Dysfunctional uterine bleeding (DUB)

Definition

Dysfunctional uterine bleeding (DUB) is abnormal bleeding from the vagina that is due to changes in hormone levels.

Alternative Names

Anovulatory bleeding; Bleeding - dysfunctional uterine; DUB; Abnormal uterine bleeding; Abnormal vaginal bleeding; Menorrhagia - dysfunctional; Polymenorrhea - dysfunctional; Metrorrhagia - dysfunctional

Causes, incidence, and risk factors

The menstrual cycle, or period, is not the same for every woman. On average, menstrual flow occurs every 28 days (most women have cycles between 24 and 34 days apart), and lasts 4 - 7 days.

The menstrual cycle of young girls who are just starting to have their periods can range from 21 to 45 days or more apart. Women in their 40s will often notice their menstrual cycles occurring less often.

During a normal menstrual cycle, levels of different female hormones made by your body go up and down. Estrogen and progesterone are two very important hormones.

Ovulation is the part of the normal menstrual cycle when an egg is released from the ovaries. The most common cause of dysfunctional uterine bleeding is when your ovaries do not release an egg. When this occurs, the hormone levels in your body are not the same, causing your period to be later or earlier and heavier than normal.

Other changes in hormones may also cause changes in your period.

See also: Menstrual periods - heavy, prolonged or irregular for information on other causes of vaginal bleeding.

Symptoms

A woman with dysfunctional uterine bleeding may notice the following changes in her menstrual cycle:

• Bleeding or spotting from the vagina occurs between periods
• Menstrual periods may be less than 28 days (more common) or more than 35 days apart
• Time between menstrual periods changes with each cycle
• Bleeding is heavier (passing large clots, needing to change protection during the night, soaking through a sanitary pad or tampon every hour for 2 - 3 hours in a row)
• Bleeding lasts for more days than normal or for more than 7 days

Other symptoms caused by changes in hormone levels are:

• Excessive growth of body hair in a male pattern (hirsutism)
• Hot flashes
• Mood swings
• Tenderness and dryness of the vagina

A woman may feel tiredness or fatigue if she is losing too much blood over time and becomes anemic.

Signs and tests

The health care provider will do a pelvic examination.

Lab tests may include:

• CBC
• Blood clotting profile
• Hormone tests
  • FSH
  • LH
  • Male hormone (androgen) levels
  • Prolactin
  • Progesterone
• Serum or urine HCG (to rule out pregnancy)
• Thyroid function tests
• Culture to look for infection

The following procedures may be done:

• Endometrial biopsy may be done to look for infection, precancer, or cancer, or to help decide on hormone treatment.
• Hysteroscopy is an office procedure in which the doctor inserts a flexible tube with a light and a tiny camera on the end into the uterus through the vagina.
• Transvaginal ultrasound may be done to look for abnormalities in the uterus or pelvis.

Treatment

Young women within a few years of their first period are often not treated unless symptoms are very severe, such as heavy blood loss causing anemia.

In other women, the goal of treatment is to control the menstrual cycle.

• Oral birth control pills or progesterone only pills are often used
• An intrauterine device (IUD) that releases the hormone progestin can be very helpful for heavy bleeding and pain

The health care provider may recommend iron supplements for women with anemia.

If you want to get pregnant, you may be given medication to stimulate ovulation.

Women whose symptoms are severe and do not respond to medical therapy may need surgical treatments including:

• Endometrial ablation or resection - destroying (cauterizing) or removing the lning of the uterus will often stop or reduce the amount of menstrual bleeding
• Hysterectomy - performed less often than in the past
• D and C - for diagnosis and to remove polyps

Expectations (prognosis)

Hormone therapy usually relieves symptoms. As long as there is no problem with anemia (low blood count), no treatment is needed.

Complications

• Infertility from lack of ovulation
• Severe anemia from prolonged or heavy menstrual bleeding
• Buildup of the uterine lining without enough menstrual bleeding (a possible factor in the development of endometrial cancer)

Calling your health care provider

Call your health care provider if you have unusual vaginal bleeding.

References

Lobo RA. Abnormal uterine bleeding: Ovulatory and anovulatory dysfunctional uterine bleeding, management of acute and chronic excessive bleeding. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed. Philadelphia, Pa: Mosby Elsevier;2007:chap 37.

Kaunitz AM, Meredith S, Inki P, Kubba A, Sanchez-Ramos L. Levonorgestrel-releasing intrauterine system and endometrial ablation in heavy menstrual bleeding: a systematic review and meta-analysis. Obstet Gynecol. 2009;113:1104-1116.

Casablanca Y. Management of dysfunctional uterine bleeding. Obstet Gynecol Clin North Am. 2008;35:219-234.

Damlo S. ACOG guidelines on endometrial ablation. Am Fam Physician. 2008;77:545-549.