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Abnormal Uterine Bleeding

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Prof Dr Hamida Begum :
A toddler by the age of 10-14 years when gradually becomes an adolescent (teen age) -then various changes occur in her body (physical) and mind (mental). One of the important manifestation of these changes is "Menarche" or starting of menstruation. As it occurs monthly so it is also called "Period/Cycle/Mashik". Usually it stays 3-7 days and amount varies from 30-80 ml. But this mense can have various aberrations from normal when it occurs every 2 or3 or 4 monthly or twice or three times in a single month and amount varies from scanty to very heavy. When no demonstrable or definite cause of this abnormal bleeding is found, it is called "Dysfunctional or Abnormal Uterine Bleeding" (DUB or AUB)".
For mense to occur regularly, some external and internal factors as body weight, social habit and rhythmic balance between secretions of hormones from ovary,adrenal and thyroid are intimately related.
Depending upon age, DUB is categorised into 3 types:
1: Adolescent/teen aged/puberty menorrhagia: sometimes it persists 3-6 months with heavy amounts putting these girls and their parents in tremendous pressure as it leads to absentism in institution or work place or anaemic heart failure leading to hospitalization for frequent blood transfusions. Most of the time their body build is either skinny or too much excess weight.
2: Reproductive age- these groups of women suffer from cyclical heavy bleeding (menorrhagia) or periods every 10-12 days interval (polymenorrhoea or polymenorrhagia) or small amount of bleeding throughout the whole month (metrotaxis).
3: Premenopausal - before established menopause,these groups of women with age range 45-50 suffer from most of the time excess bleeding.
Why DUB occurs: Normally there is intricate system of balance between blood supply and stoppage of bleeding in uterus. Whenever there is any imbalance as can occur in too much emotions, sorrows, anxiety, tension (as before or during exam) or sexual disharmony of married couple or abnormal secretions from adrenal or thyroids can lead to this DUB.
How to manage :
Perfect history, proper examination and relevant investigations to rule out known causes are paramount to diagnose a case of DUB. Also need to rule out bleeding disorders and traumatic causes. Some lab reports as blood-full blood count, bleeding and clotting time(BT/CT), prothrombin time, thyroid hormone tests, ultrasonography to exclude tumours of uterus or ovary and to see the thickness of inner lining of uterus. If facilities permit hysteroscopy(machine) can be done for both to detect and  to treat.
A DUB is treated under 3 gradual steps:
1st Step : Age related appropriate counselling is needed to get relief from anxiety, tension, mood fluctuation and sexual dissatisfactions.
Those who are obese need to loss weight by aerobics and dieting. Skinny ones need balanced diet. Anaemia  corrected by Iron, vitamin and calcium suppliments.
2nd Step: Needs some medicines as NSAID ( mefenemic acid)/blood clotting or antifibrinolytics as Tranxamic acid).
Hormonal: Combined oral contraceptives or Progesterone 1-25 days with oestrogens last 10 days can bring comfort to patient. Progesterone can be given either oral, implants or intra-uterine system (Mirena).Now a days this Mirena is showing promising results.
3rd Step: when different medications no longer relief her symptoms and or she does not like to continue medicines they need surgery.
Local surgery: curettage/ endometrial ablation or resection of inner layer of uterus or hysteroscopic removal can be done.
Women aged, family complete can go for removal of uterus (hysterectomy) by either abdominal route or by machine (laparoscopy).
 To diagnose a case of DUB proper history, examination and relevant investigations are must to find clues and to rule out definite causes. It is mandatory to treat her step by step accordingly.

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