The term dysfunctional uterine bleeding is now an old term which is more broadly termed as abnormal uterine bleeding. It is a common problem in women. In many women, this is caused by various factors and is found in the absence of any functional uterine disease or pregnancy or general medical problem. It will be found in most women at some point in their lives. It refers to heavy and unusual bleeding from the uterus through the vagina. It can occur at any time during the month including during the usual monthly menstruation. Therefore, by definition, vaginal bleeding between periods is described as one of the features of abnormal uterine bleeding. By extension, any heavy bleeding beyond what is considered ordinary during the monthly period is often considered also as abnormal uterine bleeding. The causes of this troubling condition are varied and they differ at various age brackets. Very frequently, however, such bleeding reflects the disruption that ensues when the normal cyclical monthly pattern of stimulation of the endometrium of the uterus occurs. The endometrium is the innermost layer of the womb and these changes occur in its lining or surface.
It is a different kettle of fish when such blood loss lasts for more than seven days. In bad instances, some women could change their sanitary towels every hour. In one dramatic case that stays in the memory even after all these years, a 28-year-old woman suddenly began to bleed heavily at the Maryland bus stop in Lagos one early morning in 1994. Her period had arrived five days early and she was soon soaked in her own blood. Within minutes, she fainted and was rushed into a hospital where yours truly worked as a post NYSC medical officer. Needless to say, by the time she arrived at the hospital it was determined that she had lost so much blood that she needed four pints of it just to keep her alive. And then she had two more over the next 24 hours. It was a close shave and had never been that bad. Examination revealed that she had huge multiple fibroids that were the equivalent in size of a 26-week-old pregnancy. Fearing for her life since she lived alone, she gave her consent for the required operation and then got two more pints of blood. Her life was saved. But suppose this had happened during the night with all her neighbours asleep and she had collapsed in her bathroom?
The causes of abnormal uterine bleeding are pregnancy, most surprisingly and fibroids as illustrated graphically above. Sometimes, these fibroids are large as we saw above but at other times, they are also small. A uterine infection can similarly cause abnormal bleeding and the patient would have had some indication earlier that such a problem was likely from the kind of vaginal discharge which she would have been suffering from. Some of such infections are tuberculosis of the endometrium and chronic cervicitis. Less commonly, cancer of the lining of the womb called endometrial cancer may be responsible for the problem. In most women, however, by far the most common cause of such abnormal bleeding from the uterus is a hormonal imbalance and when this is the case, the attending doctors are likely to label it as a dysfunctional uterine bleeding which is a subset of abnormal uterine bleeding. Such bleeding caused by hormone imbalance is found commonly among teenagers and in women approaching menopause. Even more rarely, such abnormal bleeding may be caused by changes in the blood levels of thyroid hormones. This is more likely to be seen in middle-aged women.
As we said above, one common cause of abnormal uterine bleeding in teenagers and young women is pregnancy. Some women have abnormal bleeding during the first few months of a normal pregnancy. And although this can cause panic and even fear, it often resolves on its own and allows the pregnancy to continue developing normally. In some other women, the use of birth control pills and the uterine contraceptive device (IUD) may also be responsible for this. We examined this topic in this column in 2016. Other women, who are not using any form of contraception, may not release any egg from their ovaries during their menstrual cycle. This leads to a hormone imbalance when the oestrogen level in the body promotes the growth of the lining of the uterus to the point that it simply becomes too thick. When the body eventually sheds this endometrium during the period, the bleeding can become excessive and unduly prolonged. This is frequently seen in teenage girls who have just started to menstruate. On the whole, this is a common problem and some estimates put it as comprising nearly one-fifth of all visits to gynaecological clinics. It can even be found in some newborn females which often corrects itself after a few days. This is described as a physiological withdrawal effect of the hormones in the mother.
Therefore, this situation is not some kind of mystery that defies understanding. Usually, a careful history-taking, methodical physical examination and the appropriate laboratory tests should aid the doctors in making a diagnosis. This may also be reached in a roundabout way when steps are taken to exclude such causes as pregnancy, pregnancy-related disorders, systemic diseases like thyroid disease, medications and disease conditions in the genital tract. Dysfunctional uterine bleeding can then be diagnosed almost as an exclusion to all the other factors named above. It may be the type associated with normal ovulation or it may not. However, the approach to making a diagnosis of its presence will sometimes help to identify the possible cause. In this way, common causes like ectopic pregnancy, miscarriage and trauma to the genital area including rape and assault of a sexual nature are easily diagnosed. So also would problems like trophoblastic disease, abruptio placentae and placenta praevia all of which can readily occur in a woman who was presumed to be pregnant. Abdominal and transvaginal ultrasound scans would help a great deal to make a diagnosis but so also would hysteroscopy and uterine biopsy.
This problem, as common as it is, continues to cause distress to many women. We have seen above that the diagnosis of the condition has got to be methodical and thorough. It is often possible to offer simple treatment options that are effective and at other times, the situation is a lot more complicated. Treatment options include the treatment of any identified infection if this is the cause and resolution can be expected. At other times, an operation is important as in the case of the young woman described above who nearly expired at a bus stop in Lagos. The use of the oral contraceptive pill and non-steroidal anti-inflammatory drugs (NSAIDs) are simple and cost effective means of treating those teenagers and young women who are found to have a hormonal imbalance. For the post-menopausal woman, dilatation and curretage can usually be offered under anaesthesia which would also offer the chance to send the scrapings to the laboratory for histology. Such a step helps to make a certain diagnosis of the probable cause of the abnormal bleeding. In the end, all women who observe a pattern of vaginal bleeding that is out of sync with their usual pattern owe it to themselves to seek help as soon as possible and be receptive to all ideas of obtaining a diagnosis.
