Dysfunctional Uterine Bleeding Workup

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

Laboratory Studies

Laboratory studies for patients with dysfunctional uterine bleeding (DUB) include human chorionic gonadotropin (HCG), complete blood count (CBC), Pap smear, endometrial sampling, thyroid functions and prolactin, liver functions, coagulation studies/factors, and other hormone assays as indicated.

  • Human chorionic gonadotropin
    • The most common cause of abnormal uterine bleeding during the reproductive years is abnormal pregnancy.
    • Rule out threatened abortion, incomplete abortion, and ectopic pregnancy.
  • Complete blood count
    • Document blood loss. Charting the number of menstrual pads used per day or keeping a menstrual calendar is helpful.
    • When in doubt, obtain a baseline CBC count for hemoglobin and hematocrit.
    • Rule out anemia.
    • Obtain a differential with platelet count if hematologic disease is suspected.
  • Pap smear should be up to date. Cervical cancer still is the most common gynecologic cancer affecting women of reproductive age in the world population.
  • Endometrial sampling
    • Perform a biopsy to rule out endometrial hyperplasia or cancer in high-risk women >35 years and in younger women at extreme risk for endometrial hyperplasia/carcinoma. Women with chronic eugonadal anovulation, obesity, hirsutism, diabetes, or chronic hypertension are at particular risk.
    • Most biopsies will confirm the absence of secretory endometrium.
  • Perform thyroid function tests and prolactin because hyperthyroidism, hypothyroidism, and hyperprolactinemia are associated with ovulatory dysfunction. Identify and treat these conditions.
  • Obtain liver function tests if alcoholism or hepatitis is suspected. Any condition affecting liver metabolism of estrogen can be associated with abnormal uterine bleeding.
  • Coagulation factors
    • Von Willebrand disease and factor XI deficiency initially might manifest during adolescence.
    • Primary or secondary thrombocytopenia can be factors in the mature patient.
    • Tailor the choice of laboratory tests to the presenting clinical situation. Generally speaking, when coagulopathies are present, heavy bleeding is regular (menorrhagia) and associated with ovulation.
  • Other hormone assays as indicated
    • For the patient with recurrent anovulatory bleeding, the mainstay of management is treatment of correctable disease.
    • Obtain a hormonal complete evaluation in women with signs of hyperandrogenism, such as those with polycystic ovarian syndrome, 21 hydroxylase deficiency, or ovarian or adrenal tumors, as dictated by their respective conditions.
    • Women in menopausal transition usually can be followed without an extensive hormonal evaluation.
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Imaging Studies

  • Generally, patients with DUB can be managed appropriately without the use of expensive imaging studies.
  • In obese patients with suboptimal pelvic examination or in patients with suspected ovarian or uterine pathology, pelvic ultrasonographic evaluation might be helpful.
  • Ultrasound can be used to examine the status of the endometrium. Endometrial hyperplasia, endometrial carcinoma, endometrial polyps, and uterine fibroids can be identified easily by this technology.
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Procedures

  • Rule out endometrial carcinoma in all patients at high risk for the condition, including patients with the following characteristics:
    • Morbid obesity
    • Diabetes or chronic hypertension
    • Age >35 years
    • Longstanding, chronic eugonadal anovulation
  • Traditionally, carcinoma was ruled out by endometrial sampling via dilation and curettage (D&C). More recently, endometrial sampling in the office via aspiration, curetting, or hysteroscopy has become popular and is also relatively accurate.
  • Real-time ultrasound measurement and evaluation of the endometrial stripe can be helpful in distinguishing individuals bleeding with thick endometrium from those with thin, denuded endometrium, endometrial polyps, uterine fibroids, or other uterine pathology.
  • Saline-infusion sonohysterography is also very useful in evaluating for intracavitary (submucosal) fibroids and endometrial polyps.
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Histologic Findings

Most endometrial biopsy specimens will show proliferative or dyssynchronous endometrium.

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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.

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