Dysfunctional Uterine Bleeding (DUB) is abnormal bleeding from the vagina or genital tract that is usually due to changes in hormone levels. It is bleeding that is NOT caused by: Pregnancy or miscarriage. Medical conditions, such as cancer or fibroids. Problems with the uterus or vagina from infection or other causes. Dysfunctional uterine bleeding (DUB), the most common cause of abnormal uterine bleeding, occurs most often in women > 45 (> 50% of cases) and in adolescents (20% of cases). About 90% of cases are anovulatory; 10% are ovulatory.
Key Points
1. Anovulatory DUB is the most common cause of abnormal uterine bleeding.
3. Dysfunctional uterine bleeding (DUB) occurs most often before age 20 and after age 40.
3. Test for treatable causes of bleeding; tests may include a pregnancy test, CBC, measurement of hormone levels (TSH, prolactin, progesterone), and often ultrasonography and endometrial sampling.
4. In women at risk, check for and treat endometrial hyperplasia.
5. If drugs are needed to control bleeding, prescribe NSAIDs, tranexamic acid, OCs, or other hormones, which are usually effective.
Related Article
- Menstrual Cycle
- Antepartum Haemorrhage (APH)
- 13 Cancer Symptoms Women Shouldn't Ignore
Pathophysiology
During an anovulatory cycle, the corpus luteum does not form. Thus, the normal cyclical secretion of progesterone does not occur, and estrogen stimulates the endometrium unopposed. Without progesterone, the endometrium continues to proliferate, eventually outgrowing its blood supply; it then sloughs incompletely and bleeds irregularly, and sometimes profusely or for a long time. When this abnormal process occurs repeatedly, the endometrium can become hyperplastic, sometimes with atypical or cancerous cells.
In ovulatory DUB, progesterone secretion is prolonged; irregular shedding of the endometrium results, probably because estrogen levels remain low, near the threshold for bleeding (as occurs during menses). In obese women, ovulatory DUB can occur if estrogen levels are high, resulting in amenorrhea alternating with irregular or prolonged bleeding.
Symptoms
Symptoms of dysfunctional uterine bleeding (DUB) include :
1. Vaginal bleeding that occurs more often than every 21 days or farther apart than 35 days (a normal teen menstrual cycle can last up to 45 days).
2. Vaginal bleeding that lasts longer than 7 days (normally lasts 4 to 6 days).
3. Blood loss of more than 80 mL (3 fl oz) each menstrual cycle [normally about 30 mL (1 fl oz)]. If you are passing blood clots and soaking through your usual pads or tampons each hour for 2 or more hours, your bleeding is considered severe.
4. Occur frequently and irregularly between menses (metrorrhagia)
Most menstrual blood is lost in the first 3 days of the period. So excessive blood loss is possible without having exceptionally long periods.
Diagnosis
A. Laboratory studies :
Studies used to exclude a pathologic source of anovulatory bleeding include the following:
1. Human chorionic gonadotropin (HCG)
2. Complete blood count (CBC)
3. Papanicolaou test (Pap smear)
4. Endometrial sampling
5. Thyroid functions and prolactin
6. Liver functions
7. Coagulation studies/factors
8. Other hormone assays, as indicated
B. Imaging studies :
In obese patients with a suboptimal pelvic examination or in patients with suspected ovarian or uterine pathology, pelvic ultrasonographic evaluation may be helpful. Ultrasonography can be used to identify uterine fibroids, as well as endometrial conditions, including hyperplasia, carcinoma, and polyps.
C. Histology :
Most endometrial biopsy specimens will show proliferative or dyssynchronous endometrium.
Treatment
1. Control of bleeding by :
- Nonhormonal treatments : NSAIDs, Tranexamic acid
- Hormone therapy : Oral contraceptives (OCs), Progestins or progesterone
2. Hysteroscopy with D & C may be therapeutic as well as diagnostic; it may be the treatment of choice when anovulatory bleeding is severe or when hormone therapy is ineffective.
