eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology

Dysfunctional Uterine Bleeding: Differential Diagnoses & Workup

Author: Amir Estephan, MD,, Resident Physician, Department of Emergency Medicine, Kings County Hospital Center, Brooklyn
Coauthor(s): Richard H Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Contributor Information and Disclosures

Updated: Feb 1, 2010

Differential Diagnoses

Abortion, Complete
Fibroids (leiomyomata)
Abortion, Incomplete
Foreign body
Abortion, Inevitable
Hydatidiform Mole
Abortion, Missed
Hyperthyroidism
Abortion, Threatened
Hypothyroidism
Abruptio Placentae
Intrauterine devices
Adenomyosis
Liver disease
Anovulation
Mullerian Duct Anomalies
Anticoagulants
Oral contraceptives
Antipsychotics
Ovarian Cysts
Arteriovenous Malformations
Pelvic Inflammatory Disease
Cervical Cancer
Placenta Previa
Cervicitis
Platelet Disorders
Coagulopathies
Polycystic Ovarian Syndrome
Cushing Syndrome
Pregnancy, Ectopic
Endocervical Polyp
Prolactinoma
Endometrial Carcinoma
Renal disease
Endometrial Polyp
Trauma
Endometriosis
von Willebrand Disease
Estrogen Therapy
Vulvovaginitis

Workup

Laboratory Studies

  • When evaluating a woman of reproductive age with vaginal bleeding, pregnancy must always be ruled out by urine or serum human chorionic gonadotropin.
  • In a patient with any hemodynamic instability, excessive bleeding, or clinical evidence of anemia, a complete blood count is essential.
  • Coagulation studies should be considered when indicated by the history or physical examination findings and in patients with underlying liver disease or other coagulopathies.
  • In patients with suspected endocrine disorders, other laboratory studies such as thyroid function tests and prolactin levels may be helpful, although these results may not be available from the ED.

Imaging Studies

  • Pelvic ultrasonography is an important imaging modality for nonpregnant patients with abnormal vaginal bleeding. It may determine the etiology of the bleeding such as a fibroid uterus, endometrial thickening, or a focal mass.
    • Thickened endometrium may indicate an underlying lesion or excess estrogen and may be suggestive of malignancy.
      • An endometrial stripe measuring less than 4 mm thick is unlikely to have endometrial hyperplasia or cancer, and biopsy is often considered unnecessary before treatment.
      • Women with a normal endometrial stripe (5–12 mm) may require biopsy, particularly if they have risk factors for endometrial cancer.
      • When the endometrial stripe is larger than 12 mm, a biopsy should be performed.6
    • Depending on the urgency to determine the etiology of bleeding and on the reliability of outpatient follow-up, ultrasonography may be deferred for outpatient evaluations because for the majority of nonpregnant patients, ultrasonographic findings do not immediately affect ED decision-making.3
  • Transvaginal ultrasonography may be particularly helpful in further delineating ovarian cysts and fluid in the cul-de-sac.
  • Computed tomography is used primarily for evaluation of other causes of acute abdominal or pelvic pain.
  • Magnetic resonance imaging is used primarily for cancer staging.

Procedures

  • Before instituting therapy, many consulting gynecologists perform endometrial sampling or biopsy to diagnose intrauterine pathology and to exclude endometrial malignancy.
  • Endometrial biopsy is indicated for the following patients with abnormal uterine bleeding6 :
    • Women older than 35 years
    • Obese patients
    • Women who have prolonged periods of unopposed estrogen stimulation
    • Women with chronic anovulation
  • Hysteroscopy is the definitive way to detect intrauterine lesions. It offers a more complete examination of the surface of the endometrium. However, it is usually reserved for treating lesions that were detected by other less invasive means.

More on Dysfunctional Uterine Bleeding

Overview: Dysfunctional Uterine Bleeding
Differential Diagnoses & Workup: Dysfunctional Uterine Bleeding
Treatment & Medication: Dysfunctional Uterine Bleeding
Follow-up: Dysfunctional Uterine Bleeding
References

References

  1. Frick KD, Clark MA, Steinwachs DM, et al. Financial and quality-of-life burden of dysfunctional uterine bleeding among women agreeing to obtain surgical treatment. Womens Health Issues. Jan-Feb 2009;19(1):70-8. [Medline].

  2. Schorge JO, Schaffer JI, Halvorson LM, Hoffman BL, Bradshaw KD, Cunningham FG. Abnormal uterine bleeding. In: Williams Gynecology. McGraw-Hill; 2008:Chap 8.

  3. Tibbles CD. Selected gynecologic disorders. In: Marx JA, Hockberger RS, Walls RM, Adams JG. Rosen's Emergency Medicine: Concepts and Clinical Practice. Vol 1. 7th ed. Mosby (Elsevier); 2009:Chap 98.

  4. Pitkin J. Dysfunctional uterine bleeding. BMJ. May 26 2007;334(7603):1110-1. [Medline].

  5. [Guideline] James AH, Kouides PA, Abdul-Kadir R, 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. Jul 2009;201(1):12.e1-8. [Medline].

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

  7. [Best Evidence] Hickey M, Higham J, Fraser IS. Progestogens versus oestrogens and progestogens for irregular uterine bleeding associated with anovulation. Cochrane Database Syst Rev. Oct 17 2007;CD001895. [Medline].

  8. Dickersin K, Munro MG, Clark M, et al. Hysterectomy compared with endometrial ablation for dysfunctional uterine bleeding: a randomized controlled trial. Obstet Gynecol. Dec 2007;110(6):1279-89. [Medline].

Further Reading

Keywords

dysfunctional uterine bleeding, DUB, dysfunctional uterine bleeding symptoms, dysfunctional uterine bleeding causes, abnormal uterine bleeding, abnormal vaginal bleeding, menorrhagia, metrorrhagia, menometrorrhagia, amenorrhea, oligomenorrhea, vaginal carcinoma, cervical cancer, uterine cancer, ovarian cancer, functional ovarian cysts, cervicitis, endometritis, salpingitis, vaginal infection

Contributor Information and Disclosures

Author

Amir Estephan, MD,, Resident Physician, Department of Emergency Medicine, Kings County Hospital Center, Brooklyn
Amir Estephan, MD, is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, and Emergency Medicine Residents Association
Disclosure: Nothing to disclose.

Coauthor(s)

Richard H Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Steven A Conrad, MD, PhD, Chief, Department of Emergency Medicine; Chief, Multidisciplinary Critical Care Service, Professor, Department of Emergency and Internal Medicine, Louisiana State University Health Sciences Center
Steven A Conrad, MD, PhD is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American College of Emergency Physicians, American College of Physicians, International Society for Heart and Lung Transplantation, Louisiana State Medical Society, Shock Society, Society for Academic Emergency Medicine, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Mark Zwanger, MD, MBA, Assistant Professor, Department of Emergency Medicine, Thomas Jefferson University
Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association
Disclosure: Pfizer Salary Employment

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD, Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center
Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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