DysIuncLIonuI ULerIne BIeedIng

Background
Abnormal uterine bleeding is a common presenting problem in the ED.Dysfunctional uterine
bleeding (DUB) is defined as abnormal uterine bleeding in the absence of organic disease.
Dysfunctional uterine bleeding is the most common cause of abnormal vaginal bleeding during a
woman's reproductive years. Dysfunctional uterine bleeding can have a substantial financial and
quality-of-life burden.
[1]
t affects women's health both medically and socially.
!athophysioIogy
The normal menstrual cycle is 28 days and starts on the first day of menses. During the first 14 days
(follicular phase) of the menstrual cycle, the endometrium thickens under the influence of estrogen. n
response to rising estrogen levels, the pituitary gland secretes follicle-stimulating hormone (FSH) and
luteinizing hormone (LH), which stimulate the release of an ovum at the midpoint of the cycle. The
residual follicular capsule forms the corpus luteum.
After ovulation, the luteal phase begins and is characterized by production of progesterone from the
corpus luteum. Progesterone matures the lining of the uterus and makes it more receptive to
implantation. f implantation does not occur, in the absence of human chorionic gonadotropin (hCG),
the corpus luteum dies, accompanied by sharp drops in progesterone and estrogen levels. Hormone
withdrawal causes vasoconstriction in the spiral arterioles of the endometrium. This leads to menses,
which occurs approximately 14 days after ovulation when the ischemic endometrial lining becomes
necrotic and sloughs.
[2]

Terms frequently used to describe abnormal uterine bleeding:
O Menorrhagia - Prolonged (>7 d) or excessive (>80 mL daily) uterine bleeding occurring at regular
intervals
O Metrorrhagia - Uterine bleeding occurring at irregular and more frequent than normal intervals
O Menometrorrhagia - Prolonged or excessive uterine bleeding occurring at irregular and more
frequent than normal intervals
O ntermenstrual bleeding - Uterine bleeding of variable amounts occurring between regular menstrual
periods
O Midcycle spotting - Spotting occurring just before ovulation, typically from declining estrogen levels
O Postmenopausal bleeding - Recurrence of bleeding in a menopausal woman at least 6 months to 1
year after cessation of cycles
O Amenorrhea - No uterine bleeding for 6 months or longer
Dysfunctional uterine bleeding is a diagnosis of exclusion. t is ovulatory or anovulatory bleeding,
diagnosed after pregnancy, medications, iatrogenic causes, genital tract pathology, malignancy, and
systemic disease have been ruled out by appropriate investigations. Approximately 90% of
dysfunctional uterine bleeding cases result from anovulation, and 10% of cases occur with ovulatory
cycles.
[3]

Anovulatory dysfunctional uterine bleeding results from a disturbance of the normal hypothalamic-
pituitary-ovarian axis and is particularly common at the extremes of the reproductive years. When
ovulation does not occur, no progesterone is produced to stabilize the endometrium; thus, proliferative
endometrium persists. Bleeding episodes become irregular, and amenorrhea, metrorrhagia, and
menometrorrhagia are common. Bleeding from anovulatory dysfunctional uterine bleeding is thought
to result from changes in prostaglandin concentration, increased endometrial responsiveness to
vasodilating prostaglandins, and changes in endometrial vascular structure.
n ovulatory dysfunctional uterine bleeding, bleeding occurs cyclically, and menorrhagia is thought to
originate from defects in the control mechanisms of menstruation. t is thought that, in women with
ovulatory dysfunctional uterine bleeding, there is an increased rate of blood loss resulting from
vasodilatation of the vessels supplying the endometrium due to decreased vascular tone, and
prostaglandins have been strongly implicated. Therefore, these women lose blood at rates about 3
times faster than women with normal menses.
[4]

pidemioIogy
requency
United States
Dysfunctional uterine bleeding is one of the most often encountered gynecologic problems. An
estimated 5% of women aged 30-49 years will consult a physician each year for the treatment of
menorrhagia. About 30% of all women report having had menorrhagia.
[4]

InternationaI
No cultural predilection is present with this disease state.
MortaIity/Morbidity
Morbidity is related to the amount of blood loss at the time of menstruation, which occasionally is
severe enough to cause hemorrhagic shock. Excessive menstrual bleeding accounts for two thirds of
all hysterectomies and most endoscopic endometrial destructive surgery. Menorrhagia has several
adverse effects, including anemia and iron deficiency, reduced quality of life, and increased
healthcare costs.
[1]

