Dysfunctional Uterine Bleeding

Rate this Article

ast Updated: March 8, 2006

Email to a Colleague
Get CME/CE for article

ynonyms and related keywords: DUB, abnormal vaginal bleeding, menorrhagia, metrorrhagia, menometrorrhagia, ovulatory DUB,
menorrhea, oligomenorrhea, polycystic ovary disease, hyperandrogenism, hirsutism, obesity, enlarged ovaries, thrombocytopenia,
pothyroidism, hyperthyroidism, liver disease, hypertension, diabetes mellitus, adrenal disorders, vaginal carcinoma, cervical cancer,
erine cancer, ovarian cancer, functional ovarian cysts, cervicitis, endometritis, salpingitis, leiomyomas, vaginal infection, polyps, ectopic
egnancy, hydatidiform mole, blood dyscrasias, excessive weight gain, increased exercise performance

INTRODUCTION

Section 2 of 10

uthor Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

ackground: Dysfunctional uterine bleeding (DUB) is the most common cause of abnormal vaginal bleeding durin
woman's reproductive years. The diagnosis of DUB should be used only when other organic and structural cause
r abnormal vaginal bleeding have been ruled out.

normal menstrual cycle occurs every 21-35 days with menstruation for 2-7 days. The average blood loss is 35-15
L total, which represents 8 or fewer soaked pads per day with usually no more than 2 heavy days.

athophysiology: During the normal menstrual cycle, the first day corresponds to the first day of menses. The
enstrual phase usually lasts 4 days and involves the disintegration and sloughing of the functionalis layer of the
ndometrium. The proliferation (follicular) phase extends from day 5 to day 14 of the typical cycle. It is marked by
ndometrial proliferation brought on by estrogen stimulation. The estrogen is produced by the developing ovarian
llicles under the influence of follicle-stimulating hormone (FSH). Cellular proliferation of the endometrium is marke
nd the length and convolutedness of the spiral arteries increases. This phase ends as estrogen production peaks,
ggering the FSH and luteinizing hormone (LH) surge. Rupture of the ovarian follicle follows, with release of the
vum (ovulation). The secretory (luteal) phase is marked by production of progesterone and less potent estrogens b
e corpus luteum. It extends from day 15 to day 28 of the typical cycle. The functionalis layer of the endometrium
creases in thickness, and the stroma becomes edematous. If pregnancy does not occur, the estrogen and
ogesterone feedback to the hypothalamus, and FSH and LH production falls. The spiral arteries become coiled a
ave decreased flow. At the end of the cycle, they alternately contract and relax, causing a breakdown of the
nctionalis layer and menses to begin.

pproximately 90% of DUB results from anovulation, and 10% occur with ovulatory cycles. During an anovulatory
ycle, the corpus luteum fails to form, which causes failure of normal cyclical progesterone secretion. This results in
ontinuous unopposed production of estradiol, stimulating overgrowth of the endometrium. Without progesterone, th
ndometrium proliferates and eventually outgrows its blood supply, leading to necrosis. The end result is
verproduction of uterine blood flow.

ovulatory DUB, prolonged progesterone secretion causes irregular shedding of the endometrium. This probably i
lated to a constant low level of estrogen that is around the bleeding threshold. This causes portions of the
ligomenorrhea - Uterine bleeding occurring at intervals of 35 days to 6 months

Amenorrhea - No uterine bleeding for 6 months or longer

he major categories of DUB include the following:

deficiency tends to be present. This is characterized by a shortened luteal phase from insufficient
progesterone production or effect. This inadequate progesterone stimulation may be coexistent with high, low
or normal estrogen levels and often results in similar problems in anovulatory cycles such as amenorrhea.

ortality/Morbidity: Morbidity is related to the amount of blood loss at the time of menstruation, which occasionall
severe enough to cause hemorrhagic shock.

though, DUB in itself is rarely fatal, distinguishing this presentation from that of endometrial cancer is important.
evelopment of endometrial cancer is related to estrogen stimulation and endometrial hyperplasia. Symptoms
clude postmenopausal bleeding, which is usually considered cancer until proven otherwise.

ace: DUB has no predilection for race; however, black women have a higher incidence of leiomyomas and higher
vels of estrogen. As a result, they are prone to experiencing more episodes of abnormal vaginal bleeding.

ge: DUB is most common at the extreme ages of a woman's reproductive years, either at the beginning or near th
nd, but it may occur at any time during her reproductive life.

Most severe cases of DUB occur in adolescent girls during the first 18 months after the onset of menstruatio
when their immature hypothalamic-pituitary axis may fail to respond to estrogen and progesterone, resulting
anovulation.

In the perimenopausal period, DUB may be an early manifestation of ovarian failure causing decreased
hormone levels or responsiveness to hormones, thus also leading to anovulatory cycles. In patients who are
40 years or older, the number and quality of ovarian follicles diminishes. Follicles continue to develop but do
not produce enough estrogen in response to FSH to trigger ovulation. The estrogen that is produced usually
results in late-cycle estrogen breakthrough bleeding.

CLINICAL

uthor Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

Section 3 of 10

istory:

Patients often present with complaints of amenorrhea, oligomenorrhea, menorrhagia, or metrorrhagia. Ask
patients to compare the number of pads or tampons used per day in a normal menstrual cycle to the number
used at the time of presentation. The average tampon holds 5 mL of blood; the average pad holds 5-15 mL o
blood.

Occasionally, bleeding is profuse with associated signs and symptoms of hypovolemia, including hypotensio
tachycardia, diaphoresis, and pallor. These patients usually do not have vaginal or pelvic pain associated wit
bleeding episodes, and other systemic symptoms rarely are noted unless vaginal bleeding has an organic
cause.

A reproductive history should always be obtained, including the following:

Menstrual regularity

Last menstrual period (LMP), including flow and duration

Gravida and para

Previous abortion or recent termination of pregnancy

Contraceptive use

Questions about medical history should include the following:

o
o

Signs and symptoms of hypovolemia

Diabetes mellitus

Hypertension

Hypothyroidism, hyperthyroidism

Liver disease

Medication usage, including exogenous hormones, anticoagulants, aspirin, anticonvulsants, and

antibiotics

Alternative and complementary medicine modalities, such as herbs and supplements

hysical:

Initial evaluation should be directed at assessing patient's volume status and degree of anemia. Examine for

pallor and absence of conjunctival vessels to gauge anemia.

Patients who are hemodynamically stable require a pelvic speculum and bimanual examination to define the
etiology of vaginal bleeding. The examination should look for the following:
o

Trauma to the vaginal walls or cervix

Foreign body

Cervical or vaginal laceration

Bleeding from the os

Uterine or ovarian structural abnormalities may be noted on bimanual examination, but a negative examinati
is insensitive for finding abnormalities.

Patients with hematologic pathology also may have cutaneous evidence of bleeding diathesis. Physical
findings include petechiae, purpura, and mucosal bleeding (eg, gums) in addition to vaginal bleeding.

Patients with liver disease that has resulted in a coagulopathy may manifest additional symptomatology
because of abnormal hepatic function. Evaluate patients for spider angioma, palmar erythema, splenomegal
ascites, jaundice, and asterixis.

Women with polycystic ovary disease present with signs of hyperandrogenism, including hirsutism, obesity,
and palpable enlarged ovaries.

