DUBbing it in
How dysfunctional uterine bleeding disrupts a woman's menstrual rhythm
By Wednesday Sevilla, MD
Correspondent
In 1589, Spanish friar Juan de Plasencia reported an odd tradition among Tagalogs when a young girl reached menarche or her first menstrual period. Upon the arrival of her menstruation, the young girl's eyes were blindfolded for four days and four nights, while all members of the extended family and friends would engage in eating and drinking as celebration for the momentous event. On the morning of the fifth day, the catalonan or priestess would then carry the young girl to the river to bathe, remove her blindfold, and wash her hair. According to the old townsfolk, the effect was that the young lady would bear many children and meet a worthy husband who would not make her a widow early in their marriage. Most of modern Philippine society has abandoned superstitious beliefs, but the implication of the act is quite remarkable--that of the reproductive capacity of the woman and how it, in terms of evolution and procreation, defined her.
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For some women, the menstrual period occurs like clockwork that what is often taken for granted is the delicate hormonal balance required to keep on schedule--a balance that once disrupted would trigger irregularities in the menses. The female reproductive system is an example of the physiological negative feedback, the body putting its own stops and checks to make sure that hormones are not overproduced.
The pituitary gland produces follicle-stimulating hormone (FSH), which functions just as what its name implies--it stimulates a follicle in the ovary into maturation. Once mature, the follicle would in turn produce increasing amounts of estradiol (E2). The pituitary gland detects this rise of E2, halting the production of FSH. This is the negative feedback. But there is also a positive feedback. E2 signals the pituitary gland to produce luteinizing hormone (LH). While all this is going on, E2 production increases further, reaching a peak simultaneous with a surge of LH. This induces ovulation.
These events constitute the first 14 days of a 28-day cycle. Meanwhile, the effects on the lining of the uterus (the endometrium) differ on what hormone is predominant. While E2 increases, the endometrium burgeons with glands that eventually become thick and compact. This goes on until ovulation, after which a body called the corpus luteum is formed from where the mature follicle came from. The corpus luteum produces another essential hormone--progesterone.
Within 24 hours of ovulation, progesterone halts the proliferation in the endometrium caused by E2 and prepares it for implantation of a fertilized ovum. Sans fertilization, at the end of a 28-day cycle, the corpus luteum shuts down its production of progesterone, E2 is withdrawn, and menstruation occurs.
Many things may disrupt this cycle--pregnancy, endocrine problems, bleeding disorders, a medical condition, eating disorders, medication, or anatomic problems in the reproductive tract. When women experience irregularities in their menstrual cycle, gynecologists would first rule out any of these causes. When all of these have been ruled out, and after exhaustive diagnostics and imaging, a diagnosis of exclusion called dysfunctional uterine bleeding (DUB) is made. DUB reflects an upset in the normal cyclic pattern of hormones--E2 and progesterone--that stimulate the endometrial lining. Bleeding is often unpredictable and may range from being heavy to light, prolonged, frequent, or random.
Tipping the scale
Dysfunctional bleeding is basically an effect of a tipping of the E2/progesterone scale. Most of the time, these women would have constant noncycling E2 levels that continue to stimulate endometrial growth. If not countered by the introduction of progesterone, the endometrium outgrows its blood supply, the tissue breaks down and tissue is sloughed off. The healing (and bleeding) that follows is irregular and dyssynchronous, not following the clockwork cycle of a healthy hormonal system. Chronic stimulation of low levels of estrogen will result in infrequent and light DUB, high levels in turn produce heavy bleeding. Keep in mind that this bleeding does not happen after ovulation; no egg is, therefore, released from the ovary, making the female essentially infertile. This further illustrates the aberration.
No exact numbers are available on DUB incidence, but experts have seen a widespread prevalence without specific geographic variation. It affects women 12 to 45 years old, but DUB occurs most in the postmenarcheal and perimenopausal ages, during which the hormonal system is most vulnerable. Adolescents often have irregular periods with anovulation since their reproductive hormonal system is still yet to mature. For women approaching menopause, the ovulation ultimately fails. Although the incidence of DUB increases with age, most consultations for irregular bleeding often come from women in their reproductive years.
Gynecologists explain that this could stem from their concern for their fertility, and all with good reason: a balanced and on-time reproductive cycle is indicative of good health. This then would then point to another common cause of DUB--obesity and related polycystic ovary syndrome (PCOS).
For most women who have experienced only few episodes of irregular bleeding, the prognosis is good. However, for those who have been bleeding longer there would be serious consequences. They may have anemia from the prolonged and heavy menstrual bleeding. Adolescents are at risk for this and it is often essential to rule out a bleeding disorder in this age group. For women desiring to bear children, infertility can result from a lack of ovulation. Females in the perimenopausal age group are at risk for developing endometrial cancer due to the prolonged buildup of the uterine lining without adequate and cyclic hormonal stimulation.
After all the other possible causes of abnormal uterine bleeding have been ruled out, women with DUB can be treated conservatively. Medical treatment is often extremely effective and well tolerated. Depending on the ovulatory status of the patient, she can be treated with drugs that decrease the bleeding. These include nonsteroidal antiinflammatory drugs (NSAIDs) such as mefenamic acid and ibuprofen, and an antifibrinolytic drug such as tranexamic acid. An important adjunct to therapy is iron supplementation to augment the evident blood loss. Since DUB is pointed to an imbalance of reproductive hormones, gynecologists also consider the option of regulating menses through exogenous administration of hormones. Women can be given progestins, estrogens, or a combination of both. Other hormones include the androgenic steroid danazol and gonadotropin releasing hormones (GnRH) agonists. If medical treatment fails to control bleeding, surgical treatment can be given. A hysterectomy or removal of the uterus, often with both uterine tubes and ovaries, can be considered but only after much consideration due to the risks that the procedure carries- hemorrhage, infection and injury to other organs such as the bladder.
At the primary care level, women should be counseled regarding the importance of their menses. Often taken for granted since the adverse effects of an irregular menstrual cycle are not as overt as other conditions, it could signal a condition that warrants further attention and management. Adolescents should be taught early on the intricacies of their physiology to give them a better appreciation and understanding of their uniqueness as a female. On the long term, a heightened awareness of reproduction and sexually transmitted infections with responsible sexual behavior is taught. Women who desire to have children should pay attention to the approximate time they ovulate, a strategy possible only in the presence of a regular menstrual cycle. For females who have completed reproduction and are approaching menopause, a concern should rise for possible malignancies that may occur and are known to be prevalent in their age group.
The Filipina has certainly come a long way from the days when the catalonan was the source of potency and power in society. Women should be aware of their bodies and on top of managing their health. An important part of this is a regular menstrual cycle indicative of good health alongside an active and vibrant lifestyle.
When Eve turns into Adam
Increased facial hair, acne, and male-pattern baldness. These are the three common physical manifestations of increased circulating androgens in women, a condition distressing to women for obvious reasons. Also termed hyperandrogenism, it constitutes one of the criteria that lead to a diagnosis of polycystic ovarian syndrome (PCOS), a hormonal disorder. Increased testosterone level occurs together with menstrual irregularities (absent, decreased or irregular menses) with or without polycystic ovaries found on ultrasonography. Highly associated with obesity and increased body-fat deposits, it is a complex disorder involving different hormones, causing many metabolic processes to go awry. Although many studies have pointed it to be a heritable condition, the factors that bring it about exist in a complicated interplay.
PCOS is a highly variable condition. Patients have to be counseled that long-term follow-up is needed to properly chart response to treatment and monitor possible complications.
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