eMedicine Specialties > Pediatrics: Surgery > Gynecology

Dysfunctional Uterine Bleeding

Author: Tod C Aeby, MD, Generalist Division Director, Assistant Professor, Department of Obstetrics, Gynecology and Women's Health, University of Hawaii, John A Burns School of Medicine
Coauthor(s): LeighAnn C Frattarelli, MD, MPH, Former Assistant Professor, Department of Obstetrics and Gynecology and Women's Health, University of Hawaii, John A Burns School of Medicine
Contributor Information and Disclosures

Updated: Jan 25, 2010

Introduction

Background

Dysfunctional uterine bleeding (DUB) is classically defined as excessively heavy, prolonged, or frequent bleeding of uterine origin that is not caused by pregnancy or recognizable pelvic or systemic disease.

DUB usually results from disordered functioning of the hypothalamic-pituitary-ovarian (HPO) axis and is often associated with anovulatory cycles. The classic definition has proved less useful because of the current understanding of the pathophysiology of DUB. However, it does highlight the fact that this is a diagnosis of exclusion. DUB occurs most often in women at the extreme ends of their reproductive lifetime. Because perimenarchal women have several anovulatory cycles per year, DUB is a common problem in adolescent females.

The normal menstrual cycle, characterized by sequential growth, maturation, and eventual sloughing of the endometrial mucosa, is produced by the cyclic release of estrogen and progesterone from the ovary. This occurs (orchestrated by the HPO axis) with amazing regularity throughout most of a woman's reproductive lifetime. An understanding of the normal cyclic fluctuations of the 2 gonadotropins (ie, luteinizing hormone [LH], follicle-stimulating hormone [FSH]) and the primary female reproductive hormones (ie, estrogen, progesterone) helps clarify the derangements associated with anovulation.

See Image 1. The first 14 days of a typical 28-day menstrual cycle (day 1 is defined as the first day of menstrual flow) are characterized by rising FSH levels, which stimulate ovarian follicle development and the subsequent production of estrogens (primarily estradiol). Serum progesterone levels are extremely low during this stage. LH levels climb more slowly but abruptly peak on day 12 or 13 in positive response to rising estrogen levels.

During that first 14 days, the endometrium, under the influence of estrogen, undergoes proliferation. The LH surge stimulates ovulation (on or about day 14) and conversion of the ovulatory follicle to a corpus luteum, which is responsible for estrogen and progesterone production. Under the influence of this progesterone, the endometrium is converted to a secretory state in preparation for implantation if fertilization of the ovum should occur. Progesterone is produced only if ovulation occurs. As LH levels drop (assuming fertilization and production of human chorionic gonadotropin [HCG] by the developing conceptus did not occur), the corpus luteum regresses, estrogen and progesterone levels plummet, and the endometrium deteriorates and is sloughed.

The normal cycle is 28-29 days (range 23-39 d) and is fairly consistent from month to month in any given woman. Normal menstrual flow lasts 7 or fewer days and produces an average total blood loss of 25-69 mL. Flow longer than 7 days and blood loss exceeding 80 mL is considered abnormal.

Pathophysiology

With anovulation, estrogen levels rise as usual in the early phase of the cycle. In the absence of ovulation, a corpus luteum never forms and progesterone is not produced. The endometrium moves into a hyperproliferative state, ultimately outgrowing its estrogen supply. This leads to irregular sloughing of the endometrium and excessive bleeding from spiral arteries that have not undergone physiological senescence.

Frequency

United States

The exact incidence of DUB is unknown. The understanding of the epidemiology comes from case series reports from tertiary institutions with patients who are unlikely to reflect the general population. Nearly one half of all women have irregular periods in the first year after menarche, and over one half of the cycles are anovulatory. Irregular periods can persist for up to 5 years after menarche in 20% of women.

International

International rates should reflect those of the United States.

Mortality/Morbidity

The main complication of DUB is anemia.

• Acute blood loss can occasionally lead to a profound anemia. Blood product transfusion (with the attendant risks and complications) is occasionally required.
• Chronic or recurrent DUB can result in an iron-deficient state.
• Blood loss in the healthy adolescent is only rarely of a fatal magnitude.

Race

Race does not seem to contribute significantly to the incidence of DUB.

Age

The average age of menarche in the United States is 12.8 years. Irregular and anovulatory cycles may persist for as long as 1-5 years after the onset of menstrual periods.

Clinical

History

Patients present with unexpected and often heavy vaginal bleeding. Irregular menstrual periods are common during the first few years after menarche. Because dysfunctional uterine bleeding (DUB) is largely a diagnosis of exclusion, exploring the more common and serious conditions on the Differential diagnosis list is prudent.

