Patient's question:
I don't have any symptoms, but I was diagnosed with mental tension, malnutrition, metabolic disorders, and environmental climate changes during the vaginal secretion test at the hospital on April 24.Doctor's answer:
Dysfunctional uterine bleeding (DUB) is a term used in modern medicine to describe abnormal uterine bleeding caused by ovary dysfunction, commonly referred to as "DUB." It often manifests as irregular menstrual cycles, excessive menstrual flow, prolonged periods, or even irregular vaginal bleeding. Any internal or external factors that affect the regulation of the hypothalamic-pituitary-ovarian axis can lead to menstrual disorders.Advice:
1. General Treatment: Patients often have poor physical condition and appear anemic. Nutritional support should be strengthened to improve overall health. Iron supplements, vitamin C, and protein can be provided. In severe cases of anemia, blood transfusions may be necessary. During bleeding, avoid excessive fatigue and strenuous exercise, and ensure adequate rest. For prolonged bleeding, antibiotics should be administered to prevent infection, and anticoagulant drugs can be used to reduce bleeding volume.
2. Medication: Hormonal therapy is highly effective but requires different approaches based on age. For adolescent girls, the primary goals are to stop bleeding, regulate cycles, and promote ovulation. For women in perimenopause, the focus is on stopping bleeding and reducing menstrual volume after hemostasis. When using sex hormones, a well-planned and rational regimen should be developed, using the lowest effective dose with close monitoring to avoid inappropriate use that could cause bleeding.
(1) Hemostasis: For patients with heavy bleeding, hormonal therapy should take effect within 6 hours, with bleeding stopping within 24–48 hours. If bleeding persists beyond 96 hours, organic lesions should be considered.
1) Progestogens: Anovulatory DUB is caused by estrogen stimulation alone. Progestogen supplementation converts the proliferative-phase or hyperproliferative endometrium to a secretory phase, leading to withdrawal bleeding after stopping the medication. This thorough endometrial shedding is also referred to as "pharmacological curettage." It is suitable for patients with a certain level of estrogen in their bodies. Synthetic progestogens are divided into two categories: 17-hydroxyprogesterone derivatives (e.g., medroxyprogesterone, megestrol) and 19-norandrosterone derivatives (e.g., norethisterone, dienogest). A high-estrogen-effect (e.g.,) 5–7.5mg can be taken orally every 6 hours. After 4 doses, bleeding should significantly decrease or stop. The frequency can then be reduced to every 8 hours, followed by gradual dose reduction (decreasing by 1/3 every 3 days) until a maintenance dose of 5mg daily is reached. The medication should be continued for about 20 days after bleeding stops, followed by withdrawal bleeding 3–7 days later.
2) Estrogens: High-dose estrogen can rapidly increase estrogen levels, promote endometrial growth, and stop bleeding by repairing the wound in a short period. It is suitable for patients with insufficient endogenous estrogen, primarily used in adolescent DUB. Currently, conjugated estrogens 1.25–2.5mg are often used every 6 hours. After bleeding stops, the dose should be reduced by 1/3 every 3 days until a maintenance dose of 1.25mg is reached. Alternatively, diethylstilbestrol 1–2mg can be used every 6–8 hours, with the same dose reduction schedule. The disadvantage of diethylstilbestrol is severe gastrointestinal reactions, slow absorption, and delayed effectiveness. In emergencies, micronized 17β-estradiol, conjugated estrogens, or ethinyl estradiol can be administered intramuscularly for rapid hemostasis. Regardless of the estrogen used, progesterone should be added 2 weeks after bleeding stops to promote endometrial transformation. For example, medroxyprogesterone 10mg can be taken orally daily for 10 days. Simultaneous withdrawal of estrogen and progesterone is beneficial for synchronized endometrial shedding, typically resulting in withdrawal bleeding 3–7 days after stopping the medication.
3) Androgens: Androgens can reduce bleeding but are ineffective in stopping bleeding during heavy loss or rapid endometrial shedding.
4) Combined Therapy: Since combined hormonal therapy is more effective than single-agent therapy, the following regimens are recommended:
① For adolescent DUB, during progestogen-induced hemostasis, a low-dose estrogen is added to overcome the limitations of single progestogen therapy, reducing progestogen dosage and preventing breakthrough bleeding. A progestogen-dominated oral contraceptive (e.g., 1 tablet) can be taken every 6 hours. After bleeding stops, the dose should be reduced as described above to a maintenance dose of 1 tablet daily for 20 days, then discontinued.
② For perimenopausal DUB, estrogen and androgen are added after progestogen-induced hemostasis. A triphasic hormone preparation (progestogen 12.5mg, estradiol 1.25mg, androgen 25mg) 2ml can be administered intramuscularly every 12 hours. After bleeding stops, the dose should be reduced to every 3 days for 20 days.
5) Prostaglandin Antagonists: Taking prostaglandin synthase inhibitors such as flurbiprofen 200mg three times daily during bleeding can reduce bleeding during endometrial shedding. This works by altering the balance between thromboxane A2 and prostacyclin. Thromboxane A2 is a precursor to platelet aggregation and smooth muscle contraction, while prostacyclin is a potent smooth muscle relaxant and antiplatelet aggregator.
6) Other Hemostatic Agents: Antilipemic drugs and hemostatic can reduce microvascular permeability, while agents like aminocaproic acid, tranexamic acid, and amicar can inhibit fibrinolysis, providing in reducing bleeding but not as a primary treatment.