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Use of Steroid Hormones for treatment
of DUB is declining, and often it's treated with
non-hormonal medication, and the patient ends up in a
hysterectomy. It's quite sad to see a healthy uterus being
removed, for a problem that is somewhere else. Let me try to
go into physiological background of DUB and try to make the
use of steroid hormone more effective.
HPO axis - a digital system: HPO
axis is an independent functional unit, that's anatomically
distributed at distant sites in the body. It has an amazing
behavior that's either it is normal, when it's ovulatory,
secretes estrogen and progesterone in a regular oscillatory
pattern. Or, it's abnormal, when it's anovulatory, and hormonal
secretion is almost continuous and in constant quantities (only
estrogen, no progesterone). This is so, because it is nature’s
check against impregnation at unwanted times. Nature takes care
that; the organism doesn’t become pregnant, at an un-optimal
time, during its physical and environmental crisis, and endanger
its pregnancy and itself. Nature does this by checking the
ovulation. so, it's interesting that, all the system in the
body, the psyche, hormones, physical status, nutrition etc
effect HPO, though it is not effected by the end organ -uterus
itself. Thus HPO is aware of the health status of the body
itself, but unaware of the bleeding problems in the uterus.
Probably, in the wild, it needn't know because, a woman had
hardly any time for menstruation. The ovulation acts as a check
valve. If the conditions are suboptimal, the nature aborts the
system, before ovulation, and prevents a pregnancy.
In a Normal Ovulatory cycle, after the
endometrium is shed, it's healed by the estrogen coming in the
following cycle. Estrogen proliferate the endometrium rapidly
and heals it. Thus, if we take the lesson from nature, estrogen
is the best to stop a bleeding. Progesterone in the secretary
phase makes the endometrium compact, and also, at its withdrawal
causes, sever vasospasm, which causes global shedding of the
endometrium, and also, limits the bleeding. Thus, the bleeding
mechanism has a natural built in mechanism to prevent excess
bleeding too. This occurs when the system is ovulatory.
In anovulatory state (not cycle, as HPO has stopped oscillating)
the HPO gives out continuous estrogen, which proliferates the
endometrium beyond the capacity of its stroma, endometrium is
shed from places, thus last longer, and because there's no
vasospasm due to absence of progesterone, bleeding is heavy.
Thus in treating DUB, our aim will be to:
1. Make sure, the uterus is sequentially stimulated by estrogen
and progesterone
2. To convert anovulatory HPO into ovulatory (if possible)
In an anovulatory woman, we can achieve our first goal, by
supplementing progesterone. She gets estrogen which comes at a
steady state from the HPO, so, we have to leave about 2 weeks
after the menstruation, and then give her progesterone tablets
for about 10 days.
If the patient presents with bleeding, we
have to arrest bleeding. The patient can’t accept to wait till
bleeding stops naturally. We have to give her estrogen to
achieve this, and then continue estrogen for about 2 weeks,
followed by progesterone. An anovulatory woman will have
slightly reduced estrogen, than the end-follicular phase of an
ovulatory woman. (If the estrogen increases to normal level,
she'll have LH surge and ovulation. Thus ovulation acts as a
check against hyper-estrogenemia) Common practice is to give
such women progesterone at higher dose, but usually she bleeds
irregularly on such treatment. Estrogen achieves hemostasis
effortlessly.
To make the HPO ovulatory, it's better to suppress it
completely, for sometime, and then, when it starts functioning
again, probably, it'll be ovulatory. OC pills (estrogen +
progesterone) are the best to achieve this. HPO is complex
system, with many interacting hormones. We can’t convert it to
ovulatory, by trying to make small changes. The tendency to
anovulation varies among women, thus, some women have strong
tendency to anovulation, owing to their enzyme variations, fat
levels, other hormone levels etc. Once a woman becomes
anovulatory, the HPO remains in that state, unless it's put back
into track by some luck. So, if a woman bleeds irregularly 3
times in 8 months, she didn’t have 3 anovulatory cycles, rather,
she was anovulatory for 8 months, since, the HPO became deranged
in the first instance.
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