Hyperactive and hypoactive thyroid can cause menstrual irregularities. Patients may have varying degrees o
characteristic vital sign abnormalities, eye findings, tremors, changes in skin texture, and weight change.
Goiter may be present.

auses:

Multiple organic pathologies can present as abnormal vaginal bleeding, including thrombocytopenia,
hypothyroidism, hyperthyroidism, Cushing disease, liver disease, hypertension, diabetes mellitus, and adren
disorders.

Pregnancy may be associated with vaginal bleeding that the patient may report as abnormal for her in term
of timing, amount, or duration.

Trauma to the cervix, vulva, or vagina may cause abnormal bleeding.

Carcinomas of the vagina, cervix, uterus, and ovaries always must be considered in patients with the
appropriate history and physical exam.

Other causes of DUB include structural disorders, such as functional ovarian cysts, cervicitis, endometritis,

salpingitis, and leiomyomas.

Polycystic ovary disease, vaginal infection, polyps, ectopic pregnancy, hydatidiform mole, blood dyscrasias,
excessive weight gain, increased exercise performance, or stress may also contribute to DUB.

Breakthrough bleeding may occur in patients taking oral contraceptives that have inadequate doses of
estrogen and progestin for the patient.
o

Intermenstrual bleeding may occur secondary to missed pills, varied ingestion times, and drug
interactions.

The most common drug interactions with OCPs occur with phenobarbital, carbamazepine, some
penicillins, tetracycline, and trimethoprim-sulfamethoxazole.

Breakthrough bleeding can indicate reduced birth control efficiency; therefore, advise using additional
birth control methods until the next menstrual cycle begins.

An iatrogenic cause of DUB is the use of progestin-only compounds for birth control. Medroxyprogesterone
acetate (Depo-Provera), a long-acting injection given every 3 months, inhibits ovulation. An adverse effect of
this drug is prolonged uterine breakthrough bleeding; this may continue after discontinuation of the drug
because of persistent anovulation. The Norplant system (surgically implanted levonorgestrel), which acts to
block some but not all ovulatory cycles, has the same adverse effects as Depo-Provera.

Contraceptive intrauterine devices (IUDs) can cause variable vaginal bleeding for the first few cycles after
placement and intermittent spotting subsequently. The progesterone impregnated IUD (Mirena) is associated
with less menometrorrhagia and usually results in secondary amenorrhea.
DIFFERENTIALS

uthor Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

bdominal Trauma, Blunt

bdominal Trauma, Penetrating
bortion, Complete
bortion, Complications
bortion, Incomplete
bortion, Inevitable
bortion, Missed
bortion, Septic
bortion, Threatened
bruptio Placentae
nemia, Acute
nemia, Chronic
ndometriosis
ypothyroidism and Myxedema Coma
iopathic Thrombocytopenic Purpura

Section 4 of 10

varian Cysts
varian Torsion
elvic Inflammatory Disease
regnancy, Ectopic
regnancy, Postpartum Hemorrhage
regnancy, Trauma
hock, Hemorrhagic
hock, Hypovolemic
hrombocytopenic Purpura

ther Problems to be Considered:

dvanced liver disease

nabolic steroids
ervical cancer
ervicitis
ervical polyps
rrhosis
ndometrial cancer
eiomyoma
eukemia
ostcoital bleeding
alpingitis
hrombocytopenia
terine cancer
terine leiomyomas
aginal lacerations
on Willebrand disease

WORKUP

uthor Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

ab Studies:

A detailed workup for DUB is beyond the scope of the ED, yet several studies are required to ensure hemod
vaginal bleeding.

In the patient with unstable vital signs, perform a CBC with platelets, prothrombin time (PT), activated partial
tests (if other signs indicate liver disease), and type and cross-match.

Pregnancy must be ruled out by urine and/or serum human chorionic gonadotropin.

Consider thyroid function tests. FSH, TSH, DHEAS, and prolactin levels should be considered, although thes

maging Studies:

Workup by the gynecologist should include pelvic ultrasonography to evaluate for fibroids or other structural
bleeding.

Transvaginal ultrasonography (TVUS): Consider TVUS if the patient may be pregnant or may have anatomic

Dilatation and curettage (D&C) can be both therapeutic and diagnostic. It may be the treatment of choice wh
extensive sampling of the uterine cavity and also has a higher sensitivity than endometrial biopsy.

Although mostly an office or intraoperative procedure, hysteroscopy can be used in place of D&C and allows
with directed biopsy.

rocedures:

Pelvic examination

Before instituting therapy, many consulting gynecologists perform an endometrial sampling or endometrial bi
exclude endometrial malignancy.

Perform endometrial biopsy for the following patients:

o

All patients older than 35 years

Obese patients

Patients with diabetes mellitus

Patients with hypertension

Patients with suspected polycystic ovarian disease

D&C is indicated in the following situations:

o

Consider D&C in patients at high risk for endometrial hyperplasia and carcinoma.

Consider D&C rather than endometrial biopsy if suspected diagnosis is endometritis, atypical hyperpla

Perform in patients having heavy, uncontrolled bleeding.

Perform if histologic examination is required but biopsy is contraindicated.

Perform if medical curettage fails.

TREATMENT

uthor Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

mergency Department Care:

Hemodynamic instability
o
o
o

Evaluate ABCs and address the priorities.

Initiate 2 large-bore intravenous lines (IVs), oxygen, and cardiac monitor.
If bleeding is profuse and the patient is unresponsive to initial fluid management, consider administrat
mg. Repeat doses if necessary until bleeding stops, which is usually within 1-5 hours.

If bleeding continues after instituting IV estrogen, insert a pediatric Foley catheter into the cervical os and inf
distended with saline until the bleeding stops. If the patient has an unusually large uterus, a larger balloon (1
may need to be clamped to reinforce the tamponade if blood begins to exit through a large-caliber catheter. T
control bleeding.

For older, hemodynamically stable (hematocrit 25-35%) patients with a known history of DUB, iron-deficiency
bleeding, administer an oral contraceptive containing a combination of high doses of estrogen and synthetic
per day for 7 days to arrest bleeding. Oral contraceptives may aggravate an already suppressed hypothalam
patients; therefore, use them only in patients with an established menstrual history. Exclude pregnancy prior
contraceptives include the following:
o

Modicon 21 (ethinyl estradiol, norethindrone)

Ortho-Novum 1/35 (ethinyl estradiol, norethindrone)

o
o

Ortho-Novum 1/50 (mestranol, norethindrone)

Levlen 21,28 (ethinyl estradiol, levonorgestrel)

o
o

Lo/Ovral (ethinyl estradiol, norgestrel)

Ortho-Cept 21 (ethinyl estradiol, desogestrel)

Demulen 1/30,50 (ethinyl estradiol, ethynodiol diacetate)

Progestins alone are the drug of choice to treat anovulatory DUB and should be reserved for patients with a
safely in the ED after the severe acute bleeding episode is curtailed with IV estrogen and pregnancy has bee

onsultations:

Seek an emergency gynecologic consultation for patients requiring hemodynamic stabilization. Should paren
bleeding in the hemodynamically unstable patient, an emergency D&C may be warranted.

