Dysfunctional Uterine Bleeding Treatment & Management

  • Author: Millie A Behera, MD; Chief Editor: Richard Scott Lucidi, MD   more...
 
Updated: Jun 16, 2011
 

Medical Care

Options for medical care of dysfunctional uterine bleeding are as follows.

  • Oral contraceptives
    • Oral contraceptive pills (OCPs) suppress endometrial development, reestablish predictable bleeding patterns, decrease menstrual flow, and lower the risk of iron deficiency anemia.
    • OCPs can be used effectively in a cyclic or continuous regimen to control dysfunctional bleeding.
    • Acute episodes of heavy bleeding suggest an environment of prolonged estrogenic exposure and buildup of the lining.
    • Bleeding usually is controlled within the first 24 hours, as the overgrown endometrium becomes pseudodecidualized. Seek alternate diagnosis if flow fails to abate in 24 hours.
    • The type of OCP and underlying patient factors may be important determinants of potential risk for complications associated with OCPs. Studies have shown an increased risk of nonfatal venous thromboembolic events (blood clots) associated with contraceptives that contain drospirenone as compared with those that contain levonorgestrel.[2]
  • Estrogen
    • Estrogen alone, in high doses, is indicated in certain clinical situations.
    • Prolonged uterine bleeding suggests the epithelial lining of the cavity has become denuded over time. In this setting, a progestin is unlikely to control bleeding. Estrogen alone will induce return to normal endometrial growth rapidly.
    • Hemorrhagic uterine bleeding requires high-dose estrogen therapy. If bleeding is not controlled within 12-24 hours, a D&C is indicated.
    • Beginning progestin therapy shortly after initiating estrogen therapy to prevent a subsequent bleeding episode from treatment with prolonged unopposed estrogen is wise.
  • Progestins
    • Chronic management of DUB requires episodic or continuous exposure to a progestin. In patients without contraindications, this is best accomplished with an oral contraceptive given the many additional benefits, including decreased dysmenorrhea, decreased blood loss, ovarian cancer prophylaxis, and decreased androgens.
    • In patients with a pill contraindication, cyclic progestin for 12 days per month using medroxyprogesterone acetate (10 mg/d) or norethindrone acetate (2.5-5 mg/d) provides predictable uterine withdrawal bleeding, but not contraception. Cyclic natural progesterone (200 mg/d) may be used in women susceptible to pregnancy, but may cause more drowsiness and does not decrease blood loss as much as a progestin.
    • In some women, including those who are unable to tolerate systemic progestins/progesterone or those who have contraindications to estrogen-containing agents, a progestin-secreting IUD may be considered that controls the endometrium via a local release of levonorgestrel, avoiding elevated systemic levels.[3]
  • On rare occasions, a young patient with anovulatory bleeding also might have a bleeding disorder. Desmopressin, a synthetic analog of arginine vasopressin, has been used as a last resort to treat abnormal uterine bleeding in patients with documented coagulation disorders. Treatment is followed by a rapid increase in von Willebrand factor and factor VIII, which lasts about 6 hours.
Next

Surgical Care

Most cases of DUB can be treated medically. Surgical measures are reserved for situations when medical therapy has failed or is contraindicated.

  • D&C is an appropriate diagnostic step in a patient who fails to respond to hormonal management.
    • The addition of hysteroscopy will aid in the treatment of endometrial polyps or the performance of directed uterine biopsies.
    • As a rule, apply D&C rarely for therapeutic use in DUB because it has not been shown to be very efficacious.
  • Abdominal or vaginal hysterectomy might be necessary in patients who have failed or declined hormonal therapy, have symptomatic anemia, and who experience a disruption in their quality of life from persistent, unscheduled bleeding.
  • Endometrial ablation is an alternative for those who wish to avoid hysterectomy or who are not candidates for major surgery.
    • Ablation techniques are varied and can employ laser, rollerball, resectoscope, or thermal destructive modalities. Most of these procedures are associated with high patient satisfaction rates.
    • Pretreat the patient with an agent, such as leuprolide acetate, medroxyprogesterone acetate, or danazol, to thin the endometrium.
    • The ablation procedure is more conservative than hysterectomy and has a shorter recovery time.
    • Some patients may have persistent bleeding and require repeat procedures or move on to hysterectomy. Rebleeding following ablation has raised concern about the possibility of an occult endometrial cancer developing within a pocket of active endometrium. Few reported cases exist, but further studies are needed to quantify this risk.
    • Endometrial ablation is not a form of contraception. Some studies report up to a 5% pregnancy rate in postablation procedures.
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Contributor Information and Disclosures
Author