3. Endometrial ablation (eg, laser, rollerball, resectoscopic, thermal, or freezing)
2. In women with endometrial hyperplasia, prevention of endometrial cancer
References
1. MSD Manual : Professional Version
http://www.msdmanuals.com/professional/gynecology-and-obstetrics/menstrual-abnormalities/dysfunctional-uterine-bleeding-dub
2. EMedicine Health
http://www.emedicinehealth.com/dysfunctional_uterine_bleeding-health/page3_em.htm
3. MedScape
http://emedicine.medscape.com/article/257007-overview
Related Article
- Menstrual Cycle
- Antepartum Haemorrhage (APH)
- 13 Cancer Symptoms Women Shouldn't Ignore
Key Points
1. Anovulatory DUB is the most common cause of abnormal uterine bleeding.
3. Dysfunctional uterine bleeding (DUB) occurs most often before age 20 and after age 40.
3. Test for treatable causes of bleeding; tests may include a pregnancy test, CBC, measurement of hormone levels (TSH, prolactin, progesterone), and often ultrasonography and endometrial sampling.
4. In women at risk, check for and treat endometrial hyperplasia.
5. If drugs are needed to control bleeding, prescribe NSAIDs, tranexamic acid, OCs, or other hormones, which are usually effective.
Related Article
- Menstrual Cycle
- Antepartum Haemorrhage (APH)
- 13 Cancer Symptoms Women Shouldn't Ignore
Pathophysiology
During an anovulatory cycle, the corpus luteum does not form. Thus, the normal cyclical secretion of progesterone does not occur, and estrogen stimulates the endometrium unopposed. Without progesterone, the endometrium continues to proliferate, eventually outgrowing its blood supply; it then sloughs incompletely and bleeds irregularly, and sometimes profusely or for a long time. When this abnormal process occurs repeatedly, the endometrium can become hyperplastic, sometimes with atypical or cancerous cells.
In ovulatory DUB, progesterone secretion is prolonged; irregular shedding of the endometrium results, probably because estrogen levels remain low, near the threshold for bleeding (as occurs during menses). In obese women, ovulatory DUB can occur if estrogen levels are high, resulting in amenorrhea alternating with irregular or prolonged bleeding.
Symptoms
Symptoms of dysfunctional uterine bleeding (DUB) include :
1. Vaginal bleeding that occurs more often than every 21 days or farther apart than 35 days (a normal teen menstrual cycle can last up to 45 days).
2. Vaginal bleeding that lasts longer than 7 days (normally lasts 4 to 6 days).
3. Blood loss of more than 80 mL (3 fl oz) each menstrual cycle [normally about 30 mL (1 fl oz)]. If you are passing blood clots and soaking through your usual pads or tampons each hour for 2 or more hours, your bleeding is considered severe.
4. Occur frequently and irregularly between menses (metrorrhagia)
Most menstrual blood is lost in the first 3 days of the period. So excessive blood loss is possible without having exceptionally long periods.
Diagnosis
A. Laboratory studies :
Studies used to exclude a pathologic source of anovulatory bleeding include the following:
1. Human chorionic gonadotropin (HCG)
2. Complete blood count (CBC)
3. Papanicolaou test (Pap smear)
4. Endometrial sampling
5. Thyroid functions and prolactin
6. Liver functions
7. Coagulation studies/factors
8. Other hormone assays, as indicated
B. Imaging studies :
In obese patients with a suboptimal pelvic examination or in patients with suspected ovarian or uterine pathology, pelvic ultrasonographic evaluation may be helpful. Ultrasonography can be used to identify uterine fibroids, as well as endometrial conditions, including hyperplasia, carcinoma, and polyps.
C. Histology :
Most endometrial biopsy specimens will show proliferative or dyssynchronous endometrium.
Treatment
1. Control of bleeding by :
- Nonhormonal treatments : NSAIDs, Tranexamic acid
- Hormone therapy : Oral contraceptives (OCs), Progestins or progesterone
2. Hysteroscopy with D & C may be therapeutic as well as diagnostic; it may be the treatment of choice when anovulatory bleeding is severe or when hormone therapy is ineffective.
3. Endometrial ablation (eg, laser, rollerball, resectoscopic, thermal, or freezing)
2. In women with endometrial hyperplasia, prevention of endometrial cancer
References
1. MSD Manual : Professional Version
http://www.msdmanuals.com/professional/gynecology-and-obstetrics/menstrual-abnormalities/dysfunctional-uterine-bleeding-dub
2. EMedicine Health
http://www.emedicinehealth.com/dysfunctional_uterine_bleeding-health/page3_em.htm
3. MedScape
http://emedicine.medscape.com/article/257007-overview
Related Article
- Menstrual Cycle
- Antepartum Haemorrhage (APH)
- 13 Cancer Symptoms Women Shouldn't Ignore
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