Consult a gynecologist if administering combination therapy to a mature patient with a history of DUB, mode

Consult a surgeon for acute hemorrhage with hemodynamic instability. One of the following procedures may
o

D&C

o
o

Hysterectomy (rare)
Endometrial ablation

MEDICATION

uthor Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

though definitive therapy is beyond the scope of the emergency physician, knowledge of these regimens will help
ymptoms.

rug Category: Steroid hormones -- These agents are used because of their hemodynamic effects in the uteru
Drug Name

Estrogens, conjugated (Premarin) -- Causes vasospasm of uterine ar

coagulation-related functions, which decrease uterine bleeding. Use i
rapid growth of endometrial tissue over denuded and raw epithelial su

Adult Dose

Severe uncontrolled bleeding with problems of hemostasis: 25 mg IV

bleeding stops; not to exceed 4 doses
Moderate bleeding: 2.5 mg PO qd for days 1-25, followed by progeste

Pediatric Dose

Not established; use judiciously in children whose bone growth is not

epiphyseal closure

Contraindications

Documented hypersensitivity; known or suspected pregnancy; breast

genital bleeding; active thrombophlebitis or thromboembolic disorders
thrombosis, or thromboembolic disorders associated with previous es
treatment of breast or prostatic malignancy)

Interactions

May reduce hypoprothrombinemic effect of anticoagulants; barbiturat

induce hepatic microsomal enzymes may reduce levels; pharmacolog
corticosteroids may occur as a result of estrogen-induced inactivation
seizure control has been noted when administered concurrently with

Pregnancy

X - Contraindicated in pregnancy

Precautions

Certain patients may develop undesirable manifestations of excessive

abnormal or excessive uterine bleeding or mastodynia; may cause so
(exercise caution); prolonged unopposed estrogen therapy may incre

Drug Name

Medroxyprogesterone acetate (Provera) -- DOC for most patients with

bleeding episode controlled, can be used alone in patients with adequ
estrogen to cause endometrial growth. Progestin therapy in adolesce
withdrawal bleeding until positive feedback system matures. Progesti
support and organize endometrium to allow organized sloughing after
rapidly because of an organized slough to the basalis layer. These dr
bleeding episodes, yet produce a normal bleeding episode following t

Adult Dose

10 mg PO qd for first 10-12 d of menstrual cycle

Depo-medroxyprogesterone (Depo-Provera) as 150 mg IM q3mo
Progestin-only oral contraceptive pills: Daily after acute phase of blee
For acute moderate bleeding: Oral contraceptive pills qid for 5-7 d or

Pediatric Dose
Contraindications

Not recommended

Documented hypersensitivity; cerebral apoplexy; undiagnosed vagina

dysfunction
Interactions

May decrease effects of aminoglutethimide

Pregnancy

X - Contraindicated in pregnancy

Precautions

Caution in asthma, depression, renal or cardiac dysfunction, or throm

rug Category: Nonsteroidal anti-inflammatory drugs (NSAIDS) -- These agents can decrease DUB throug

eeding is controlled; NSAIDS need only to be taken during menstruation.

Drug Name

Naproxen (Naprosyn, Aleve, Naprelan) -- For relief of mild to moderat

reactions and pain by decreasing activity of cyclooxygenase, which is
synthesis.
NSAIDs decrease intraglomerular pressure and decrease proteinuria

Adult Dose

For moderate bleeding: 500 mg PO bid (with foods)

Pediatric Dose

<12 years: Not established

>12 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding

Interactions

Coadministration with aspirin increases risk of inducing serious NSAI

probenecid may increase concentrations and, possibly, toxicity of NSA
hydralazine, captopril, and beta-blockers; may decrease diuretic effec
increase PT when taking anticoagulants (instruct patients to watch for
risk of methotrexate toxicity; phenytoin levels may be increased when

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Category D in third trimester of pregnancy; acute renal insufficiency, i

hyponatremia, and renal papillary necrosis may occur; patients with p
compromised renal perfusion risk acute renal failure; leukopenia occu
returns to normal during therapy; persistent leukopenia, granulocytop
further evaluation and may require discontinuation of drug

FOLLOW-UP

uthor Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

urther Outpatient Care:

All patients with abnormal vaginal bleeding who are discharged from the ED receive follow-up from their fam

/Out Patient Meds:

Patients with bleeding heavy enough to decrease hematocrit may be given ferrous sulfate tablets (325 mg tid

Hormone regimens, including combination oral contraceptives and cyclic progestins, should be continued for
consulting gynecologist.

omplications:

Anemia

Adenocarcinoma of the uterus (if prolonged, unopposed estrogen stimulation)

Significant adverse effects of individual oral contraceptive preparations

rognosis:

Most patients do well once a diagnosis is established and an appropriate hormone regimen is started by a gy
cure rate among those with anovulatory bleeding.

Prognosis varies with pathophysiologic process.

In young women, most anovulatory cycles can be treated confidently and successfully with physiologically so
intervention.

atient Education:

Instruct patients to continue prescribed medications, although bleeding may still be occurring during the early
combination of estrogens for the first 25 days and a progesterone during the last 10 days of their cycle, they
cessation of the regimen.

Young patients with small amounts of irregular bleeding need reassurance and observation only prior to insti
pharmacologic intervention will not be necessary once menstrual cycles become regular.

Discuss ways patient can avoid prolonged stress and emotional turmoil.

For excellent patient education resources, visit eMedicine's Women's Health Center. Also, see eMedicine's p
Mittelschmerz.
MISCELLANEOUS

uthor Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

edical/Legal Pitfalls:

All patients should be examined for pregnancy complications, threatened or incomplete abortion, and ectopic
and should be considered only after other causes of abnormal vaginal bleeding have been investigated.

Patients older than 35 years or those with other risk factors for endometrial cancer should have endometrial
manipulation.
www.emedicine.com

Dysfunctional Uterine Bleeding

Objectives

Become familiar with the normal menstrual cycle and the

pathophysiology of DUB.
Understand options for evaluation of DUB.
Develop an understanding of treatment options for DUB.

Introduction
Dysfunctional uterine bleeding (DUB) is defined as abnormal uterine
bleeding caused by a hormonal mechanism. Any alteration of the normal
menstrual cycle mechanisms can lead to steady-state estrogen production
and DUB.

The Normal Menstrual Cycle 1,2

The events of the menstrual cycle are shown in Figure 1. The first day of a
typical cycle (day l) corresponds to the first day of menses. The menstrual
phase usually lasts 4 days and involves the disintegration and sloughing
of the functionalis layer of the endometrium. Prostaglandins are involved in
regulation of menses, with prostaglandin F2-alpha causing myometrial
contractions and vasoconstriction, and prostaglandin E2 causing
vasodilitation and muscle relaxation. 1
The proliferative (follicular) phase extends from day 5 to day 14 of the
typical cycle. It is marked by endometral proliferation brought on by
estrogen stimulation. The estrogen is produced by the developing ovarian
follicles under the influence of follicle stimulating hormone (FSH). There is
marked cellular proliferation of the endometrium and an increase in the
length and convolutedness of the spiral arteries. Endometrial glands
develop and contain some glycogen. This phase ends as estrogen
production peaks (must be greater than 200 pg/ml for more than 24

hours), triggering the FSH and luteinizing hormone (LH) surge. 1 Rupture of
the ovarian follicle follows, with release of the ovum (ovulation).
The secretory (luteal) phase is marked by production of progesterone
and less potent estrogens by the corpus luteum.2 It extends from day 15 to
day 28 of the typical cycle. The functionalis layer of the endometrium
increases in thickness, and the stroma becomes edematous. The glands
become tortuous with dilated lumens and stored glycogen. If pregnancy
occurs, the placenta produces human chorionic gonadotropin (HCG) to
replace progesterone, and the endometrium (and pregnancy) is
maintained.
If pregnancy does not occur, the estrogen and progesterone feed back to
the hypothalamus, and FSH and LH production falls. The spiral arteries
become coiled and have decreased blood flow. At the end of this period,
they alternately contract and relax, causing disintegration of the
functionalis layer and menses.

