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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
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
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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.
Menstrual regularity
Contraceptive use
Hypertension
Hypothyroidism, hyperthyroidism
Liver disease
hysical:
Initial evaluation should be directed at assessing patient's volume status and degree of anemia. Examine for
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
Foreign body
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.
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,
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
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Section 4 of 10
varian Cysts
varian Torsion
elvic Inflammatory Disease
regnancy, Ectopic
regnancy, Postpartum Hemorrhage
regnancy, Trauma
hock, Hemorrhagic
hock, Hypovolemic
hrombocytopenic Purpura
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.
Obese patients
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
TREATMENT
uthor Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography
Hemodynamic instability
o
o
o
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
o
o
o
o
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
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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
Adult Dose
Pediatric Dose
Contraindications
Interactions
Pregnancy
X - Contraindicated in pregnancy
Precautions
Drug Name
Adult Dose
Pediatric Dose
Contraindications
Not recommended
dysfunction
Interactions
Pregnancy
X - Contraindicated in pregnancy
Precautions
rug Category: Nonsteroidal anti-inflammatory drugs (NSAIDS) -- These agents can decrease DUB throug
Drug Name
Adult Dose
Pediatric Dose
Contraindications
Interactions
Pregnancy
Precautions
FOLLOW-UP
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All patients with abnormal vaginal bleeding who are discharged from the ED receive follow-up from their fam
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
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.
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
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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
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.
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
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.
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
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.
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
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
RR = 2 to 14
RR= 0.5 to 1
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.
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
Comments
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:
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.
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.
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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:
Stress or illness
The start of menstruation in adolescence Regular ovulatory cycles may not
develop for a few months or even years.
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:
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
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.
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
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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
Symptoms:
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)
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:
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