Dysfunctional Uterine Bleeding (DUB)

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Dysfunctional Uterine Bleeding (DUB) is abnormal bleeding that occurs within or outside the menstrual cycle, due to malfunctioning of the working mechanism of the hypothalamic-pituitary axis, ovary, endometrium without organic abnormalities of both genital and ekstragenital.

Pathophysiology
Dysfunctional Uterine Bleeding (DUB) can occur in ovulatory cycles, anovulatorik or in a state with persistent follicles.
In the ovulatory stage, bleeding may occur in mid-menstrual or simultaneously with menstruation. Bleeding is due to the persistent corpus luteum with low estrogen levels, while progesterone continues to form.

In anovulatorik cycle, is common during perimenopause and the reproductive period. The basis of the bleeding that occurs in cycles anovulatorik this is because no ovulation, the corpus luteum is not formed. By itself will be low levels of progesterone and estrogen overload. Because estrogen is high then the excessive proliferation of endometrial experience (hyperplasia). With low levels of progesterone, the endometrial thickness was not followed by the formation of a good buffer, rich in blood vessels and glands. These networks are fragile, easily letting go of the surface, and cause bleeding. Bleeding in one place are recovering, bleeding arise elsewhere, so that bleeding does not occur simultaneously.
So the basic anovulatorik bleeding in this case due to:

• The endometrium is thick and brittle
• Release of the endometrium does not coincide
• No rhythmic vasoconstriction
• There is no tissue collapse.

Dysfunctional Uterine Bleeding (DUB) on the state of persistent follicles, often encountered during perimenopause, rare in the reproductive period. Because of the continuous influence of estrogen, endometrial hyperplasia will experience both types of simple hyperplasia, or atypical adenomatus. Adenomatus and atypical types of this malignancy is pembakal (pre-cancerous), so it needs special handling.

Clinical Features

1. Bleeding can occur at any time in the menstrual cycle
2. Bleeding can be a little bit, continuous or multiple and repetitive.
3. Most often encountered during menarche or during perimenopause.

Etiology
The cause of Dysfunctional Uterine Bleeding (DUB) is known with certainty is difficult
Dysfunctional Uterine Bleeding(DUB) is common in:

1. Polycystic ovary syndrome (PCOS)
2. Obesity
3. Immaturity of the hypothalamic-pituitary axis-the ovaries, for example in pre-menopause.
4. Psychiatric disorders, and others.

Diagnosis
Anamnesa
It is important to conduct a careful diagnose, to ask the age of menarche, menstrual cycles after menarche, length and amount of menstrual blood. Also need to be asked anyway background and family life back latat emotional.

Examination
General Examination
Aimed to determine the possibility of abnormality is the cause of bleeding. Consider the possibility of metabolic disease, other systemic diseases or chronic diseases including hemostasis disorders.

Gynecological examination

1. Examination in to get rid of organic abnormalities that can cause abnormal bleeding, for example: cervical polyps, ulcers, injury, erosion, inflammation, tumors, abortion, malignancy, and others.
2. To make a diagnosis on the girl does not need to be done curette.
3. In women who are married, curettage should be performed for diagnosis.
4. On histopathological examination, usually obtained endometrial hyperplasia.

Diagnosis APPEALS
All disorders that can cause abnormal bleeding from the uterus.

Procedure
Managemet
Treatment Principle

1. Makes the diagnosis of Dysfunctional Uterine Bleeding (DUB), by removing the possibility of organic abnormalities.
2. Stop the bleeding
3. Regulate menstruation returned to normal
4. When anemis (Hb <8 g%) were given transfusions.

Stop the bleeding

1. Curettage (no need to Hospital Admission, except when going in tranfusion) Done for patients who are married.
2. Drugs (priority of choice, according to serial number):

a. Estrogen

Usually selected natural estrogen, such as conjugated estrogens (conjugated estrogens), for example: Estradiol valerate (Premarin). Estrogen type is more advantageous, because it does not burden the liver and did not increase levels of renin and blood clotting disorders. Another type of estrogen is ethinyl estradiol. This type of estrogen is metabolized in the liver, so liver function is more disturbing.

Dosage:

• When bleeding a lot (profus) Hospital Admission, given conjugated estrogen (Premarin) at a dose of 25 mg iv, repeated every 3-4 hours, giving a maximum of 4 times.
• If the bleeding is not a lot, can be given: 20 mg estradiol Benzoas i.m. Conjugated estrogens 2.5 mg per oral, 7 - 10 days.

b. Combination pill

Purpose: to transform the endometrium into pseudodesidual reaction.

Dosage:

• When bleeding a lot (profus) can be given 4 x 1 for 70-10 days, followed 1 x 1 for 3-6 cycles.

c. Progesterone

Purpose: to provide the balance of influence of estrogen. Progesterone is a type of progesterone that elected a molecule resembling natural progesterone. Included in this type is Medroksi progesterone acetate (MPA) and Diprogesteron. The type of progesterone that androgenic (testosterone derivatives) are not widely used, because it has androgenic effects (acne, hair growth, etc.), and may decrease HDL cholesterol.

Dosage:

• MPA 10 -20 mg per day (Primolut N), for 7 - 10 days or Norethisteron 3 x 1 tablet, 70-10 days.
• If there are contraindications of estrogen, may be given injections of 100 mg im Progesterone, in order to stimulate the endometrium and resilience in vasomotor rhythmic contractions. For this purpose can be used DMPA.

d. Compounds antiprostaglandin

Use antiprostaglandin compound is mainly given to patients with contraindications to estrogen and progesterone, such as liver failure or malignancy. Drugs that are used eg mefenamic acid with a dose of 3 x 500 mg per day. Regulate Menstruation Immediately after the bleeding stops, continue therapy to regulate menstruation.
To set this period can be given:

• Oral pills for 3-6 months
• Progesterone 2 x 1 tablet for 10 days, starting on day 14 -15 menstruation.