Terms 1-4

Normal menstruation - regular cyclic uterine blood flow lasting 2 to 6 days

with an interval of 21 to 35 days and a typical blood loss of 20 to 60 ml.
Menorrhaga - prolonged or excessive uterine bleeding occurring at regular
intervals.
Metrorrhaga - uterine bleeding occurring at irregular and more frequent
than normal intervals.
Menometrorrhagia - prolonged or excessive uterine bleeding occurring at
irregular and more frequent than normal intervals (the 2 above combined.)
Intermenstrual bleeding - (commonly called "spotting") uterine bleeding of
variable amounts occurring between regular menstrual periods.
Polymenorrhea - uterine bleeding occurring at regular intervals of less
than 21 days.
Oligomenorrhea - uterine bleeding occurring at intervals of 35 days to six
months.
Amenorrhea - no uterine bleeding for 6 months or longer.

Pathophysiology
DUB is most common near the beginning and end of a woman's
reproductive life, but may occur at any time. In the first 18 months after
menarche, the immature hypothalamin-pituitary axis may fail to respond to
estrogen and progesterone, resulting in anovulation. 2,3 In obese women,
the non-ovarian endogenous estrogen production may upset the normal
menstrual cycle.5 As menopause approaches, decreases in hormone
levels or in responsiveness to hormones also may lead to anovulatory
DUB. Potential causes of vaginal bleeding are shown in Table 1.

Table 1. Causes of dysfunctional uterine bleeding.

Endocrine
Cushing's disease
immature hypothalamin-pituitary
axis
hyperprolacinemia
hypothyroidism
menopause
obesity
polycystic ovary disease
premature ovarian failure
Stuctural lesions
adenomyosis
coagulopathies

Infections
chlamydia
gonorrhea
PID
Medications
hormonal agents
low-dose oral contraceptive pills
(OCPs)
nonprogestin-containing IUDs
nonsteroidal anti-inflammatory drugs
(NSAIDS)
Norplant System

condyloma acuminata
dysplastic or malignant lesion of the
cervix or vagina
endometiosis
endometrial cancer
uterine or cervical polyps
uterine leiomyomata
trauma

progestin-only contraceptive (the

"mini pill")
tamoxifen
warfarin
Pregnancy
ectopic pregnancy
incomplete abortion
pregnancy complications

Most cases of DUB are caused by anovulatory cycles that result in high
steady-state estrogen with no progesterone.l,5,6 The continuous estrogen
stimulation causes continuous development of the functionalis layer until
estrogen feedback produces a slow drop in FSH. Eventually, the blood
supply is outgrown and parts of the endometrium slough. Estrogen,
however, promotes healing of the endometrium so some parts are always
healing as others slough, resulting in menometrorrhagia. 2,3
A luteal phase deficiency also may result in DUB. It is characterized by a
shortened luteal phase from insufficient progesterone production or
effect.6,7 The insufficient progesterone stimulation may be coexistent with
high, low, or normal estrogen levels and often will result in similar
problems in anovulatory cycles. This problem, along with the loss of LH
surge, may be especially prominent in amenorrheic athletes. 6-8
Another mechanism of DUB, especially in patients who are 40 years old
and older, is diminishing number and quality of ovarian follicles. Follicles
continue to develop but do not produce enough estrogen in response to
FSH to trigger ovulation. Estrogen continues to be produced, which
usually results in late cycle estrogen breakthrough bleeding. 1,2
Improper balance of estrogen and progesterone may result in DUB. It may
result in low estrogen states from low-dose oral contraceptive pills (OCPs),
resulting in insufficient build up of stable endometrial lining, with resultant
prolonged light bleeding.3-9 DUB can also be caused by high progestin
activity oral contraceptive pills.3 These patients will often need a higher
level of estrogen or a lower activity progestin.9 Bleeding irregularities are
very common with the Norplant System, depo-medroxyprogesterone
injection, and the "mini pill," which is often the reason these contraceptives
are discontinued.10,11 Nonprogestin-containing IUDs also may cause DUB.4
Nonsteroidal anti-inflammatory drugs (NSAIDS) or supplemental estrogen
as described below may help with this side-effect.

Endocrine disorders also may cause DUB. Hyperprolactinemia inhibits

production and release of gonadotropin-releasing hormone. Polycystic
ovary disease often presents as anovulatory cycles resulting in DUB. 5
Hypothyroidism, hyperthyroidism, and Cushing's disease can be
associated with DUB.4,12 Finally, premature ovarian failure may be a factor
in patients who present with DUB.5
Postcoital bleeding usually indicates a structural lesion of the cervix or
vagina.1 Infectious etiologies such as chlamydia and gonorrhea must be
excluded or treated. Uterine or cervical polyps also may be a source of
bleeding.4 Dysplastic or malignant lesion of the cervical or vaginal
epithelium may cause irregular or postcoital bleeding. 2,4
An enlarged uterus may be caused by adenomyosis, uterine fibroids,
endometriosis, or pregnancy.2,4,13 Submucosal myomas and endometrial
polyps are associated with DUB in both premenopausal and
postmenopausal women.13 Ectopic pregnancy and pregnancy
complications also must be ruled out. A high index of suspicion for the
possibility of pregnancy must be maintained. 2,4 Endometrial cancer should
be excluded, especially in older and high-risk patients with this
symptom.1,2,4

Endometrial Cancer
One of the most important goals in work-up of DUB is to rule out
endometrial cancer, especially in older women. Development of
endometrial cancer is related to estrogen stimulation and endometrial
hyperplasia. Risk factors are shown in Table 2. Symptoms include
postmenopausal bleeding, which is usually considered endometrial cancer
until proven otherwise. 14 Bleeding prevalence may be as high as 1/3 of
cases, and the presence of uterine myomas should NOT delay appropriate
work-up. Other symptoms may include metrorrhagia, lower abdominal pain
or pressure, and (rarely) back pain or lower extremity edema secondary to
metastasis.
Clinical findings most commonly are a normal exam of vagina, uterus, and
cervix, although advanced disease may be associated with enlarged
uterus or pelvic mass. Cervical and vaginal metastasis can cause cervical
stenosis, pyometra, or a mucosanguineous vaginal discharge. Regional
metastasis may present as a bladder or rectal mass.

Table 2. Risk factors for endometrial cancer. 41-47 (RR = relative risk)
Age - 75% of cases occur after

RR (age > 60 years) = 5.2

menopause
with peak incidence in the late 60s.
RR= 3 to 10
Obesity - especially upper body fat.
This may
be secondary to increased estrogen
production and bioavailability.

RR = 5.2

Polycystic ovary disease.

RR = 2 to 14

Unopposed exogenous estrogen.

RR= 0.5 to 1

When progestins are added (oral

contraceptives
or with replacement therapy), relative RR = 2 to 2.8
risk is less
than for the general population.
Diabetes (all types grouped).
Personal or family history of ovarian RR = 1.3
or breast
cancer. Women who are overweight RR (entering menopause after age
and have
52) = 2.5
had breast cancer are at even greater
risk.
RR = 7.5
Nulliparity.
Late menopause.
Tamoxifen therapy - Use for greater
than one
year is an independent risk factor.

