DYSFUNCTIONAL UTERINE BLEEDING – HOMOEOPATHY IS AT RESCUE

            

 Dysfunctional uterine bleeding (DUB) is a condition that affects nearly every woman at some point in her life, typically in the adolescent or perimenopausal period. It also called abnormal uterine bleeding (AUB), DUB is a condition that causes vaginal bleeding to occur from uterus outside of the regular menstrual cycle. DUB is usually due to hormonal disturbances like reduced levels of progesterone causes low levels of prostaglandin F2alpha and causes menorrhagia; increased levels of tissue plasminogen activator (TPA) (a fibrinolytic enzyme) leads to more fibrinolysis.

A normal menstrual cycle is characterized by an approximate flow of 30 mL per period, which lasts for 2 to 7 days and occurs with a mean interval of 21 to 35 days.

DUB can be characterized clinically by amount, duration, and periodicity as

Oligomenorrhea: menstruation occurring with intervals of more than 35 days

Polymenorrhea: menstruation occurring regularly with intervals of less than 21 days

Metrorrhagia: menstrual bleeding occurring at irregular intervals or bleeding between menstrual cycles

Menorrhagia: regular menstrual cycles with excessive flow (technically more than 80 mL of volume) or menstruation lasting more than 7 days

Menometrorrhagia: menstrual bleeding occurring at irregular intervals with excessive flow or duration.

Aetiology & Pathophysiology

DUB can be due to anovulation (Anovulatory DUB) or to local defects in hemostasis (Ovulatory DUB). About 90% of cases are anovulatory; 10% are ovulatory.

Anovulatory DUB:

During an anovulatory cycle, the corpus luteum does not form. Thus, the normal cyclical secretion of progesterone does not occur, and estrogen stimulates the endometrium unopposed. Without progesterone, the endometrium continues to proliferate, eventually outgrowing its blood supply; it then sloughs incompletely and bleeds irregularly, and sometimes profusely or for a long time. When this abnormal process occurs repeatedly, the endometrium can become hyperplastic, sometimes with

atypical or cancerous cells.

Ovulatory DUB:

In ovulatory DUB, progesterone secretion is prolonged; irregular shedding of the endometrium results, probably because estrogen levels remain low, near the threshold for bleeding (as occurs during menses). In obese women, ovulatory DUB can occur if estrogen levels are high, resulting in amenorrhea alternating with irregular or prolonged bleeding.

A less common cause of DUB; believed to be caused by a defect in local endometrial hemostasis. The mechanism is unknown, but theories include prostaglandin imbalance and alterations in fibrinolysis.

Prostaglandin F2 causes constriction of spiral arteries found in the endometrium, whereas prostaglandin

E2 has vasodilating properties and antiplatelet effects. Alterations in prostaglandin production, with a shift toward more prostaglandin E2 and less prostaglandin F2, lead to increased fibrinolytic activity noted in the endometrium of women with menorrhagia

Other causes of uterine bleeding, such as pregnancy, lesions of the reproductive tract (eg, uterine fibroids), iatrogenic causes, or other medical conditions (eg, thrombophilia, hypothyroidism) must be excluded in order to establish the diagnosis

Half of all women who present with menorrhagia have bleeding that is unacceptable to them but is within the normal range, although reported menorrhagia should be treated as such. Objective measurement of menorrhea is clinically meaningless outside the context of clinical trials

DUB occurs in approximately 10% to 30% of reproductive-aged women and has a negative impact on the quality of life of affected women, whether young or old. Twenty-percent of cases of DUB occur in adolescence, and 40% of cases occur in patients over age 40

Risk factors:

Risk factors associated with the development of DUB include the following:

Adolescence:

·        Anovulatory cycles occur in 55% to 82% of female adolescents at menarche and typically continue until 2 years after menarche

·        Anovulatory bleeding is common among adolescents due to the immaturity of the hypothalamicpituitary- ovarian axis

Perimenopause:

·        DUB in perimenopausal women is related to declining ovarian function

·        Observational data show increased variability of the menstrual pattern in women approaching menopause

Obesity:

·        DUB in overweight women results from altered estrogen-to-progesterone ratios and increased peripheral conversion of androgens to estrogens. The estrogen-driven endometrial proliferation eventually leads to endometrial overgrowth and abnormal bleeding patterns

·        Weight loss in obese patients presumably restores regular menstrual cycles by decreasing the adipose tissue available for conversion of androgens to estrogen

Polycystic ovary syndrome (PCOS):

·        Menstrual irregularity is seen in two thirds of adolescents with PCOS and typically presents with anovulatory symptoms mimicking DUB