• Bleeding associated with complications of pregnancy: Consider any woman of reproductive age pregnant until proven otherwise (with a negative pregnancy test result). Frequently, adolescents do not report sexual behavior, and assuming the history may be less than accurate is prudent. Nevertheless, ask the patient about risk factors for pregnancy and about symptoms of pregnancy, including the following:
  • Symptoms of breast tenderness, nausea, urinary frequency, and fatigue
  • Bleeding associated with severe pain or cramping
  • Bleeding associated with the passage of tissue
• Coagulation defects: Depending on the population studied, adolescents with acute menorrhagia could have a 20-30% incidence of a coagulation disorder. Von Willebrand disease, idiopathic thrombocytopenic purpura (ITP), and leukemia are the more common etiologies. Focus questioning on the following:
  • Family history of bleeding disorders
  • Excessive bleeding associated with minor injuries (eg, small cuts, dental procedures), phlebotomy, or their first period
  • Frequent or prolonged nose bleeds
  • Easy bruising, purpura, or petechiae
• Bleeding from an anatomic cause: Anatomic causes of abnormal bleeding can occur anywhere along the female genital tract. Survey the entire organ system with a systematic series of questions, including the following:
  • Recent traumatic intercourse
  • History of sexually transmitted infections, abnormal discharge, or pelvic pain
  • Change in abdominal girth
• Medication-related DUB: Obtain a complete history of recent medication use. Specific medications to look for include use of hormonal contraceptive methods, anticoagulants, aspirin, or nonsteroidal anti-inflammatory drugs (NSAIDs).
• Polycystic ovarian syndrome (PCOS): PCOS is a common cause of anovulation and oligomenorrhea and should always be considered in the differential diagnosis. Some of the physical manifestations of this syndrome (usually due to elevated androgen levels) can be avoided if the diagnosis is made and treatment is begun at an early stage. Common symptoms include the following:
  • Irregular periods
  • Male-pattern hair growth and/or acne
  • Excessive body weight
  • Infertility
• Systemic disease: These disease states often cause abnormal bleeding through their impact on the HPO axis. Ask the patient about typical symptoms of diabetes or thyroid disease. Additionally, questions aimed at discovering a history suggestive of an eating disorder are important.

Physical

As in the history, focus the physical examination on uncovering signs of the more common or serious items on the Differential diagnosis list.

• General physical examination: A complete examination is always important and should pay special attention to the following:
  • Inadequate or excessive weight gain
  • Physical signs of a bleeding dyscrasia (ie, petechiae or purpura)
  • Physical signs of anemia (ie, pale coloring, dry mucus membranes)
  • Acne and/or hirsutism
  • Thyroid enlargement
  • Tanner breast stage and evidence of nipple discharge
  • A palpable abdominal mass, liver enlargement, and/or splenic enlargement
• Pelvic examination: Perform pelvic examination with careful consideration of the patient's age, sexual history, and use of tampons. Make every effort to make this portion of the examination as comfortable and atraumatic as possible. Considerable psychological damage can result from an examination that is performed in a rushed and insensitive manner. If the practitioner is inexperienced in adolescent pelvic examinations, a review of the proper techniques is in order. If the patient is not sexually active, the bimanual examination may be more comfortable when performed using a single, well-lubricated finger in the rectum rather than in the vagina. Most significant pelvic pathology can be felt in this manner.
  • Tanner stage and distribution of pubic hair
  • Discharge and excoriations suggesting chronic vaginal candidiasis
  • Old or acute vulvar and vaginal lacerations and condition of hymnal ring
  • Retained foreign bodies, such as toilet tissue, tampons, or tampon fragments (These occasionally cause a chronic blood-tinged vaginal discharge.)
  • Microscopic examination of the vaginal discharge, cervical cultures or DNA probe for Neisseria gonorrhoeae and Chlamydia infection, and Papanicolaou test (Pap smear) if indicated by sexual history
  • Evidence of cervical lesions, cervical motion tenderness, or an open cervical os
• Uterine size and any pelvic masses or tenderness

Causes

Anovulation can result from dysfunction in any compartment of the HPO axis. In the pediatric age group, the vast majority of cases can be attributed to an immature axis with acyclic hormonal stimulation of the endometrium. Although anovulatory bleeding can occur in any reproductive-aged female, the following patients may be at greater risk for DUB:

• Adolescents during the first 3-5 years after menarche
• Patients with eating disorders (eg, anorexia nervosa, bulimia)
• Adolescents with a body mass index (BMI) higher than 30
• Morbidly obese women
• Adolescents under significant psychological stress
• Athletes
  

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