Evaluation
Evaluation of DUB emphasizes establishing the cause and ruling out
endometrial cancer. A typical algorithm (Figure 2) begins with a thorough
history. Important factors to document include patient's age, last menstrual
period, last normal menstrual period, amounts and duration of bleeding,
postcoital bleeding, medications (especially hormonal agents, NSAIDS, or
warfarin), history of any endocrine abnormalities, symptoms of pregnancy,
symptoms of coagulopathies, contraceptive history, and history of trauma.

General physical examination should focus on symptoms of

endocrinopathies, including polycystic ovary disease (including obesity
and hyperandrogenism), hyperprolactinemia, and hypothyroidism. 2 Pelvic
examination is unnecessary in oligomenorrheic patients who are not
sexually active and are within 18 months of menarche. 3 Otherwise,
gynecologic examination includes inspection of the vagina and cervix for
physical lesions (polyps, leiomyomata, tears, malignancy, or incomplete
abortion) or infection. The size, shape, position, and firmness of the uterus
should be examined. Note any signs of excessive blood loss.
Basal temperature charting may assist in determining when and whether
ovulation occurs, if the patient will cooperate with testing. The patient may
take her temperature any time during the day as long as she is consistent
from day to day. A rise in basal temperature of 0.3 C to 0.6 C is indicative
of ovulation. This determination may also be made using serum
progesterone determination in the luteal phase, with a level greater than 3
mg/mL indicating ovulation has occurred.2

Table 3. Laboratory tests to consider for DUB. Testing should

be individualized based on each patiet's history and physical
findings.
Test
urine pregnancy test
CBC
PT/PTT
Pap smear*
FSH
liver function tests
TSH
prolactin level
DHEAS

Indication (to rule out)

pregnancy
anemia
coagulpathy (especially in
adolescents
cervical cancer
> 40IU/L suggests ovarian failure
liver disease
thyroid disease
pituitary adenoma (with breast
discharge)
polycystic ovary disease
* if there is no evidence of infection and it is indicated

Diagnostic Tests
Endometrial biopsy (EMB) is the most commonly used diagnostic test for
DUB (pages 17 -19). It provides an adequate sample for diagnosis of
endometrial problems in 90% to 100% of cases, 15,16 but may fail to detect
polyps and leiomyomas.17 It is indicated in all women with DUB who are 35
years of age or older, since their risk of developing malignancy is much
higher.2,3 Any woman with amenorrhea for one year or longer who
experiences uterine bleeding also should have an EMB. 2 The newer slim
endometrial suction currettes (Pipelle) produce samples comparable to
older, more traumatic methods but with less pain.1,3,15,16,18 Sampling should
be performed late in the cycle if possible, so it can be determined if
ovulation has taken place.3
Uterine ultrasound, especially transvaginal ultrasonography (TV-US),
can give information about suspected structural problems including fibroid
tumors.2,17,19 It is classically indicated when physical exam indicates
anatomic gynecologic abnormalities, especially of the ovaries where other
methods provide poor information.19 The endometrial stripe assessment on
TV-US can provide information about the ovulatory stage of the
endometrium that has a 93% correlation with hystological diagnosis. 19 An
endometrial thickness measurement of less than 4 to 7 mm is rarely
associated with cancer, and endometrial sampling may not be necessary
in such patients.17, 20, 21
Dilatation and curettage (D&C) allows more extensive sampling of the
uterine cavity and has the advantage of being both diagnostic and
therapeutic. It may be the treatment of choice when bleeding is severe or
necessitates blood transfusions. 2 It has a higher sensitivity than
endometrial biopsy, especially with smaller in-situ lesions. It is often used
when EMB is inadequate, the cervical os is stenotic, or DUB treatment
fails. 1, 3, 18 When D&C is combined with endometrial biopsy, the detection
rate approaches 100%. Fractional D&C is usually not used in teenagers,
because they rarely have endometrial cancer and the procedure may
damage the cervix or uterus. 5 It is currently required for the staging of
occult cancer. 14, 22
Hysteroscopy can be used in place of D&C for most indications, and
allows for direct visualization of the endometrial cavity with directed
biopsy. Hysteroscopy is more sensitive than fractional D&C, especially at
diagnosing polyps and submucosal leiomyomas, but it may miss
endometritis. 23, 24 When combined with EMB, it has almost 100% accuracy
in diagnosing endometrial dysplasia and cancer. 24 It may eventually
become required for staging of occult cancer. Like EMB, it often can be
performed in the office setting and may be used for treatment of DUB (see
below.) 24

Treatment
There are medical, surgical, and combined methods of treating DUB. The
choice of approach depends on the cause, severity of bleeding, patient's
fertility status, need for contraception, and treatment options available at
the care site. A typical algorithm for the treatment of mild to moderate DUB
is shown in Figure 3.
Cases of acute, heavy, uncontrolled bleeding should be treated with
intravenous estrogen, 25mg every 4 hours, to a maximum of 3 doses or
until bleeding stops (Table 4.) 25 Oral conjugated estrogen also may be
given in divided doses up to 10mg per day, although this regimen often
causes nausea and vomiting. In less severe cases, conjugated estrogens
at doses of 2.5 to 5mg per day stops the bleeding over 24 to 48 hours.
Regardless of which regimen is used, it should be followed by conjugated
estrogen at 1.25 to 2.5mg plus 10mg of medroxyprogesterone per day for
about 10 days. Withdrawal bleeding should then occur as all drugs are
withdrawn. 3 In postmenopausal women, continuous estrogen therapy with
conjugated estrogens (0.625 - 1.25mg) plus cyclic medroxyprogesterone
(10 mg ) for 10 - 14 days of each month may be continued. 3 This regimen
works best in patients with atrophic epithelium. 1

Table 4. Medical Therapies for DUB. 1,2,3,12,29

Therapy

Comments

Medroxyprogesterone (Provera) Works well to correct midcycle spotting and

10 mg
when
PO/day for 10 to 12 days
the EMB demonstrates proliferative
endometrium.
Depo-medroxyprogesterone
150 mg
Also provides contraception.
IM every 3 months
Progesterone in oil 100 - 200
mg IM
Also provides contraception.
Progestine-only oral
contraceptives pills

For acute moderately heavy bleeding. The

rest of the pills may then be taken Q day until
Oral contraceptive pillls up to the pack is completed, followed by an
additional 2 months of OCPs.
Qid for 5 to 7 days or until
bleeding stops
For acute, heavy, uncontrolled bleeding.
Intravenous estrogen 25 mg
Q4 hrs-- maximum of 3 doses For acute, heavy, uncontrolled bleeding.
or until bleeding stops
Often causes nausea and vomiting. Should
be followed by conjugated estrogen 1 .25 to
2.5 mg plus 10 mg of medroxyprogesterone
Oral conjugated estrogen
(Premarin) divided doses up per day for about 10 days.
to 10 mg/day
For less severe bleeding. Often causes
nausea and vomiting. Should be followed by
conjugated estrogen 1.25 to 2.5 mg plus 10
Oral conjugated estrogen
mg of medroxygesterone per day for abouth
(Premarin) 2.5 to 5 mg/day
10 days.
Conjugated estrogen 1.25
mg/day

Used for DUB and patients with low-dose

OCPs with midcycle spotting.

Conjugated estrogens 0.625

to 1.25 mg
Q day plus cyclic
medroxyprogesterone 10 mg
for 10 to 14 days each month

Used in treatment of peri- or

postmenopausal women.
Mainly used for chronic DUB. Good for
patients who desire pregnancy.