Cigarette smoking:

·        Women who smoke cigarettes have a 47% risk of experiencing abnormal uterine bleeding due to the antiestrogenic effect of cigarette smoke

Clinical manifestations

Symptoms of dysfunctional uterine bleeding may include:

·        Bleeding or spotting from the vagina between periods

·        Periods that occur less than 28 days apart (more common) or more than 35 days apart

·        Time between periods changes each month

·        Heavier bleeding (such as passing large clots, needing to change protection during the night, soaking through a

·        sanitary pad or tampon every hour for 2 - 3 hours in a row)

·        Bleeding lasts for more days than normal or for more than 7 days

Other symptoms caused by changes in hormone levels may include:

·        Excessive growth of body hair in a male pattern (hirsutism)

·        Hot flashes

·        Mood swings

·        Tenderness and dryness of the vagina

·        A woman may feel tired or have fatigue if she is loses too much blood over time. This is a symptom of anemia.

Diagnosis

v Blood tests, which may include:

·           Pregnancy test (human chorionic gonadotropin, or hCG).

·           Complete blood count (CBC), to check for signs of disease, infection, and anemia.

·           Thyroid-stimulating hormone (TSH) to check for a thyroid gland problem, which can cause menstrual irregularity.

·           Serum prolactin level, to check for a pituitary gland problem, which can interfere with or stop the menstrual cycle.

·           Serum ferritin, to check for anemia, a symptom of heavy blood loss.

v Pap smear and cultures to check for infection or abnormal cervical cells.

v Urine test to screen for infection, disease, and other signs of poor health.

v Transvaginal pelvic ultrasound, to check for any abnormalities in the pelvic area. After the pelvic exam, a transvaginal ultrasound is often the next step in diagnosing a vaginal bleeding problem. If a pelvic mass is found, ultrasound results are useful for making further testing and treatment decisions.

v Sonohysterogram, which uses ultrasound to monitor the movement of a salt solution (saline), which is injected into the uterus. This test may be done to look for uterine polyps or fibroids.

Complications:

·        Anemia

·        Adenocarcinoma of the uterus, because of prolonged, unopposed estrogen stimulation. Adverse effects of oral contraceptive preparation.

MANAGEMENT

Conservative Management

The goal of therapy should be to arrest bleeding, replace lost iron to avoid anemia, and prevent future bleeding.

·        Supplement iron through diet or orally in case of severe anemia.

·        Rest and reassurance.

Natural Remedies

·        In order to get deal with heavy uterine bleeding it is really essential to  take a diet that is rich in iron, vitamin A and vitamin C. Iron rich foods are eggs, green leafy veggies, spinach, red meats, cereals and iron enriched breads.

·        Bioflavonoid supplements and other vitamin E are also recommended to help treat patients those suffering from heavy bleeding. Vitamin K is actually known for its blood clotting properties and helps to treat this disorder efficiently.

·        Stiptic herbs those such as birthroot, shepherd's purse, yarrow, witch hazel, blue cohosh and cranesbill strictly tighten the blood vessels and are further recommended for the prevention and treatment of the dysfunctional uterine bleeding.

·        The Himalayan Styplon is a wonderful herbal Himalayan remedy which has styptic and astringent properties. Not only this, it has anti inflammatory and deculcent actions too which cure cases of abnormal bleeding. For bleeding control, it can be consumed three times a day and later can be reduced to two times a day. It has no side effects as such if the dosage is proper and effectively manages bleeding by facilitating haemostasis.

·        Boil the bark of Asoka tree in the milk and dilute it with water in advance. Give this infusion to those patient twice in a day. This natural remedy is moderately effective in treating patients with abnormal uterine bleeding issue.

·        Banana flower is one of the most successful natural remedies for treating ovulatory uterine bleeding just because of its soothing properties. Cook a banana flower and then have it with a small bowl of curd to reduce effectively the bleeding.

HOMOEOPATHIC MANAGEMENT

·        Management of DUB primarily involves prescribing a constitutional Homoeopathic remedy capable of working on the uterus and the entire endocrinal system.  This approach usually helps in correcting the pathology associated with DUB

·        There are numerous remedies capable of influencing this condition. The remedy prescribed is chosen after carefully understanding your entire constitution, which includes:

o   Presence of any genetic predisposition

o   Physical makeup (obesity)

o   Peculiarities of menstrual cycle

o   entire physical and personality characteristics

·        Homeopathy for DUB should be continued for a significant duration of time as the appearance and normalization of the menstrual cycle as well as decrease or absence of other symptoms are the only means by which improvement can be monitored

Some Homoeopathic remedies for DUB are:

