Overview

Dysfunctional uterine bleeding (DUB) is heavy or irregular menstrual bleeding that is not
caused by an underlying anatomical abnormality, such as a fibroid, lesion, or tumor.
DUB is the most common type of abnormal uterine bleeding.
Most cases of DUB are associated with anovulatory bleeding (menstruation that occurs
without ovulation). Anovulatory bleeding is common in women who have ust started
menstruating and during the several years preceding menopause. !hen ovulation does
not occur, the level of estrogen and progesterone in the uterus is disturbed, leading to
DUB. Anovulation, however, does not always lead to DUB and there are other causes
as well. !omen with ovulatory cycles (cycles that involve ovulation) may also
e"perience DUB.
Menstrual cycles vary in duration, fre#uency, and intensity, ma$ing abnormalities difficult
to determine. !omen who have DUB may e"perience a variety of patterns of bleeding.
A woman who bleeds for longer than a wee$, bleeds more than every % wee$s or so,
bleeds between periods, or bleeds e"cessively should see a doctor or other health care
provider.
DUB is usually painless. Diagnosis involves ruling out other causes of abnormal
bleeding. &reatment depends on the intensity and timing of the bleeding, the patient's
age, and if she is trying to conceive.
DUB and Anovulation
Anatomy of the endometrium
&he endometrium is the mucous surface that lines the inside of the uterus. (t is
responsive to hormonal changes and contains several layers of cells that vary in
appearance and number throughout the menstrual cycle. During the luteal phase (i.e., )
wee$s prior to menstruation), the endometrium is thic$, its epithelial cells and glands are
enlarged, and the arteries are swollen. At menstruation, the endometrium sheds.
*ollowing menstruation, the endometrium regenerates.
The normal menstrual cycle
Menstruation is triggered by a sudden decrease in progesterone and estrogen
secretions. &he menstrual flow is made up of endometrial cells and tissue, blood, and
cervical and vaginal mucus and cells.
After menstruation, the increased secretion of estrogen causes cellular growth and the
regeneration of the endometrium. &his first half of the menstrual cycle is $nown as the
follicular phase.
+vulation (the release of an egg from the ovary) normally occurs ) wee$s after the first
day of the last menstrual cycle. After ovulation, the secretion of progesterone stops the
growth of the endometrium, balancing out the effects of the estrogen. (f conception does
not occur, progesterone production declines, and menstrual bleeding begins again.
Anovulatory bleeding
,ormally during the menstrual cycle, the production of progesterone in the latter )
wee$s of the cycle balances out the regenerative effects of estrogen, halting further
endometrial growth. (n anovulation, the level of estrogen does not decline, and
progesterone is not secreted to balance out the effects of estrogen.
-ndometrial growth does not stop and the endometrial tissue accumulates and thic$ens,
resulting in abnormally heavy bleeding. Also, without progesterone, the endometrium
lac$s structural support and sloughs off irregularly, causing heavy and.or irregular
periods.
Anovulatory periods are common in the ) or % years following menarche (first menstrual
period) and during the several years preceding menopause. Up to /01 of menstrual
cycles are anovulatory during the first year following menarche. As a woman
approaches menopause, she may have / to 20 anovulatory periods a year.
!omen who ta$e oral contraceptives and those on estrogen replacement therapy may
also have anovulatory cycles. 3tress and illness can also trigger anovulation.
Causes
+vulatory DUB (not associated with anovulation) is less common than anovulatory DUB,
and the bleeding, though abnormally heavy, is usually regular.
+vulatory DUB may be due to abnormalities in the )4wee$ luteal phase of menstruation
that occurs ust before bleeding begins. (t can also result from an 5atrophic
endometrium5 that can result from a high progesterone to estrogen ratio, which may
occur in women who ta$e progesterone4only contraceptives. A lac$ of cell4building
estrogen causes the endometrium to slough off and bleed irregularly.
Patterns of abnormal uterine bleeding
DUB can result in the following menstrual patterns6
polymenorrhea (fre#uent, regular periods that occur less than every )2 days)
hypermenorrhea (e"cessively heavy bleeding during a normal4length period)
menorrhagia (prolonged or e"cessive bleeding lasting longer than a wee$ that
occurs at regular intervals)
metrorrhagia (periods that occur at irregular intervals, or fre#uent bleeding of
various amounts,though not heavy)
menometrorrhagia (fre#uent, e"cessive, and prolonged bleeding that occurs at
irregular intervals)
Other types of abnormal uterine bleeding
Most abnormally heavy uterine bleeding has no underlying anatomical cause and is
considered DUB. &here are, however, underlying conditions that may cause similar
symptoms. Diagnosing DUB involves ruling out other conditions, including the following6
uterine lesions (e.g., fibroids, polyps, cancer)
damage from an intrauterine contraceptive device (IUD)
pelvic inflammatory disease (bacterial infection of the uterus,
fallopian tubes, and other areas of the pelvis)
adenomyosis (benign growth of the endometrium into the
underlying muscular layer of the uterus)
ectopic pregancy (pregnancy that occurs outside of the uterus)
hydatid mole (abnormal mass in the uterus caused by a poorly
developed or degenerating fertilized egg)
uterine leiomyoma (benign, fibrous tumor that occurs in up to
4! of women by age 4)
endometritis (inflammation of the endometrium caused by a
bacterial infection)
trauma and se"ual abuse
medications
foreign bodies (e.g., tampon, condom)
Diagnosis
Diagnosis typically involves a medical history, physical and pelvic e"amination,
laboratory tests, and sometimes imaging tests. In women over age #$, a
biopsy (removal of a small sample of tissue for microscopic e"amination) or a
D % & (dilation and curretage) is performed to rule out endometrial hyperplasia
or cancer.