Clomiphene citrate (Clomid,

Serophene)
Progesterone-containing IUD Effective for long-term use. Much experience
with long-term use for other problems. Watch
for GI and renal side-effects.
NSAIDS Naproxen
(Naprosyn) 500 mg BiD,
menfenamic acid (Ponstel)
Androgenic side-effects limit use. Acts as
500 mg TiD,
anti-estrogen and prevents ovulation.
ethamsylate 500 mg QiD
Primarily used to thin the endometrium prior
Danazol (Danocrine) 200 to to surgery. Used when hormonal methods
800 mg/day
have failed or are containdicated. May cause
for 3 to 6 months
ospeporiis the chrnoic use, DUB will also
recur in up 10 10:of women treants
GnRH agonists goserelin
acetate (Zoladex), 3.6 mg SQ
every 28 days; leuprolide
acetate (Lupron) or nafarelin
acetate (Syneral)
In cases of moderately heavy DUB, oral contraceptive pills (OCPs) may
be given up to four times a day for 5 to 7 days or until bleeding stops. 2, 3
The rest of the pills may then be taken once a day until the pack is finished
and withdrawal bleeding occurs. In anovulatory patients, this is followed by
an additional 2 months of OCPs as usually prescribed. This regimen will
stabilize the epithelium, slough excessive build-up, and provide
contraception. OCPs may also be started initially at one pill every day in
milder cases of DUB. 2 - 4, 7 If the patient is already on OCPs and
experiencing DUB, a change to a higher estrogen activity OPC is
indicated. 3
Medroxyprogesterone (Provera) at 10mg PO per day for 10 to 12 days
has traditionally been one of the most common methods used to control
DUB. This "medical curettage" works well to correct midcycle spotting and
when the EMB demonstrates proliferative endometruim. 1 - 3 Depomedroxyprogesterone (150mg) or progesterone in oil (100 - 200mg) may
be given intramuscularly to achieve similar effects. 2, 3 The progestin-only
contraceptive pills also work well and, like depo-Provera, have the added
benefit of providing contraception. 3 Breast tenderness and mood swings
are possible side-effects of therapy. These regimens work especially well
with chronic or milder acute DUB. Progestin-containing IUDs, together
with oral or transdermal estrogen, may control DUB in postmenopausal
patients. 26, 27

Nonsteroidal anti-inflammatory drugs (NSAIDS) can decrease DUB,

probably through inihibition of prostaglandin synthesis. 27 Naproxen
(Naprosyn) 500mg twice daily, mefenamic acid (Ponstel) 500mg three
times daily, or ethamsylate 500mg four times a day has been shown to
decrease menstrual flow. 28 - 30 Once bleeding is controlled, NSAIDS need
only be used during menstruation. 27 These drugs are safe for long-term
usage, and the long-term effects are well studied. Aspirin does not appear
to be effective. 4
The androgenic synthetic steroid danazol (Danocrine), which is
traditionally used to treat endometriosis, can be used to treat DUB.
Similarly, the GnRH agonists goserelin acetate (Zoladex,) leuprolide
acetate (Lupron,) or nafarelin acetate (Syneral) induce a
hypogonadotropic state which stops dysfunctional bleeding. 27, 28, 31 They
all produce hypogonadism and induce ammenorrhea. Because of their
side effects, these drugs are used when hormonal methods have failed or
are contraindicated. These agents are primarily used to thin the
endometrium prior to surgical intervention. 4, 12, 31 - 34 Research involving
estrogen and progesterone "add back" therapy may provide a means of
overcoming the long- and short-term side-effects. 27, 31, 35, 36 DUB will recur
in up to 50% of women treated.
Dilatation and curettage (D&C) may ameliorate DUB, as well as
diagnose potential dysplasia or malignancy. It is sometimes avoided in
adolescents because of concerns about possible infertility. Repeated
procedures may result in intrauterine adhesions. 12
Neodymium:yttrium-aluminum-garnet (Nd:YAG) laser endometrial
ablation is a newer method of surgically treating the endometrium. It has
a success rate of approximately 85% and is more effective in patents over
the age of 35 years. 37 Amenorrhea may occur in 29% of patients. There
is some concern that cancers could be missed, since no tissue is available
for pathologic study. 37 Possible risks include fluid overload, endometritis,
and uterine perforation. 37 Laser equipment is expensive and requires
special safety precautions. 4
Hysteroscopic transcervical resection of the endometrium (TCRE)
makes use of an electrocautery loop or ball to remove or coagulate the
endometrium to stop DUB. It may reduce the need for hysterectomy by up
to 90%, 29, 38, 39 and has been shown to have a lower overall procedure cost
(including retreatment costs and eventual hysterectomies) than immediate
hysterectomy for more severe DUB. 33 The goal is to ablate the
endometrium and encourage endometrial adhesions resulting in hypo- or
amenorrhea. The hysteroscope is considerably less expensive to buy and
maintain than the laser but carries the risks of fluid overload, endometritis,
and uterine perforation. 24, 34, 29, 38 The potential fluid overload problem can

be alleviated by the use of carbon-dioxide gas or Dextran 70 solution to

distend the uterus. 24 Hysteroscopy is most effective in women who are
over the age of 35, and postmenopausal HRT may be safely started or
continued in patients after endometrial ablation. 29, 39 There have been 3
reported cases of adenocarcinoma diagnosed after endometrial ablation
for DUB. 40, 41
The enometrium may also be hysteroscopically ablated via the insertion of
a thermal uterine balloon. The system consists of a control system
attached to a 16cm by 5mm catheter with a latex balloon on the end that
houses a heating element. A sterile 5%dextrose solution is instilled until
the pressure reaches between 160 and 180mmHg. The solution is heated
to 87 degrees C. for 8 minutes and then the device is removed. The
treatment has been fount to be as efficatious as roller-ball ablation with
less complications. 41a
Hysterectomy remains the most absolutely curative treatment for DUB.
Elective hysterectomy has a mortality rate of six per 10,000 operations.
One randomized study found that hysterectomy was associated with more
morbidity and much longer healing times than endometrial ablation. 12
Fortunately, a recent study found that sexual functioning improved overall
after hysterectomy with an increase in sexual activity abd a decrease in
problems with sexual functioning. 48 It still remains a popular method of
treating DUB, especially in industrialized countries.
www.sh.lsuhsc.edu/fammed/outpatientmanual/dub/htm

Definition
Dysfunctional uterine bleeding is irregular, abnormal uterine bleeding that is not caused
by a tumor, infection, or pregnancy.
Description
Dysfunctional uterine bleeding (DUB) is a disorder that occurs most frequently in women
at the beginning and end of their reproductive lives. About half the cases occur in women
over 45 years of age, and about one fifth occur in women under age 20.
Dysfunctional uterine bleeding is diagnosed when other causes of uterine bleeding have
been eliminated. Failure of the ovary to release an egg during the menstrual cycle occurs
in about 70% of women with DUB. This is probably related to a hormonal imbalance.
DUB is common in women who have polycystic ovary syndrome (cysts on the ovaries).
Women who are on dialysis may also have heavy or prolonged periods. So do some
women who use an intrauterine device (IUD) for birth control.

DUB is similar to several other types of uterine bleeding disorders and sometimes
overlaps these conditions.

Menorrhagia
Menorrhagia, sometimes called hypermenorrhea, is another term for abnormally long,
heavy periods. This type of period can be a symptom of DUB, or many other diseases or
disorders. In menorrhagia, menstrual periods occur regularly, but last more than seven
days, and blood loss exceeds 3 oz (88.7 ml). Passing blood clots is common. Between
15-20% of healthy women experience debilitating menorrhagia that interferes with their
normal activities. Menorrhagia may or may not signify a serious underlying problem.

