Abnormal and ''dysfunctional' uterine bleeding (''DUB')

''Abnormal uterine bleeding' includes any bleeding which is abnormal in its degree and timing. ''Dysfunctional uterine bleeding', or ''DUB', is abnormal bleeding which has no obvious pathology.

In the developing world, abnormal uterine bleeding usually has some obvious pathology. The list of its possible causes is a long one and is given below. Only diagnose DUB after you have excluded obvious pathology. DUB occurs most commonly at the extremes of reproductive life: (1) In young girls for their first few cycles, before these settle into a normal pattern. (2) In older women nearing the menopause, before complete amenorrhoea sets in. DUB should be an uncommon diagnosis in the prime of life; if you make it often, you are probably misdiagnosing abortions or chronic ectopics. In the developing world it seems to be rare, even in older women, perhaps because patients here are more tolerant of minor menstrual irregularities. This is in sharp contrast to the industrial world, where DUB is one of the commonest gynaecological diagnoses.

The commonest cause of DUB is the failure to ovulate. Because ovulation does not occur in the middle of a cycle as it should, the corpus luteum does not develop and produce progesterone normally. The endometrium grows abnormally thick under the influence of unopposed oestrogen, and eventually begins to shed unevenly. Courses of progestogen stop bleeding temporarily, and when these are stopped normal periods usually follow.

The important diseases not to miss are carcinoma of the cervix (very common), and, usually after the menopause, carcinoma of the endometrium (rare in the developing world). The investigation of abnormal bleeding often requires a ''D and C', but you may not have time to do very many of these, so you will probably have to limit yourself to priorities. These are intermenstrual bleeding, and especially postcoital bleeding, which does not have some more obvious cause. Heavy regular periods are a common complaint, and are usually benign.

Mr Printer. Please take in the ''not in series figure': ''Ovular cycles' somewhere here.

ABNORMAL UTERINE BLEEDING HISTORY. A careful history and examination will nearly always reveal some obvious cause. ''When did the bleeding start? Last year? At Easter? At the beginning of the cold season? For how many days do you bleed and when?'' Ask about the last episode. ''Are you bleeding now?'' ''Were you bleeding last week? Last month?'' Describe the bleeding pattern by giving approximate dates and amounts. Make sure the patient distinguishes blood escaping vaginally, from blood in her urine.

CAUTION ! (1) Avoid statements like ''Has periods [mu]2 a month', ''polymenorrhoea', ''menorrhagia', etc. (2) Ask about postcoital bleeding. (3) Bleeding patterns are imperfectly matched to diagnoses, so don't always expect her history to give you the answer.

EXAMINATION. Is she anaemic? Examine her abdomen. Examine her cervix with a speculum. Do a Pap smear (M 29.1).

DIAGNOSIS AND TREATMENT. The treatment of most conditions is described elsewhere. Diagnose ''DUB' by exclusion, and remember that a ''D and C' is not automatic treatment for all forms of uterine bleeding.

Pregnancy-related. Abortion in all its forms (16.2), ectopic pregnancy (16.7).

Contraception-related. ''Depo provera' or a loop (M 3.10).

Hormone treatment elsewhere at a health centre or by a private doctor.

Pathology in the genital tract. Fibroids (20.6), cervical polyp (20-5), chronic pelvic infection (6.6), vaginitis (trichomonas, atrophic menopausal or foreign body), cervical erosion, cervicitis, ovarian cysts and tumours (20.7), carcinoma of the cervix (common, 32.35), endometrial carcinoma (rare, 32.25), choriocarcinoma (uncommon, 32.38).

If she is less than 20, and you have excluded the above pathology, she probably has DUB. Avoid treating her if you can. If treatment seems to be necessary, try cyclical progestogens (see below) first. If they fail and bleeding is severe or persistent, curette her.

If she is between 20 and 40, she can have most of the pathology listed above. Don't miss carcinoma of the cervix. If she has intermenstrual or postcoital bleeding, be sure to take a wedge or punch biopsy of any hard, friable, or ulcerated area on her cervix. A ''D and C' will not diagnose carcinoma of the cervix (32.35); you can almost always diagnose this by looking at her cervix with a speculum. See also Section 32.35.

If she is over 40, and especially if she has postmenopausal bleeding (bleeding 1 year or more after the menopause), always do a ''D and C' to exclude carcinoma of the endometrium. Other causes include fibroids, especially prolapsed submucosal fibroids (20-4), and senile vaginitis.

If she has a heavy loss and no obvious cause, and emergency treatment is necessary, see below.

CYCLICAL PROGESTOGENS TO STOP ACUTE BLEEDING NOW, give her norethistrone 5 mg 3 times daily for 5[nd]10 days. Or, give her one ''combined' contraceptive pill twice daily for 10 days. Bleeding will probably stop while she takes these pills. She will get a withdrawal bleed (normal, scanty, or heavy) 2[nd]3 days after stopping them, but this should not last more than a week, after which normal periods should restart. Explain this to her. See her again in a month, to see if treatment has worked, and she has stopped bleeding.

If she has not stopped bleeding: (1) your diagnosis was wrong. Or, (2) she did not take her tablets regularly. Or, (3) her DUB is unsuited to hormonal treatment. So do a ''D and C''.

FOR RECURRENT DUB treat her as for an acute episode, then put her on the ''combined pill', as for contraception without a ''D and C'.

CAUTION ! ''DUB' is only a diagnosis of exclusion, and in many settings an immediate ''D and C' is simpler.