Dysfunctional Uterine Bleeding

Dysfunctional uterine bleeding (DUB) is bleeding from the lining of the uterus that is inconsistent with ones normal bleeding pattern. By definition It is abnormal bleeding due to hormonal imbalance and not from anatomical abnormalities such as fibroids, polyps, scarring or cancer. DUB is very common. It accounts for a large percent of visits to the gynecologist and is one of the leading causes of hysterectomy. It consumes a significant amount of health care dollars and can severely compromise ones quality of life.

The cause of DUB is felt to be anovulation or the failure to stimulate adequately the release of an egg during the normal cycle. This phenomenon leads to unopposed estrogen stimulation of the uterine lining or endometrium with resultant poorly balanced uncontrolled growth of this tissue. Normally, when an egg is released (ovulation) progesterone is secreted from the ovary. Progesterone compliments the effects of estrogen and together they allow a complete maturation of the inner lining of the uterus. Following ovulation progesterone is secreted for about fourteen days then its production shuts way down. This shutting down triggers a period which is normally a well orchestrated, finite bleed that allows the endometrial lining to be shed. When ovulation does not occur the circulating estrogen stimulates the lining to grow unchecked and ultimately a disorganized, unpredictable bleeding pattern develops.

The initial evaluation of DUB is designed to eliminate other anatomical or hormonal reasons for abnormal bleeding. These include ultrasound, endometrial biopsy and hysteroscopy; all of which can be performed in an office setting. Hysteroscopy allows a direct visualization of the uterine cavity and is an excellent tool for eliminating intrauterine pathology (abnormalities within the uterus). Blood tests may be obtained and it is always important to eliminate pregnancy and blood clotting disorders as a cause of DUB. Once the diagnosis has been established treatment is centered on reestablishing a cyclic normalcy to periods or eliminating the bleeding altogether. There are many treatment options.

The management of DUB depends on a women's age, her desire to preserve fertility, the amount and acuteness of the bleeding and her underlying medical condition. Progesterone either as an oral cyclic regiment, injection or birth control pill is often first line therapy. Often no other therapy will be needed and the bleeding will stabilize with these regiments. When medical therapy fails surgery is indicated. Historically hysterectomy has been the procedure of choice. Over the last decade endometrial ablation has evolved as a less invasive, alternative to hysterectomy. Endometrial ablation can be safely performed in an outpatient setting with fast recovery times and greatly reduced postoperative discomfort. Initially, endometrial ablations were done with an operating hysteroscope or resectosope and electric current was used to ablate the endometrium. Recent modern advances have simplified the procedure making it more accessible to those physicians not trained in hysteroscopic technique. One such method involves introducing a balloon catheter into the uterus. The balloon covers the entire surface of endometrium such that when heated they ablate the lining and destroy the uterine lining. Ultimately when all else fails to control the bleeding hysterectomy is indicated. It is definitive therapy for DUB and has a one hundred percent success rate. The vaginal approach is preferred to an abdominal incision although laparascopic assisted vaginal hysterectomy (LAVH) is also used. The potential complications of hysterectomy are numerous and the recovery time from surgery is significantly longer than other treatment modalities. It should be reserved for only the most resistant and unresponsive dysfunctional bleeding.