Indicated Remedies	Indications
Sepia	·        Bearing down sensation as if everything would escape through vulva;must cross limbs to prevent protrusion or press against vulva.  ·        Menses too late and scanty, irregular; exceptionally menses may be early and profuse; sharp clutching pains. Violent stitches upward in the vagina from uterus to umbilicus. Vagina painful, especially on coition. ·        Hot Flashes at menopause with weakness and perspiration. Sepia patient dreads to alone, weeps when telling her complaint, irritable, very sad and Indifferent to those loved most.
Lachesis	·        Lachesis has hemorrhagic tendency. Very important during the climacteric. Cannot bear anything tight anywhere. ·        Climacteric troubles, palpitation, flashes of heat, hemorrhages, vertex headache, fainting spells worse pressure of clothes. ·        Menses too short, too feeble; pains all relieved by the flow. Left ovary very painful and swollen, indurated. ·        Great loquacity.Jealous.
Phosphorus	·        Hemorrhage from uterus between periods. Menses too early and scanty- not profuse but last too long.Weeps before menses. ·        Frequent and profuse hemorrhages from uterus caused by cancerous affection. ·        Weakness, blue circles around eyes and anxiety after menses. ·        Infertility.
Calcarea Carbonica	·        Menses too early, too profuse, too long with vertigo, toothache and cold,damp feet. Least excitement causes hemorrhage from uterus.Cutting pains in uterus during menstruation. ·        Before menses, headache, colic, chilliness and leucorrhea. ·        Infertility with copious menses. ·        Increased menstruation about external genitals.
Pulsatilla	·        Menses too late, scanty, thick, dark, clotted, changeable, intermittent. Menses suppressed from wet feet, nervous debility or anemia. ·        Chilliness, nausea, downward pressure, painful with intermittent menstrual flow. ·        Weeps when telling complaints, changeable, contradictory. Patient seeks the open air and always feel better there. Symptoms ever changing. Thirstless, peevish and chilly.
Ammonium Carb	·        Menses too frequent, profuse, early, copious, clotted, black.Menses preceded by gripping colic, black and acrid blood. ·        Cholera like symptoms at the commencement of menstruation.
Lycopodium	·        Menses too late, last too long, too profuse. Coition painful, dry vagina. Right ovarian pain. ·        Discharge of blood from genitals during stool. ·        Melancholy; afraid to be alone.Little things annoy. Headstrong and haughty when sick.
Ambra Grisea	·        Thin, scrawny women. Adapted to hysterical subjects. Anemic and sleepless. ·        Weakness,coldness and numbness,usually of single parts, fingers, arms etc. Music aggravates symptoms. ·        Menses too early. Discharge of blood between periods, bleeding at every little accident. Profuse,bluish leucorrhea. ·        Itching of pudendum with soreness and swelling. Worse at night.
Arsenicum Album:-	·        Arsenic is useful in persistent hemorrhages i.e. metrorrhagia or menorrhagia, of a low type depending upon some degeneration in the organ affected. Burning pains with hemorrhage. ·        Metrorrhagia of dark blood and increased sexual desire. Main affection in right ovary with marked burning, tensive pains and restlessness which is somewhat relieved by constantly moving the feet. Menstrual colic better from warm applications.
Belladona	·        Menses are early,copious, bright red and attended with cramp-like tearing pain in the back, arms etc; throbbing headache; most intensely painful congestive dysmenorrhea; bearing down; cutting pain from behind forward or vice versa; menstrual flow offensive; lochia offensive. Uterine hemorrhage; blood pours out and feels hot; uterine hemorrhage with bearing down in the back.
Bovista	·        Menses too early and profuse; worse at night. Diarrhea before and during menses. Cannot wear tight clothing around the waist. Traces of blood between menses. Soreness of pubis during menses. ·        Metrorrhagia. ·        Leucorrhea acrid, thick, tough, greenish follows menses. ·        Uterine hemorrhage when the uterus is engorged, particularly when there is bleeding between menses from any little over-exertion. Here it is exactly like Ambra Grisea, but menstrual flow of Bovista occurs chiefly or only at night or early in the morning.
Cantharides	·        Puerperal metritis with inflammation of bladder. Menses too early and too profuse; black swelling of vulva with irritation. ·        Constant discharge from uterus; worse false step. Burning pain in ovaries. ·        Retained placenta with painful urination.
Carbo Animalis	·        Menses too early, frequent, long lasting, followed by great exhaustion, so weak can hardly speak. Menstrual flow only in morning. Burning in vagina and labia. ·        Cancer of uterus.
