Dysfunctional uterine bleeding, like functional menorrhagia, is a disorder of function, but in this case the problem is caused by abnormal hormone balance. The reproductive tract remains essentially normal, although the endometrium may not show secretory (progesterone-related) changes. The disorder usually originates from a disorder of the hypothalamic-pituitary-ovarian axis.

In many cases of dysfunctional uterine bleeding, ovulation does not occur normally, or fails entirely. This leads to an imbalance in the hormones — oestrogen is still produced, but progesterone production is either far too low or entirely absent. This results in unopposed oestrogenic stimulation of the endometrium (‘unopposed’ suggests a lack of the normal amounts of progesterone) and leads to the characteristic bleeding patterns — an erratic cycle, no obvious signs of ovulation, and irregular or prolonged episodes of bleeding.

In the normal course of events, oestrogen is accompanied (opposed) by progesterone, and it is primarily the progesterone production and withdrawal that maintains the regularity of the endometrial shedding (and therefore the period). When ovulation does not occur, oestrogen continues to stimulate the endometrial cells, which grow and thicken. However, the absence of progesterone means that the endometrium does not develop the usual structural features of the secretory phase, including the spiral arterioles. Their function is to nourish the endometrium and to control blood loss once menstruation commences.

Without the development of these blood vessels, circulation throughout the thickened endometrium is incomplete and eventually fails; and the tissue becomes fragile and starts to break down. This does not occur uniformly throughout the endometrium — some sections are shed while others remain intact, resulting in the spotting and erratic blood loss characteristic of the condition.

In a normal cycle, the usual mechanisms for slowing the blood loss are shared by prostaglandins and spasm of the spiral arterioles. With these structures being absent, haemostasis is impaired and excessive flooding can occur. This type of dysfunctional uterine bleeding is most common when regular ovulation is at its most fragile: amongst teenage women who have just started to menstruate, and around the menopause. It can also be a feature of any condition where ovulation does not occur, such as after stress, but can occur in relation to other less common conditions such as thyroid disease and androgen excess.

Diagnosis

As with functional menorrhagia, the diagnosis of dysfunctional uterine bleeding is a diagnosis of exclusion and examinations are performed to eliminate other conditions as the cause of bleeding.

Signs and symptoms highly suggestive of dysfunctional uterine bleeding are:

• The age of the woman

Women who are establishing their normal cyclical pattern at the menarche, and women whose cycles are slowing down around menopause, are more likely to develop anovulatory dysfunctional uterine bleeding.

• Normal uterine size and normal cervix

Because spotting is a feature of cervical conditions, a healthy cervix is unlikely to be causing inter-menstrual or premenstrual bleeding. Uterine size and shape will change if the woman has fibroids or adenomyosis, which are common causes of heavy menstruation.

• A recent history of persistent or severe stress

Ovulatory failure or disrupted progesterone production can occur after stress because of the effect on the hypothalamic-pituitary function.

• A negative pregnancy test

Pregnancy-related bleeding is the most common cause of abnormal menstrual patterns amongst women who are sexually active.

• No pain during either a vaginal examination or abdominal palpation Pelvic inflammatory disease and endometriosis are two conditions which can cause symptoms similar to dysfunctional uterine bleeding; however, both are usually accompanied by pain during an examination.

The medical approach

The treatment for dysfunctional uterine bleeding is similar to that described for functional menorrhagia. A synthetic progesterone (for example, Provera or Primolut) is used to try to interrupt the abnormal hormonal pattern and regulate the cycle. A progestogen (levonorgestrel)-releasing IUD can also be inserted to reduce bleeding. Usually a D&C or hysteroscopy is performed for older women to determine whether the bleeding is caused by endometrial hyperplasia or cancer.

The natural therapist’s approach

The treatment of dysfunctional uterine bleeding is based on a multi-faceted approach which aims to:

• re-establish ovulation

• support the luteal phase of the cycle

• treat stress where appropriate

• utilise all or any of the treatments for functional menorrhagia as necessary

At the menarche, the occurrence of erratic cycles is so common that it is usually thought of as being physiological — in other words, a normal feature of the physiology of this age group. For this reason, young women with dysfunctional bleeding patterns do not normally require any treatment unless the bleeding is particularly severe and causing other problems. Herbal remedies which are appropriate for bleeding experienced around the menarche are Achillea millefolium, Equisetum arvense, Rubus idaeus and Alchemilla vulgaris.

