eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology

Dysfunctional Uterine Bleeding: Differential Diagnoses & Workup

Author: Nedra R Dodds, MD, Medical Director, Opulence Aesthetic Medicine
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: Jun 9, 2009

Differential Diagnoses

Abdominal Trauma, Blunt
Endometriosis
Abdominal Trauma, Penetrating
Hypothyroidism and Myxedema Coma
Abortion, Complete
Idiopathic Thrombocytopenic Purpura
Abortion, Complications
Ovarian Cysts
Abortion, Incomplete
Ovarian Torsion
Abortion, Inevitable
Pelvic Inflammatory Disease
Abortion, Missed
Pregnancy, Ectopic
Abortion, Septic
Pregnancy, Postpartum Hemorrhage
Abortion, Threatened
Pregnancy, Trauma
Abruptio Placentae
Shock, Hemorrhagic
Anemia, Acute
Shock, Hypovolemic
Anemia, Chronic
Thrombocytopenic Purpura

Other Problems to Be Considered

Advanced liver disease
Anabolic steroids
Cervical cancer
Cervicitis
Cervical polyps
Cirrhosis
Endometrial cancer
Leiomyoma
Leukemia
Postcoital bleeding
Salpingitis
Thrombocytopenia
Uterine cancer
Uterine leiomyomas
Vaginal lacerations
Von Willebrand disease

Workup

Laboratory Studies

  • A detailed workup for DUB is beyond the scope of the ED, yet several studies are required to ensure hemodynamic stability in patients presenting with vaginal bleeding.
  • In the patient with unstable vital signs, perform a CBC with platelets, prothrombin time (PT), activated partial thromboplastin time (aPTT), liver function tests (if other signs indicate liver disease), and type and cross-match.
  • Pregnancy must be ruled out by urine and/or serum human chorionic gonadotropin, before consideration of any imaging studies or further referral or detailed examination.
  • Consider thyroid function tests. FSH, TSH, DHEAS, and prolactin levels should be considered, although these results may not be available from the ED.

Imaging Studies

  • Workup by the gynecologist should include pelvic ultrasonography to evaluate for fibroids or other structural lesions that may cause abnormal vaginal bleeding.
  • Transvaginal ultrasonography (TVUS): Consider TVUS if the patient may be pregnant or may have anatomic problems or polycystic ovarian syndrome.
  • Dilatation and curettage (D&C) can be both therapeutic and diagnostic. It may be the treatment of choice when bleeding is severe, and it allows more extensive sampling of the uterine cavity and also has a higher sensitivity than endometrial biopsy.
  • Although mostly an office or intraoperative procedure, hysteroscopy can be used in place of D&C and allows direct visualization of the endometrial cavity with directed biopsy.

Procedures

  • Pelvic examination
  • Before instituting therapy, many consulting gynecologists perform an endometrial sampling or endometrial biopsy to diagnose intrauterine pathology and to exclude endometrial malignancy.
  • Perform endometrial biopsy for the following patients:
    • All patients older than 35 years
    • Obese patients
    • Patients with diabetes mellitus
    • Patients with hypertension
    • Patients with suspected polycystic ovarian disease
  • D&C is indicated in the following situations:
    • Consider D&C in patients at high risk for endometrial hyperplasia and carcinoma.
    • Consider D&C rather than endometrial biopsy if suspected diagnosis is endometritis, atypical hyperplasia, or carcinoma.
    • Perform in patients having heavy, uncontrolled bleeding.
    • Perform if histologic examination is required but biopsy is contraindicated.
    • Perform if medical curettage fails.

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. [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][Full Text].

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

  3. Herbst A, Mishell D, Stenchever M. Abnormal uterine bleeding. In: Comprehensive Gynecology. 2nd ed. Mosby-Year Book; 1992:1083-1097.

  4. Johnson CA. Making sense of dysfunctional uterine bleeding. Am Fam Physician. Jul 1991;44(1):149-57. [Medline].

  5. Physician's Desk Reference. 50th ed. Medical Economics Books; 1996.

  6. Pritchard JA, MacDonald PC, Gant NF. Complications of pregnancy. In: William's Obstetrics. 19th ed. McGraw-Hill Professional Publishing; 1993:819-820.

  7. Rosenfeld JA. Treatment of menorrhagia due to dysfunctional uterine bleeding. Am Fam Physician. Jan 1996;53(1):165-72. [Medline].

  8. Seamen C, Slovis C. Abnormal vaginal bleeding in the nonpregnant patient. Emerg Med Rep. 1996;17:219-226. [Medline].

Further Reading

Contributor Information and Disclosures

Author

Nedra R Dodds, MD, Medical Director, Opulence Aesthetic Medicine
Nedra R Dodds, MD is a member of the following medical societies: American Academy of Anti-Aging Medicine, American Academy of Cosmetic Surgery, American College of Emergency Physicians, American Medical Association, National Medical Association, and Society for Academic Emergency Medicine
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: Medicines Company Consulting fee Consulting; 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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