The term dysfunctional uterine bleeding is used when there is heavy or irregular vaginal bleeding and where uterus, ovaries and fallopian tubes are found to be structurally and organically normal on bimanual examination. DUB occurs most commonly at the beginning and at the end of the reproductive years-shortly after the onset of menstrual cycle in an adolescent girl, when the hypothalamic ovarian axis is depressed because of low estrogen output.
In the perimenopausal period, DUB may be an early manifestation of ovarian failure. DUB is usually painless.
PATHOPHYSIOLOGY-
Approximately 90% cases of DUB result from anovulatory and 10% cases from ovulatory cycles. Normally during the menstrual cycle, the production of progesterone in the later half of the cycle balances out the regenerative effects of estrogen, stopping further endometrial growth.
In anovulatory cycle, the corpus luteum fails to form and progesterone is not secreted, resulting in overgrowth of endometrium and also it lacks structural support, sloughs off causing irregular and /or heavy bleeding. Women who take oral contraceptives and those on estrogen replacement therapy may have anovulatory cycles. Stress and illness can also trigger anovulation.
In ovulatory DUB, prolonged progesterone secretion causes irregular shedding of the endometrium. This causes portions of the endometrium to degenerate and results in spotting.
SIGNS AND SYMPTOMS-
Patients often present with history of amenorrhea, oligomenorrhoea, menorrhagia, or metrorrhagia. There may be anemia, pallor, hypotension, tachycardia. Certain questions regarding the reproductive history like previous abortion or recent termination of pregnancy, contraceptive use, gravida and para medical history of some diseases like Diabetes mellitus, Hypertension, Hyper and hypothyroidism liver disease, use of medicines as anticoagulants, aspirin, anticonvulsants, antibiotics should be asked.
There are some organic causes of abnormal vaginal bleeding which should be ruled out.
Trauma to the cervix, vulva or vagina, carcinoma of cervix, uterus and ovaries, functional ovarian cysts, cervicitis, endometritis, salpingitis, polycystic ovarian disease, vaginal polyps, ectopic pregnancy, hydatidiform mole, uterine fibroids, Blood dyscrasias, obesity, increased exercise performance, or stress may contribute to DUB. Intermenstrual bleeding, due to missed contraceptive pills should be noted. Depo- Provera a long acting injection given every three months inhibits ovulation and prolonged uterine bleeding may occur because of persistent anovulation. The Norplant system( surgically implanted levonorgestrel) which acts to block some, but not all ovulatory cycles, has the same effects as Depo-provera.
Laboratory Findings-
1 A blood examination to know the Hb level.
2 Thyroid Function Tests.
3 Pregnancy should be ruled out by urine test.
4 Abdominal and transvaginal ultrasound for the evaluation of uterine fibroids or polycystic ovarian syndrome.
5 Pap smear
6 Endometrial biopsy for those who are- obese, more than 35 years of age, hypertensive, diabetic, or with suspected polycystic ovarian disease
7 Chest X- ray to rule out tuberculosis
COMPLICATIONS :
Anemia
Adenocarcinoma of the uterus, because of prolonged, unopposed estrogen stimulation.
Adverse effects of oral contraceptive preparation.
TREATMENT-
Conservative- Supplement iron through diet or orally in case of severe anemia.
Rest and reassurance.
HOMOEOPATHIC TREATMENT-
We can save many patients from unnecessary hysterectomy by properly selected medicines. A detailed case taking is essential to know the constitutional remedy. The acute remedy will check the bleeding which has to be controlled and the deep acting constitutional and miasmatic remedy will prevent the recurrence. A regular estimation of Hb level, blood pressure, USG, and if necessary endometrial biopsy would ensure the physician and the patient, of the progress and prognosis.
The homoeopathic remedies with their indications are :
CALCAREA CARB.- A plump, female of any age, having too early, too profuse and too long lasting periods, if complains of gushing of blood after physical exertion, is chilly with perspiring cold hands and feet is sure to be a calc. carb patient. DUB in calc. pt. can occur because of over lifting, excitement, shock, fear, emotional disturbances or from straining the muscles.
PHOSPHORUS- Bright red hemorrhage from the uterus lasting too long. The concomitants are thirst for icy cold water, with dry tongue, backache, blue rings around the eyes. The oversensitive females, susceptible to external impressions like sound, light, odors, touch, electrical changes, anxious, fearful in dark and when alone. A young phos. girl has grown too rapidly, has delicate skin, long silky eyelashes, with graceful manners and excellent mental development with weak physique, having hereditary tendency to tuberculosis or history of some bone disease in early childhood.
SABINA- Frequent, profuse and prolonged menses, flow continuous till the next period. Liquid bright red blood intermingled with clots. Pain from sacrum to pubes or from vagina upto uterus and to umbilicus. Labour like pains appear and a clot is passed again followed by bright red blood. DUB during the peri and premenopausal phase in females who have become weak by overwork or much childbearing, has suffered from repeated hemorrhages, have become anemic and exhausted, regain health till broken down by another hemorrhage.
BELLADONNA- Sensation of hot blood gushing out with oversensitiveness to jar, touch and sudden appearance and disappearance of pain shooting in every direction.
IPECAC – Nausea and vomiting with the hemorrhage, out of proportion to the amount of blood lost.
SECALE COR.- Expulsion of dark clots with bearing down pains followed by thin watery offensive blood oozing as if uterus has lost the power to contract. The secale pt. is thin, scrawny, never takes on fat, cold, yet dislikes covering.
CINCHONNA- It will help pt. to regain strength, after loss of blood in those having vertigo, noises in the ears, and all the symptoms of anemia, insomnia after bleeding. Cinchona patient is chilly, sensitive to noise, building castles in the air, planning in the bed at night. .
CARBO VEG.- Atony of uterus, when after delivery or menses, the uterus does not contract and dark passive hemorrhage continues almost till the next period, with dragging down sensation in uterus as if everything would escape Concomitant symptoms may be flatulence, eructations, internal burning with external coldness, cold breath, tongue and face but she wants to be fanned.
ARNICA – where injury is the cause of bleeding.
USTILAGO- Blood half liquid half clotted, spongy cervix easily bleeding, at slightest provocation. Hypertrophy of the uterus, it feels drawn into a knot.
NIT. ACID – Muddy water like blood oozing after parturition or curetting.
Whenever, the best selected remedy fails to control DUB, psora is at the background. One or two doses of sulphur, in high potency will always check the bleeding and when Sulph. has exhausted its action Psor. comes to help. The indications of Sul. are DUB after a history of suppressed menses, heat and burning of palms and soles, vertex. feeling of hunger at 11 a.m..
HELONIAS- DUB at puberty, with consciousness of uterus, tired backachy females.
Other small remedies are Millifolium, Trillium, Thlaspi bursa, Erigeron, Hammamelis.
A word of caution – There should always be a set time period to watch the action of the indicated remedy and if there is no improvement necessary investigations should be done. The chances of carcinoma in a lady at climaxes with prolonged DUB should always be kept in mind.
good article.informative one .thank u very much