Ovulation

In order to re-establish ovulation, it is first necessary to identify the reason it stopped. This may be related to the stage of the menstrual cycle — that is, around menopause or the menarche — or ovulation may temporarily stop because of stress, over-exercising, low body weight or a poor quality diet. Sometimes the exact cause is unknown (idiopathic).

(Ovulatory failure can be related to other more complex hormonal irregularities which involve other endocrine glands such as the thyroid or the adrenal gland; or to a major disruption in ovarian function, as is seen in polycystic ovaries; or to abnormal activity of the hypothalamic-pituitary unit, such as hyperprolactinaemia. These conditions are treated by rectifying the abnormal function of the endocrine gland/s involved.)

There is a long herbal history of the use of ‘female tonics’ to re-establish normal bleeding patterns. These are assumed to have regulatory effects on the hormonal axis and ovulation, but as yet the mechanisms by which this occurs are largely unknown. Many of these herbs contain steroidal saponins which may interact with the hypothal-amus or the pituitary to re-establish ovulation. The important tonic herbs are Tribulus terrestris, Asparagus racemosa, Angelica sinensis, Cimicifuga racemosa and Aletris farinosa.

A combination of herbs containing steroidal saponins and Vitex agnus-castus is commonly used to treat dysfunctional uterine bleeding. Vitex agnus-castus has been shown to stimulate ovulation, and is specific to problems of the luteal phase of the cycle and hypothalamic-pituitary function. Since dysfunctional uterine bleeding is primarily a relative progesterone deficiency due to an irregularity of ovulation, this is usually an effective combination.

Vitex agnus-castus can be used for menstrual irregularity associated with menopause, but in this case is it more favourably combined with Cimicifuga racemosa. It is unwise for women to self-medicate with Vitex agnus-castus because it can cause menstrual irregularity if incorrectly administered.

Aletris farinosa and Angelica sinensis are both Warming adaptogens for the reproductive organs and have similar effects on ovarian function to Tribulus terrestris or Asparagus racemosa. Cimicifuga racemosa, slightly Cooler than the other two, is sedative, oestrogenic, adaptogenic and is the herb of choice for peri-menopausal complaints.

The luteal phase

Vitex agnus-castus is the primary herb for problems associated with the luteal phase. Trials have verified its use in dysfunctional uterine bleeding, endometrial hyperplasia, anovulatory cycles and polymenorrhoea. It should be started as close as possible to day one of the cycle and continued throughout the whole menstrual cycle including the period. A three-month course is usually necessary and some women may need longer courses to regulate ovulatory patterns. Vitex is usually given as a single morning dose of 2 ml of fluid extract.

Although vitamin B6 is useful to control symptoms associated with premenstrual hormone irregularities, there is no evidence that it will rectify the causes of dysfunctional uterine bleeding. Even so, vitamin B6 is a useful medication when troubling PMS-type symptoms are associated with the abnormal bleeding pattern, and can be used either alone or in combination with B complex.

The usual dose of B6 is 50-100 mg twice daily for 7-10 days before the period, although some authors suggest that doses between 150-200 mg daily are more beneficial. Vitamin B6 is relatively safe, but there may be side-effects at higher doses and the lowest dose that gives the best therapeutic response is recommended.

The nervous system

Nervines are important in the treatment of dysfunctional uterine bleeding because of the effect of stress on the hormonal axis. Any of the herbs in these categories will have a beneficial effect; the nervines which are clinically superior include Hypericum perforatum, Leonurus cardiaca and Verbena officinalis.

Nervine herbs can be either Cooling, Warming or neutral. In general, Warming nervines are useful for lack of vitality and debility {Matricaria cbamomilla, Verbena officinalis, Leonurus cardiaca) and Cooling nervines have a more sedating effect (Hypericum perforatum, Humulus lupulus, Bupleurum falcatum).

Uterine tone

Alchemilla vulgaris is very effective for dysfunctional uterine bleeding because it has anti-haemorrhagic effects and is believed to improve progesterone production. Trillium erectum contains saponins (plant hormone-like substance) which seem to be capable of regulating both the blood flow and the hormone balance. These herbs are considered to be ‘specific’ to the treatment of dysfunctional uterine bleeding which is caused by failure to ovulate, and can regulate both cycle length and menstrual loss within 1-3 cycles. They are often prescribed with Vitex agnus-castus.

Self care

The dietary advice outlined for functional menorrhagia is important. It is also necessary to minimise stress because, apart from anything else, erratic and heavy bleeding is stressful in itself and the worry associated with the implications of the symptoms may feed into the stress cycle and worsen the symptoms. Stress management, including long, slow, distance exercise is discussed in ‘The usual suspects’.

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