Questions and answers
Dear doctor, May God continue to bless the works of your hands. Please how far is the advice below true about drinking water? “If cold water does not affect you at a young age, it will harm you during your old age. Cold water closes 4 veins of the heart and causes heart attack. Cold drinks are the main reasons for heart attack. It also creates problems in the liver. It makes fat stick with the liver. Most people waiting for liver transplant are victims of cold water. Cold water also affects the internal walls of the stomach. It affects the large intestines and results in cancer.” I am a 76-year-old man and I drink cold water. With my little background in science I disagree with the above views. It is as if you pour cold water directly on organs. But by the time the water gets to the organs, there must be some temperature changes. Doctor, what do you think? 0805xxxxxxx
Thank you for your prayers, sir. This claim is the most unbelievable thing one has ever heard about the drinking of cold water. In fact, water is probably the most beneficial drink a human being can consume whether it is cold or warm as long as it is tolerable. Water is not able to cause any of the wild claims above in the piece you have quoted. Please continue to drink and enjoy your cold water. It is certainly healthy to do so.
Dear doctor, if a woman has undergone a fibroid surgery before getting pregnant, when is it safe for the doctor or nurse to palpate her during pregnancy without risking a miscarriage? Thanks. 0811xxxxxxx
Well, it is safe. Between the scar or the skin and where the baby lies, there are many layers of protection. It is not usual to palpate the uterus before the 14th week of pregnancy and certainly beyond this point, there is nothing to fear in the normal pattern of clinical palpation.
Dear doctor, I am 18 years old. I observed that I developed terrible itching around my pubic region and in my body. Anytime I scratch it, it turns into red rashes. It started last year. What could be the cause, sir? And what cream and drugs do you recommend for me? I am afraid of taking injections so I would rather take drugs. Thank you sir. 0904xxxxxxx
Thank you very much for your question. It is my belief that your problem has gone beyond the realm of taking a few pills or applying a cream. However, it does sound like some kind of allergic reaction to some agent that sets off the reaction so it is a better deal to go to a hospital and allow a doctor to examine your skin properly. When they do so, a diagnosis can be made and you can then get a prescription. At this point, it is not possible to determine what your treatment will look like.
Dear doctor, how is your day going? Is it possible to medically treat and cure erectile dysfunction and premature ejaculation? If yes, can you treat me and at what cost? 0803xxxxxxx
Thank you and good day to you as well. My day is going rather well. The problems you highlighted above are eminently treatable. However, the expert trained to treat your kind of condition is called a urologist and it is better for your regular doctor to refer you to one such urologist who can treat you and cure your condition based on your age and whether you have some other disease condition you are presently treating as well.
Dear doctor, I’m an avid reader of your column in Sunday PUNCH and I cannot thank you enough for your good work to humanity. The 16-year old reader who, among other complaints, talked about inability to move the body while asleep reminds me of what I read about sleep paralysis, a condition I’ve been suffering from since my youth. I’m now a 63-year-old male. Occasionally, while asleep, I feel conscious and see the presence of a strange/known person in the room trying to touch or hold me down. I will neither be able to move my body nor shout while this experience lasts. At best I’ll manage to struggle and scream before I can “come back to life.” At times I consider it a spiritual attack. Is the experience normal, doctor? [email protected]
Thank you very much for your kind words. The young boy is able to gnash his teeth or bite hard on them for a couple of minutes during the attacks until he recovers fully. It is certainly not a spiritual attack but it does closely resemble sleep paralysis which many of us have actually experienced usually during periods of REM (Rapid Eye Movement) sleep. During moments like this, the brain acts as though the rest of the body is disconnected from the rest and the individual has become a sort of prisoner inside his own body. So in a way, yes, it is normal. But the young teenager concerned needs to see a doctor and it is my sincere hope that his parents oblige him.
Dear doctor, a colleague at work confided in me that her 18-year old daughter woke up yesterday morning with her spine jutting out at the back. Now, she cannot walk; she is in severe pain and I feel sad hearing this. We are confused and don’t know where to go. My colleague is battling with health challenges of her own and we would like to know from you where we can take her to. We both live in the Egbeda area of Lagos State but we cannot even carry her because of the pain she has. Thank you sir. 0802xxxxxxx
It is a complex issue if she was not previously known to be ill. As things are now, she will have pains which might be quite bad and can worsen still. She will be paralysed even if partially. Since you live in Lagos, I would advise that you take her to the National Orthopedic Hospital, Igbobi. If you are unable to transport her on your own, you can call the Lagos State ambulance service on 757 or 112. They are trained well for this kind of work.
Dear doctor, thank you very much doctor for your advice regarding my son aged 10 years. I live in the United States of America with him and sometime ago I reached out to you on this platform because I was confident that he needed to be de-wormed but the doctors here do not really believe in that. He eats well now after adding multivitamins to his diet and now weighs 35.7 kg. I am grateful for your help and I am writing to you at the doctor’s office who is also wondering what magic I performed. Now, how do we sustain his current weight and ensure he continues to grow normally from this point onwards? Thank you sir. +1xxxxxxxxxx
That’s nice to know. Thank you very much for the feedback. You should regularly get him to see the paediatricians you have access to and continue to have a proper evaluation performed on your son on a regular basis. Also more attention should be paid to his feeding. The B-complex you are using now is a good appetite stimulant and you can appreciate its utility thus far and so there is no harm in continuing its use for the time-being until it is determined that he can now eat on his own without having to be stimulated with the use of vitamins.
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