Millie A Behera, MD  Assistant Professor, Adjunct, Division of Reproductive Endocrinology and Fertility, Department of Obstetrics and Gynecology, Duke University Medical Center; Associate Medical Director, Fertility Treatment Center, Scottsdale

Millie A Behera, MD is a member of the following medical societies: American Association of Gynecologic Laparoscopists, American College of Obstetricians and Gynecologists, and American Society for Reproductive Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Thomas Michael Price, MD  Associate Professor of Reproductive Endocrinology, Director of Reproductive Fellowship Training Program, Duke University Medical Center

Thomas Michael Price, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, Phi Beta Kappa, and Society for Gynecologic Investigation

Disclosure: Clinical Advisors Group Consulting fee Consulting; MEDA Corp Consulting Consulting fee Consulting; Gerson Lehrman Group Advisor Consulting fee Consulting; Roche/GSK Spokesperson Consulting fee Consulting; Adiana Grant/research funds PI

Specialty Editor Board

Anthony Charles Sciscione, DO  Professor, Department of Obstetrics and Gynecology, Drexel University College of Medicine; Director, Maternal and Fetal Medicine, Christiana Care Health System; Director, Delaware Center for Maternal and Fetal Medicine

Anthony Charles Sciscione, DO is a member of the following medical societies: American College of Obstetricians and Gynecologists and American Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

A David Barnes, MD, PhD, MPH, FACOG  Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, California), Pioneer Valley Hospital (Salt Lake City, Utah), Warren General Hospital (Warren, Pennsylvania), and Mountain West Hospital (Tooele, Utah)

A David Barnes, MD, PhD, MPH, FACOG is a member of the following medical societies: American College of Forensic Examiners, American College of Obstetricians and Gynecologists, American Medical Association, Association of Military Surgeons of the US, and Utah Medical Association

Disclosure: Nothing to disclose.

Frederick B Gaupp, MD  Consulting Staff, Department of Family Practice, Hancock Medical Center

Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians

Disclosure: Nothing to disclose.

Chief Editor

Richard Scott Lucidi, MD  Associate Professor of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine

Richard Scott Lucidi, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists and American Society for Reproductive Medicine

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author John T Queenan, Jr, MD to the development and writing of this article.

References

  1. [Guideline] James AH, Kouides PA, Abdul-Kadir R, Edlund M, Federici AB, Halimeh S, et al. Von Willebrand disease and other bleeding disorders in women: Consensus on diagnosis and management from an international expert panel. Am J Obstet Gynecol. May 28 2009;[Medline].

  2. Jick SS, Hernandez RK. Risk of non-fatal venous thromboembolism in women using oral contraceptives containing drospirenone compared with women using oral contraceptives containing levonorgestrel: case-control study using United States claims data. BMJ. Apr 21 2011;342:d2151. [Medline]. [Full Text].

  3. Teichmann A, Apter D, Emerich J, Greven K, Klasa-Mazurkiewicz D, Melis GB, et al. Continuous, daily levonorgestrel/ethinyl estradiol vs. 21-day, cyclic levonorgestrel/ethinyl estradiol: efficacy, safety and bleeding in a randomized, open-label trial. Contraception. Dec 2009;80(6):504-11. [Medline].

  4. Ash SJ, Farrell SA, Flowerdew G. Endometrial biopsy in DUB. J Reprod Med. Dec 1996;41(12):892-6. [Medline].

  5. Bayer SR, DeCherney AH. Clinical manifestations and treatment of dysfunctional uterine bleeding. JAMA. Apr 14 1993;269(14):1823-8. [Medline].

  6. Bongers MY, Bourdrez P, Heintz AP, et al. Bipolar radio frequency endometrial ablation compared with balloon endometrial ablation in dysfunctional uterine bleeding: impact on patients' health-related quality of life. Fertil Steril. Mar 2005;83(3):724-34. [Medline].

  7. Bongers MY, Mol BW, Brolmann HA. Current treatment of dysfunctional uterine bleeding. Maturitas. Mar 15 2004;47(3):159-74. [Medline].