Metrorrhagia
Metrorrhagia is bleeding between menstrual periods. Bleeding is heavy and irregular as
opposed to ovulatory spotting which is light bleeding, in mid-cycle, at the time of
ovulation.

Polymenorrhea
Polymenorrhea describes the condition of having too frequent periods. Periods occur
more often than every 21 days, and ovulation usually does not occur during the cycle.
Causes and symptoms
Dysfunctional uterine bleeding often occurs when the endometrium, or lining of the
uterus, is stimulated to grow by the hormone estrogen. When exposure to estrogen is
extended, or not balanced by the presence of progesterone, the endometrium continues
to grow until it outgrows its blood supply. Then it sloughs off, causing irregular bleeding. If
the bleeding is heavy enough and frequent enough, anemia can result.
Menorrhagia is representative of DUB. It is caused by many conditions including some
outside the reproductive system. Causes of menorrhagia include:

adenomyosis (a benign condition characterized by growths in the area of the

uterus)
imbalance between the hormones estrogen and progesterone
fibroid tumors
pelvic infection
endometrial cancer (cancer of the inner mucous membrane of the uterus)
endometrial polyps
endometriosis (a condition in which endometrial or endrometrial-like tissue
appears outside of its normal place in the uterus)
use of an intrauterine device (IUD) for contraception
hypothyroidism

blood clotting problems (rare)

lupus erythematosus
pelvic inflammatory disease
steroid therapy
advanced liver disease
renal (kidney) disease
chemotherapy (cancer treatment with chemicals)

To diagnose dysfunctional uterine bleeding, many of the potential causes mentioned

above must be eliminated. When all potential causes connected with pregnancy,
infection, and tumors (benign or malignant) are eliminated, then menorrhagia is
presumed to be caused by dysfunctional uterine bleeding.
Diagnosis
Diagnosis of any menstrual irregularity begins with the patient herself. The doctor will ask
for a detailed description of the problem, and take a history of how long it has existed,
and any patterns the patient has observed. A woman can assist the doctor in diagnosing
the cause of abnormal uterine bleeding by keeping a record of the time, frequency,
length, and quantity of bleeding. She should also tell the doctor about any illnesses,
including long-standing conditions, like diabetes mellitus. The doctor will also inquire
about sexual activity, use of contraceptives, current medications, and past surgical
procedures.

Laboratory tests
After taking the woman's history, the gynecologist or family practitioner does a pelvic
examination and Pap smear. To rule out specific causes of abnormal bleeding, the doctor
may also do a pregnancy test and blood tests to check the level of thyroid hormone.
Based on the initial test results, the doctor may want to do tests to determine the level of
other hormones that play a role in reproduction. A test of blood clotting time and an
adrenal function test are also commonly done.

Imaging
Imaging tests are important diagnostic tools for evaluating abnormal uterine bleeding.
Ultrasound examination of the pelvic and abdominal area is used to help locate uterine
fibroids, also called uterine leiomyoma, a type of tumor. Visual examination through
hysterscopy--where a camera inside a thin tube is inserted directly into the uterus so that
the doctor can see the uterine lining--is also used to assess the condition of the uterus.
Hystersalpingography can help outline endometrial polyps and fibroids and help detect
endometrial cancer. In this procedure an x ray is taken after contrast media has been
injected into the cervix. Magnetic resonance imaging (MRI) of the pelvic region can also
be used to locate fibroids and tumors.

Invasive procedures Endometrial biopsy (the removal and examination of endometrial

tissue) is the most important testing procedure. It allows the doctor to sample small areas
of the uterine lining, while cervical biopsy allows the cervix to be sampled. Tissues are
then examined for any abnormalities.
Dilation and curettage (D & C), once common is rarely done today for diagnosis of DUB.
It is done while the patient is under either general or regional anesthesia. Women over 30
are more likely to need a D & C, as part of the diagnostic procedure, than younger
women.
Because DUB is diagnosed by eliminating other possible disorders, diagnosis can take a
long time and involve many tests and procedures. Older women are likely to need more
extensive tests than adolescents because the likelihood of reproductive cancers is
greater in this age group, and therefore must be definitively eliminated before treating
bleeding symptoms.
Treatment
Treatment of DUB depends on the cause of the bleeding and the age of the patient.
When the underlying cause of the disorder is known, that disorder is treated. Otherwise
the goal of treatment is to relieve the symptoms to a degree that uterine bleeding does
not interfere with a woman's normal activities or cause anemia.
Generally the first approach to controlling DUB is to use oral contraceptives that provide a
balance between the hormones estrogen and progesterone. Oral contraceptives are often
very effective in adolescents and young women in their twenties. NSAIDs (nonsteroidal
anti-inflammatory drugs), like Naprosyn and Motrin, are also used to treat DUB.
When bleeding cannot be controlled by hormone treatment, surgery may be necessary.
Dilation and curettage sometimes relieves the symptoms of DUB. If that fails, endometrial
ablation removes the uterine lining, but preserves a woman's uterus. This procedure is
sometimes be used instead of hysterectomy. However, as it affects the uterus, it can only
be used when a woman has completed her childbearing years. The prescription of iron is
also important to decrease the risk of enemia.
Until the 1980s, hysterectomy often was used to treat heavy uterine bleeding. Today
hysterectomy is used less frequently to treat DUB, and then only after other methods of
controlling the symptoms have failed. A hysterectomy leaves a woman unable to bear
children, and, therefore, is limited largely to women who are unable to, or uninterested in,
bearing children. Still, hysterectomy is a common treatment for long-standing DUB in
women done with childbearing.
Alternative treatment
Alternative practitioners concentrate on good nutrition as a way to prevent heavy periods
that are not caused by uterine fibroids, endometrial polyps, endometriosis, or cancer. Iron
supplementation (100 mg per day) not only helps prevent anemia, but also appears to
reduce menorrhagia in many women. Other recommended dietary supplements include
vitamins A and C. Vitamin C improves capillary fragility and enhances iron uptake.
Vitamin E and bioflavonoid supplements are also recommended. Vitamin E can help
reduce blood flow, and bioflavonoids help strengthen the capillaries. Vitamin K is known

to play a role in clotting and is helpful in situations where heavy bleeding may be due to
clotting abnormalities
Botanical medicines used to assist in treating abnormal bleeding include spotted
cranesbill (Geranium maculatum), birthroot (Trillium pendulum), blue cohosh
(Caulophyllum thalictroides), witch hazel (Hamamelis virginiana), shepherd's purse
(Capsella bursa-pastoris), and yarrow (Achillea millifolia). These are all stiptic herbs that
act to tighten blood vessels and tissue. Hormonal balance can also be addressed with
herbal formulations containing phytoestrogens and phytoprogesterone.
Prognosis
Response to treatment for DUB is highly individual and is not easy to predict. The
outcome depends largely on the woman's medical condition and her age. Many women,
especially adolescents, are successfully treated with hormones (usually oral
contraceptives). As a last resort, hysterectomy removes the source of the problem by
removing the uterus, but this operation is not without risk, or the possibility of
complications.
Prevention
Dysfunctional uterine bleeding is not a preventable disorder.

www.ahealthyme.com

What Is It?
Dysfunctional uterine bleeding, also called anovulatory bleeding, is any bleeding
from the vagina that varies from a woman's normal menstrual cycle. The normal
cycle is triggered by signals from hormones. Dysfunctional uterine bleeding occurs
when the cycle's hormonal signals get thrown off. This can include alternating
periods that are heavy and light, spotting or unpredictable shorter and longer
cycles.
Regular monthly menstrual cycles flush out the endometrial lining, which is the
blood-enriched layer of tissue that grows inside the uterus every month in
anticipation of a possible pregnancy.
If ovulation does not occur, periods can be delayed, which allows the lining to grow
thicker. For this reason, delayed periods are often heavy ones.
Lighter periods, or spotting between periods, may represent an endometrial lining
that is unstable and leaking, either because hormonal levels don't adequately
support it or because the lining may be too thick.
Other factors that can change bleeding patterns include:

Hormonal abnormalities (thyroid problems, hyperprolactinemia)

Medications
Excessive exercise or weight loss
Obesity

 Stress or illness
The start of menstruation in adolescence Regular ovulatory cycles may not
develop for a few months or even years.

