liver or renal disease, hemodialysis, rapid weight loss, bulimia, exercise and emotions. Medications such as anticoagulants, steroids, phenothiazines, anticholinergics, digitalis, and even diet pills and vitamins have also been associated with abnormal bleeding.

Evaluation. The investigation of abnormal bleeding in patients between menarche and age 20, as in other age groups, requires a thorough history, a complete physical examination and selected laboratory test. The history should be taken with and without the patient's parent in the room and should be directed toward the possibility of pregnancy or its complications, coagulation defects, drug (medications) use, dietary extremes, maternal history of drug use during pregnancy, recent contraceptive use, sexually transmitted diseases, trauma (including sexual abuse), headaches and visual changes.

It is important to obtain a detailed menstrual history, including age of onset, frequency, duration (number of days of bleeding) and an

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