  8. Bourdrez P, Bongers MY, Mol BW. Treatment of dysfunctional uterine bleeding: patient preferences for endometrial ablation, a levonorgestrel-releasing intrauterine device, or hysterectomy. Fertil Steril. Jul 2004;82(1):160-6, quiz 265. [Medline].

  9. Casablanca Y. Management of dysfunctional uterine bleeding. Obstet Gynecol Clin North Am. Jun 2008;35(2):219-34. [Medline].

  10. Chullapram T, Song JY, Fraser IS. Medium-term follow-up of women with menorrhagia treated by rollerball endometrial ablation. Obstet Gynecol. Jul 1996;88(1):71-6. [Medline].

  11. Claessens EA, Cowell CA. Dysfunctional uterine bleeding in the adolescent. Pediatr Clin North Am. May 1981;28(2):369-78. [Medline].

  12. Crosignani PG, Rubin B. Dysfunctional uterine bleeding. Hum Reprod. Jul 1990;5(5):- Rubin B. [Medline].

  13. Demers C, Derzko C, David M, et al. Gynaecological and obstetric management of women with inherited bleeding disorders. Int J Gynaecol Obstet. Oct 2006;95(1):75-87. [Medline].

  14. DeVore GR, Owens O, Kase N. Use of intravenous Premarin in the treatment of dysfunctional uterine bleeding--a double-blind randomized control study. Obstet Gynecol. Mar 1982;59(3):285-91. [Medline].

  15. DeVore GR, Owens O, Kase N. Use of intravenous Premarin in the treatment of dysfunctional uterine bleeding--a double-blind randomized control study. Obstet Gynecol. Mar 1982;59(3):285-91. [Medline].

  16. Dodson MG. Use of transvaginal ultrasound in diagnosing the etiology of menometrorrhagia. J Reprod Med. May 1994;39(5):362-72. [Medline].

  17. Díaz S, Croxatto HB, Pavez M, et al. Clinical assessment of treatments for prolonged bleeding in users of Norplant implants. Contraception. Jul 1990;42(1):97-109. [Medline].

  18. Edlund M, Blomback M, von Schoultz B, et al. On the value of menorrhagia as a predictor for coagulation disorders. Am J Hematol. Dec 1996;53(4):234-8. [Medline].

  19. Ely JW, Kennedy CM, Clark EC, et al. Abnormal uterine bleeding: a management algorithm. J Am Board Fam Med. Nov-Dec 2006;19(6):590-602. [Medline]. [Full Text].

  20. Falcone T, Desjardins C, Bourque J, et al. Dysfunctional uterine bleeding in adolescents. J Reprod Med. Oct 1994;39(10):761-4. [Medline].

  21. Ferenczy A, Gelfand M. The biologic significance of cytologic atypia in progestogen-treated endometrial hyperplasia. Am J Obstet Gynecol. Jan 1989;160(1):126-31. [Medline].

  22. Ferenczy A, Gelfand MM, Tzipris F. The cytodynamics of endometrial hyperplasia and carcinoma. A review. Ann Pathol. Sep 1983;3(3):189-201. [Medline].

  23. Franks S, Adams J, Mason H, et al. Ovulatory disorders in women with polycystic ovary syndrome. Clin Obstet Gynaecol. Sep 1985;12(3):605-32. [Medline].

  24. Gervaise A, de Tayrac R, Fernandez H. Contraceptive information after endometrial ablation. Fertil Steril. Dec 2005;84(6):1746-7. [Medline].

  25. Hopkins MP, Androff L, Benninghoff AS. Ginseng face cream and unexplained vaginal bleeding. Am J Obstet Gynecol. Nov 1988;159(5):1121-2. [Medline].

  26. Jayasinghe Y, Moore P, Donath S, et al. Bleeding disorders in teenagers presenting with menorrhagia. Aust N Z J Obstet Gynaecol. Oct 2005;45(5):439-43. [Medline].

  27. Kadir RA, Economides DL, Sabin CA, et al. Frequency of inherited bleeding disorders in women with menorrhagia. Lancet. Feb 14 1998;351(9101):485-9. [Medline].

  28. LaCour DE, Long DN, Perlman SE. Dysfunctional uterine bleeding in adolescent females associated with endocrine causes and medical conditions. J Pediatr Adolesc Gynecol. Apr 2010;23(2):62-70. [Medline].