The end of menstruation Dysfunctional uterine bleeding is common in the

months to years before menopause.

Symptoms
Irregular bleeding can come at different times from month to month and last for
different amounts of time. The amount of blood flow may vary from light to
extremely heavy with large clots. In some people, the bleeding may be associated
with uterine cramps.

Diagnosis
Your doctor will ask about your medical history and about symptoms that might
suggest a cause for the irregular bleeding or other hormonal abnormalities. The
doctor may do various tests to check for these causes of abnormal bleeding
patterns:

Pregnancy Urine or blood tests

Thyroid hormone and prolactin hormone abnormalities Blood tests
Menopause (especially in women in their 40s or 50s) Blood tests to

determine if estrogen levels are falling, which suggests the beginning stages
of menopause
Abnormalities of the uterus or ovaries A transvaginal ultrasound, in which a
small, rodlike probe is inserted into the vagina to take measurements of the
endometrial lining
Possible cancer in women over 35; or those who have had breast, ovarian or
colon cancer; or who have a strong family history of these cancers; or who
have not had a period in six months An endometrial biopsy, done in the
office, in which the doctor uses a speculum to look at the cervix, then inserts
a thin, straw-like tube through the cervix into the uterus, and brushes it
along the endometrial layer to collect a tissue sample

If you have heavy bleeding, your doctor will check iron levels in your blood to see if
you are anemic.

Expected Duration
Most women have a period that is irregular in timing or in the amount of bleeding
at some point during their menstrual years, most often because of a cycle without
a normal ovulation. Normal periods may resume as early as the next period or
might take a few months to become regular again. Some women become regular
only with the help of treatments, such as birth control pills. If irregular periods
signal the beginning of menopause, the last period may not occur for a few months
or a few years.

Prevention

There is no way to prevent dysfunctional uterine bleeding. See a doctor promptly if

you continue to have irregular periods. Early diagnosis and treatment can help to
make your periods regular again, which is important for your overall health.

Treatment
If the cause of dysfunctional uterine bleeding is another medical condition, treating
that condition should restore normal cycles. Otherwise, treatment is based on the
cause, the amount of bleeding and the woman's reproductive goals (whether she
wants to have children or not).
Birth control pills, which combine the hormones estrogen and progesterone, can
regulate and decrease the amount of bleeding. Your doctor may recommend that
you take monthly pills containing progesterone only. Women seeking to become
pregnant may be treated with medications to help their ovaries ovulate more
regularly.
Heavy bleeding can be stopped with higher doses of hormone pills either
estrogen or progesterone. When bleeding is more severe, hospitalization may be
necessary. If hormonal therapy does not work, a surgical D and C (dilation and
curettage) can stop severe cases of bleeding. During this procedure, the tissue
lining of the uterus is removed, allowing a healthier lining to take its place.
If an endometrial biopsy reveals endometrial hyperplasia, which is a thicker and
abnormal looking hormone-stimulated lining , closer monitoring with treatment
may be required, especially in older women and postmenopausal women on
hormone replacement therapy. Endometrial hyperplasia increases a woman's risk of
developing endometrial cancer.

When To Call A Professional

Call your doctor right away for an evaluation if you are having fevers, abdominal
pain or heavy bleeding with dizziness or fainting.
If your periods are irregular over a few months, make an appointment to see your
doctor. Be prepared to tell your doctor the dates of your last few periods.

Prognosis
There are many effective treatments to help regulate periods and control irregular
bleeding. If you have irregular periods and are having difficulty becoming pregnant,
you can take drugs that stimulate ovulation. Having irregular periods, however,
does not mean you are infertile. You still need to use protection against pregnancy
when you are sexually active.

Additional Info
www.intelihealth.com

Dysfunctional uterine bleeding (DUB)

Definition:
Dysfunctional uterine bleeding (DUB) is abnormal vaginal bleeding that occurs during a
menstrual cycle that produced no egg (ovulation did not take place).

Alternative Names:
Anovulatory bleeding; Bleeding - dysfunctional uterine; DUB

Causes, incidence, and risk factors:

Anovulatory or dysfunctional uterine bleeding is a diagnosis of exclusion. This means that
it is determined only AFTER other causes of abnormal uterine bleeding -- such as
systemic diseases, medications, early pregnancy disorders, eating disorders,
gynecological infections, structural anomalies, or tumors -- have been ruled out.
Anovulatory cycles are common for the first year after menarche (when a girl begins to
menstruate), and later in life as a woman approaches menopause (when menstrual
periods stop). Approximately 20% of cases occur in adolescents and 40% in women over
40. Obesity, excessive exercise, and emotional stress may be risk factors for DUB.

Symptoms:

Vaginal bleeding between periods

Abnormal menstrual periods
Variable menstrual cycles (usually less than 28 days between menstrual periods)
Variable menstrual flow ranging from scanty to profuse
Infertility
Mood swings
Hot flashes
Vaginal tenderness
Hirsuitism -- excessive growth of body hair in a male pattern

Signs and tests:

A pelvic examination will be performed.
Tests to evaluate women with DUB usually include:

CBC
Serum HCG (to rule out pregnancy)
Thyroid function tests specific hormonal regulation tests
o Prolactin
o Androgen levels
o FSH (follicle-stimulating hormone)
o LH (luteinizing hormone)

Diagnostic procedures that may be performed include:

Endometrial biopsy
D and C (dilatation and curettage)

Pelvic ultrasound
Hysteroscopy

Treatment:
Young women within several years of menarche (the first menstrual period) are not
treated unless symptoms are exceptionally severe, such as heavy blood loss causing
anemia.
In women of childbearing age, treatment is aimed at achieving regular menstrual cycles
with normal patterns. Oral contraceptives or progestogen therapy are frequently used for
this purpose. If anemia is present, iron supplementation may be recommended. If
pregnancy is desired, ovulation induction may be attempted with medication.
Women whose symptoms are severe and resistant to medical therapy may choose
surgical treatments including endometrial ablation (a procedure that burns or removes the
lining of the uterus) or hysterectomy.
In older women who may be approaching menopause, treatment may be elected to offset
symptoms. Women may choose from treatments such as hormone supplementation or
surgery.

Expectations (prognosis):
Hormonal regulation is usually successful in alleviating symptoms. Induced ovulation, in
women desiring pregnancy, is successful in approximately 80% of cases.

Complications:

Infertility resulting from lack of ovulation

Severe anemia as a result of prolonged or heavy menstrual bleeding
Prolonged buildup of the uterine lining without adequate menstrual bleeding (a
possible factor in the development of endometrial cancer)

www.umc-cares.org