Carbo Veg	·        Premature, too copious menses, pale blood. Continuous dark hemorrhage. Patient wants to be fanned, anemic, skin cool and bluish, pulse rapid and weak ·        Burning pains across the sacrum and lower portion of the spine with hemorrhage.Carbo veg is torpid, sluggish.
Cinchona Officinalis	·        Menses too early, profuse with pain. Leucorrhea bloody. Bleeding is dark and clotted. Hemorrhage is so profuse it produce condition of collapse, cool face, gasping for breath, patient demands to be fanned.
Erigeron Canadensis	·        Hemorrhage from uterus with painful micturition. Profuse bright red blood. Pain in left ovary and hip. ·        Metrorrhagia with violent irritation of rectum and bladder; and prolapse of uterus. Menorrhagia. Bloody lochia returns after least motion, comes in gushes; between periods, leucorrhea with urinary irritation; pregnant women with “weak uterus”, a bloody discharge on slight exertion. Erigeron is indicated in hemorrhages from uterus with painful urination. Hemorrhage comes in fits and starts; it comes with a sudden gush and then stops again.
Ferrum Metallicum	·        Anemic women with fiery red face whose menses remit a day or two and then return. ·        Menses too early, too profuse, last too long; pale , watery. Sensitive vagina. ·        Discharge of long pieces from uterus. ·        Tendency to abortion. Prolapse of vagina. ·        Flow of bright red blood often mixed with coagula, associated with great deal of flushing.
Hamamelis Viriginica	·        Menses dark, profuse, with soreness in abdomen. Bruised soreness of affected parts.Metrorrhagia occurring midway between menstrual periods. Inter menstrual pain.Vicarious menstruation. ·        Ovarian congestion with neuralgia; feel very sore.Uterine hemorrhage, bearing down pain in back. ·        Vagina very tender. Profuse leucorrhea. Vaginismus, ovaritis, soreness over whole abdomen. ·        The flow is dark and rather passive and there is a feeling of soreness in the affected area.
Ipecacuanha	·        Hemorrhage bright red and profuse. ·        Uterine hemorrhage profuse, bright red, gushing with nausea. Pain from naval to uterus. ·        Menses too early and too profuse.
Millefolium	·        Invaluable remedy for various types of hemorrhages; blood bright red. ·        Menses early, profuse, protracted. Hemorrhage bright red, fluid. ·        Millefolium is suited for a profuse, bright red flow , unattended with pain.
Nux Vomica	·        Menses too early, lasts too long; always irregular, blood black with faint spells. ·        Prolpase of uterus. Dysmenorrea with pain in sacrum and constant urging to stool. ·        Metrorrhagia with sensation as if bowels wanted to move.
Sabina	·        Menses bright red, clotted and worse from any motion. Hemorrhage is attended with pain extending from the pubes through to the sacrum and with pains in the legs. Uterine pains extend to thighs. ·        Discharge of blood between periods with sexual excitement. ·        Retained placenta; intense after pains. ·        Menorrhagia in women who aborted readily. Inflammation of ovaries and uterus after abortion. ·        Pain from sacrum to pubis and from below upwards shooting up in the vagina.
Sanguinaria Can	·        Metrorrhagia occurring at the climacteric age. Bleeding is of bright red, clotted and frequently offensive. Metrorrhagia with flushes of heat and with sick headache.
Secale Cornutum	·        Hemorrhages; continued oozing; thin, fetid, watery black blood. Whole body is pervaded by a sense of great heat so all the Secale patients are better from cold. ·        Menses irregular, copious, dark; continuous oozing of watery blood until next period. ·        The flow of blood is passive; it is attended with tingling in the limbs. ·        Although the surface of the body is cold, the patient persistently expresses her desire to be uncovered.
Trillium Pendulum	·        A general hemorrhagic medicine with great faintness and dizziness. ·        Uterine hemorrhage with sensation as though hips and back were falling to pieces; better by tight bandages. ·        Gushing of bright blood on least movement. ·        Metrorrhagia at climacteric. Hemorrhage from fibroids. ·        Prolapse with great bearing down. Blood is bright red, profuse and is attended by a faint feeling in the epigastrium, pain in back, coldness of extremities, prostration and rapid, feeble pulse.
Ustilago Maydis	·        Vicarious menstruation. Profuse menstruation after miscarriage; discharge of blood from slightest provocation; bright red; partly clotted. ·        Menorrhagia at climacteric. ·        Oozing of dark blood, clotted, forming long black strings. Cervix bleed easily. ·        Ovaries burn, painful and swelled. ·        Uterine hemorrhage is partly fluid and partly clotted, bright red.