  29. [Best Evidence] Lethaby A, Augood C, Duckitt K, et al. Nonsteroidal anti-inflammatory drugs for heavy menstrual bleeding. Cochrane Database Syst Rev. Oct 17 2007;CD000400. [Medline].

  30. Lethaby A, Farquhar C, Cooke I. Antifibrinolytics for heavy menstrual bleeding. Cochrane Database Syst Rev. 2000;CD000249. [Medline].

  31. [Best Evidence] Lethaby A, Irvine G, Cameron I. Cyclical progestogens for heavy menstrual bleeding. Cochrane Database Syst Rev. Jan 23 2008;CD001016. [Medline].

  32. Lethaby AE, Cooke I, Rees M. Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev. Oct 19 2005;CD002126. [Medline].

  33. March CM. Hysteroscopy. J Reprod Med. Apr 1992;37(4):293-311; discussion 311-2. [Medline].

  34. Margolis MT, Thoen LD, Boike GM, et al. Asymptomatic endometrial carcinoma after endometrial ablation. Int J Gynaecol Obstet. Dec 1995;51(3):255-8. [Medline].

  35. Meyer WR, Walsh BW, Grainger DA, et al. Thermal balloon and rollerball ablation to treat menorrhagia: a multicenter comparison. Obstet Gynecol. Jul 1998;92(1):98-103. [Medline].

  36. Munro MG. Dysfunctional uterine bleeding: advances in diagnosis and treatment. Curr Opin Obstet Gynecol. Oct 2001;13(5):475-89. [Medline].

  37. Ravn SH, Rosenberg J, Bostofte E. Postmenopausal hormone replacement therapy--clinical implications. Eur J Obstet Gynecol Reprod Biol. Feb 1994;53(2):81-93. [Medline].

  38. Rodeghiero F. Management of menorrhagia in women with inherited bleeding disorders: general principles and use of desmopressin. Haemophilia. Jan 2008;14 Suppl 1:21-30. [Medline].

  39. Rogers PA, Martinez F, Girling JE, et al. Influence of different hormonal regimens on endometrial microvascular density and VEGF expression in women suffering from breakthrough bleeding. Hum Reprod. Dec 2005;20(12):3341-7. [Medline].

  40. Rose EH, Aledort LM. Nasal spray desmopressin (DDAVP) for mild hemophilia A and von Willebrand disease. Ann Intern Med. Apr 1 1991;114(7):563-8. [Medline].

  41. Sagiv R, Ben-Shem E, Condrea A, et al. Endometrial carcinoma after endometrial resection for dysfunctional uterine bleeding. Obstet Gynecol. Nov 2005;106(5 Pt 2):1174-6. [Medline].

  42. Schneider LG. Causes of abnormal vaginal bleeding in a Family Practice Center. J Fam Pract. Feb 1983;16(2):281-3. [Medline].

  43. Smith CB. Dysfunctional uterine bleeding. Am Fam Physician. Sep 1987;36(3):161-8. [Medline].

  44. Solnik JM, Guido RS, Sanfilippo JS, et al. The impact of endometrial ablation technique at a large university women's hospital. Am J Obstet Gynecol. Jul 2005;193(1):98-102. [Medline].

  45. Speroff L, Glass R, Kase N. Dysfunctional uterine bleeding. In: Clinical Gynecologic Endocrinology & Infertility. 1999:575-591.

  46. Strickland JL. Management of abnormal bleeding in adolescents. Mo Med. Jan-Feb 2004;101(1):38-41. [Medline].

  47. van Bogaert LJ. Diagnostic aid of endometrium biopsy. Gynecol Obstet Invest. 1979;10(6):289-97. [Medline].

  48. Van Zon-Rabelink IA, Vleugels MP, Merkus HM, et al. Efficacy and satisfaction rate comparing endometrial ablation by rollerball electrocoagulation to uterine balloon thermal ablation in a randomised controlled trial. Eur J Obstet Gynecol Reprod Biol. May 10 2004;114(1):97-103. [Medline].

  49. Wathen PI, Henderson MC, Witz CA. Abnormal uterine bleeding. Med Clin North Am. Mar 1995;79(2):329-44. [Medline].

  50. Wilansky DL, Greisman B. Early hypothyroidism in patients with menorrhagia. Am J Obstet Gynecol. Mar 1989;160(3):673-7. [Medline].

  51. Wren BG. Dysfunctional uterine bleeding. Aust Fam Physician. May 1998;27(5):371-7. [Medline].

 
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