Medical history
'he medical history involves gathering detailed information about the
menstrual pattern. (or most women, the interval between, the duration of, and
the amount of menstrual flow stay relatively constant through the reproductive
years. It may be helpful to )eep a *menstrual diary* for several months
preceding the office visit to monitor differences in the normal menstrual
pattern.
+ther helpful information includes a list of medications and nonprescription
drugs, a se"ual history (including pregnancy and contraception information),
symptoms of infection and disease (including gynecologic disorders), recent
surgery, and a history of in,ury to the area.
-eight loss, eating disorders, stress, and e"cessive e"ercise can cause
anovulation, leading to DU., so the medical history should involve these
aspects of the woman/s lifestyle.
Physical and pelvic eaminations
'he physical e"amination focuses on medical conditions that may cause DU..
'he doctor e"amines the thyroid, breasts, liver, and s)in for ecchymotic lesions
(large, irregular, discolored areas of the s)in) and hirsutism (e"cessive hair
growth in unusual places). +besity may also be a factor.
'he pelvic e"amination involves evaluating the e"ternal and internal organs to
identify the source and degree of bleeding, determine the size and shape of
the uterus, and detect abnormalities.
!aboratory tests
0aboratory tests include a pregnancy test (for women who may be pregnant),
a complete blood count, and 1ap smear. +ther tests may also be done,
depending on the circumstances and the differential diagnosis.
"maging tests
2ome women re3uire a pelvic or transvaginal ultrasound. Ultrasound produces
an image of the endometrium that may ma)e it easier to diagnose certain
conditions, such as leiomyomas (benign, fibrous tumors that occur in 4! of
women by age of 4 and may cause abnormal bleeding).
Diagnosis may involve a new techni3ue )nown as a sonohysterography, which
involves in,ecting a saline solution into the uterine cavity while the transvaginal
ultrasound is performed. 2aline enhances the ultrasound pictures by acting as
a contrast medium, ma)ing abnormal structures more visible, and opens up
the uterus and separates the uterine walls, ma)ing the endometrium easier to
see.
#omen over age $%
In women older than #$, the endometrial cells are e"amined under a
microscope to rule out endometrial hyperplasia and cancer. 'his is usually
done using endometrial biopsy, an outpatient procedure that involves inserting
a narrow tube into the uterus through the vagina and suctioning out a small
amount of tissue from several areas of the uterine wall. 'he procedure ta)es
only minutes.
4ndometrial biopsy is the most widely used and most effective diagnostic test
for detecting precancerous and cancerous cells on the endometrium. 5
procedure )nown as a D % & (dilation and curettage) may be used in certain
circumstances and involves dilating the cervi" and inserting an instrument
called a curette into the uterus through the vagina. 'he curette is used to
scrape the uterine wall and collect tissue. It is an outpatient procedure that
ta)es about an hour and re3uires anesthesia.
'he tissue is sent to a laboratory, e"amined under a microscope, and
evaluated for cancerous or precancerous abnormalities. 1lease go to
endometrial cancer for more information.
If the biopsy or D % & reveals no abnormality, the patient is treated for DU.,
usually with hormones.
Treatment
DUB is usually painless and is generally not a problem unless the woman is upset by
the bleeding or is trying to conceive.
7ormone therapy typically involves oral contraceptives or progesterone therapy to
regulate bleeding patterns. &reatment depends on the patient8s age and the severity and
timing of the bleeding.
Removal of the endometrium
(f hormone therapy is not effective, the endometrium may be removed. -ndometrial
ablation is usually the method of choice, although some patients choose a hysterectomy
or D 9 :.
Endometrial ablation
-ndometrial ablation is the removal or destruction of the entire endometrium as well as a
superficial layer of the underlying smooth muscle (myometrium). &he procedure may be
done using a laser (e.g., ,d6;A< laser), a thermal balloon, a hysteroscope, or a
resectoscope.
-ndometrial ablation is about /01 successful in reducing heavy periods and may
eliminate menstruation altogether. Advantages of the procedure over hysterectomy
include6
it is safer, less invasive, and does not re#uire a surgical incision
it is less e"pensive
it re#uires a shorter hospital stay
women can resume normal activity within days, compared to = to > wee$s
Thermal balloon
'he thermal balloon procedure involves inserting a balloon into the uterine
cavity, filling the balloon with fluid, and heating the fluid to destroy
endometrial tissue.
Hysteroscopy
5 hysteroscope is a thin, telescopic instrument that is inserted through the
cervi" into the uterus. 'he instrument has a camera and a light attached so
the inside of the uterus can be viewed on a screen. -hen an endoscope is used
to view the inside of the uterus, the procedure is called a diagnostic
hysteroscopy. 5n operative hysteroscopy involves using a hysteroscope with
surgical instruments attached to cut and remove tissue.
Resectoscopy
6esectoscopy involves using hysteroscope with a wire loop attached. 'he wire
carries an electric current to cut and coagulate (solidify) the endometrial
tissue. 'his procedure is also )nown as electrocoagulation.
Hysterectomy
7ysterectomy involves removing the uterus. 7ysterectomies include subtotal
hysterectomy (removal of the uterus, but not the cervi") and total
hysterectomy (removal of the uterus and the cervi"). 'he procedure can be
performed through the vagina, through an incision in the abdomen, or
laparoscopically (through a small incision in the abdomen).
D & C
D % & (dilation and curettage) involves dilating the cervi" and inserting an
instrument called a curette into the uterus through the vagina. 'he curette is
used to scrape the uterine wall and collect tissue. 'he long8term benefits of
this procedure are unclear, and it is often performed in con,unction with
hysteroscopy.