Hormonal Imbalance Series: Dysfunctional Uterine Bleeding

2. Dysfunctional Uterine Bleeding (DUB) 

What is Dysfunctional Uterine Bleeding (DUB)

Dysfunctional uterine bleeding (DUB) is abnormal bleeding from the uterus that is not due to pregnancy or other recognizable pathology in the women’s uterus, pelvic or systemic disease. It is a functional problem of the uterus largely due to hormonal imbalance and not related to structural or anatomical problem. It is commonly present as heavy menstrual bleeding (menorrhagia). However, the doctor can only derive to a diagnosis of DUB after all other causes for abnormal and heavy menstrual bleeding in a patient have been investigated and excluded. 

Who gets DUB and why is it important to know

Almost every woman is at risk of experience DUB in their lifetime. Dysfunctional uterine bleeding occurs most often in adolescent and in women after 40 and close to menopausal age. Studies showed that nearly 80% of heavy menstruation (i.e. menstrual blood loss >80 mls permonth) is caused by DUB. Heavy menstrual bleeding may affect a woman’s health both medically and socially causing problem such as iron deficiency anaemia and social phobia or discomfort respectively. Dysfunctional uterine bleeding is the commonest cause of iron deficiency anaemia in women in the developed world and of chronic illness in developing world.  It also affects productivity as almost 10 % of women absent from work due to heavy menstrual bleeding. For adolescent, heavy menstrual bleeding resulting in anaemia affects their school performance as they often feel lethargic and unable to participate in school activities too. 

What are other causes of abnormal menstrual bleeding?

Other than DUB, the functional problem that often responsible for heavy or abnormal menstruation, there are many structural and systemic cause that need to be investigated and excluded first before DUB can be diagnosed. Other causes of abnormal uterine bleeding include the following:

• Uterine Fibroid
• Uterine Polyp
• Uterine hyperplasia
• Uterine Cancer
• Adenomyosis
• Intrauterine Device (IUCD)
• Thyroid disease
• Blood disorders
• Kidney disease

Treatment of DUB: What to expect from your gynaecologist?

Although abnormal menstrual bleeding is often due to functional or hormonal imbalance but diagnosis of dysfunctional uterine bleeding cannot be made based on assumption without going through a full examination and investigation because it is not always the case. Your doctor will ask you about your personal and family health history and your menstrual cycle. It may be helpful to keep track on your menstrual cycle before your visit. Note the date, length, and type (light, medium, heavy, spotting) of your bleeding on a calendar. Based on your symptom your doctor might order some test which includes a pap test and ultrasound of the pelvis to rule out those structural causes of the abnormal bleeding. You also may have a test to see if you are pregnant. For women after 40, it is necessary to have a biopsy of the endometrium and a hysteroscopy to assess the endometrium and rule out serious pathology like endometrial hyperplasia or cancer.

The approach to the treatment of DUB is depending on the age and whether you want to have children. Most women with DUB can be treated medically and others may need surgery. The following are options of medical treatment that you may expect from your doctor.

• Tranexamic acid – to be taken for 5 days during heavy period; effective in reducing menstrual blood loss by 50%. For young woman and adolescent, it is recommended that tranexamic acid is the first line therapy for DUB.
• NSAID/Ponstan ─ to be taken for few days during heavy period; effective in reducing menstrual blood loss by 30-50% and relief period cramps.
• OCPill ─ to be taken everyday for months; effectively reduced menstrual blood loss by 30-50% and relief period cramps. It also offers protection against pregnancy.

• MIRENA IUS ─ a T shape intrauterine device containing progesterone hormones.  For older women, it is highly recommended that MIRENA IUS to be the first line therapy, i.e first treatment option to be offered to the patient as it is the most effective in reducing menstrual blood loss by almost 70-90%.
• Hysterectomy ─ removal of the uterus is reserved as the last option to be offered if everything else has failed.