Race
Dysfunctional uterine bleeding has no predilection for race; however, black women have a higher
incidence of leiomyomas and, as a result, they are prone to experiencing more episodes of abnormal
vaginal bleeding.
Age
Dysfunctional uterine bleeding is most common at the extreme ages of a woman's reproductive years,
either at the beginning or near the end, but it may occur at any time during her reproductive life.
O Most cases of dysfunctional uterine bleeding in adolescent girls occur during the first 2 years after
the onset of menstruation, when their immature hypothalamic-pituitary axis may fail to respond to
estrogen and progesterone, resulting in anovulation.
O Abnormal uterine bleeding affects up to 50% of perimenopausal women. n the perimenopausal
period, dysfunctional uterine bleeding may be an early manifestation of ovarian failure causing
decreased hormone levels or responsiveness to hormones, thus also leading to anovulatory cycles.
n patients who are 40 years or older, the number and quality of ovarian follicles diminishes. Follicles
continue to develop but do not produce enough estrogen in response to FSH to trigger ovulation.
The estrogen that is produced usually results in late-cycle estrogen breakthrough bleeding.
[2]

istory
O Patients often present with complaints of amenorrhea, menorrhagia, metrorrhagia, or
menometrorrhagia. The amount and frequency of bleeding and the duration of symptoms, as well as
the relationship to the menstrual cycle, should be established. Ask patients to compare the number of
pads or tampons used per day in a normal menstrual cycle to the number used at the time of
presentation. The average tampon or pad absorbs 20-30 mL or vaginal effluent. Personal habits vary
greatly among women; therefore, the number of pads or tampons used is unreliable. The patient
should be questioned about the possibility of pregnancy.
[3]

O A reproductive history should always be obtained, including the following:
O Age of menarche and menstrual history and regularity
O Last menstrual period (LMP), including flow, duration, and presence of dysmenorrhea
O Postcoital bleeding
O Gravida and para
O Previous abortion or recent termination of pregnancy
O Contraceptive use, use of barrier protection, and sexual activity (including vigorous sexual activity or
trauma)
O History of sexually transmitted diseases (STDs) or ectopic pregnancy
O Questions about medical history should include the following:
O Signs and symptoms of anemia or hypovolemia (including fatigue, dizziness, and syncope)
O Diabetes mellitus
O Thyroid disease
O Endocrine problems or pituitary tumors
O Liver disease
O Recent illness, psychological stress, excessive exercise, or weight change
O Medication usage, including exogenous hormones, anticoagulants, aspirin, anticonvulsants, and
antibiotics
O Alternative and complementary medicine modalities, such as herbs and supplements
O An international expert panel including obstetrician/gynecologists and hematologists has issued
guidelines to assist physicians to better recognize bleeding disorders, such as von Willebrand
disease, as a cause of menorrhagia and postpartum hemorrhage and to provide disease-specific
therapy for the bleeding disorder.
[5]
Historically, a lack of awareness of underlying bleeding disorders
has led to underdiagnosis in women with abnormal reproductive tract bleeding. The panel provided
expert consensus recommendations on how to identify, confirm, and manage a bleeding disorder. f a
bleeding disorder is suspected, evaluation for a coagulation problem is required and consultation with
a hematologist is suggested. An underlying bleeding disorder should be considered when a patient
has any of the following:
O Menorrhagia since menarche
O Family history of bleeding disorders
O Personal history of 1 or several of the following:
O Notable bruising without known injury
O Bleeding of oral cavity or G tract without obvious lesion
O Epistaxis >10 min duration (possibly necessitating packing or cautery)
!hysicaI
O Vital signs, including postural changes, should be assessed. nitial evaluation should be directed at
assessing the patient's volume status and degree of anemia. Examine for pallor and absence of
conjunctival vessels to gauge anemia.
O An abdominal examination should be performed. Femoral and inguinal lymph nodes should be
examined. Stool should be evaluated for the presence of blood.
O Patients who are hemodynamically stable require a pelvic speculum, bimanual, and rectovaginal
examination to define the etiology of vaginal bleeding. A careful physical examination will exclude
vaginal or rectal sources of bleeding. The examination should look for the following:
O The vagina should be inspected for signs of trauma, lesions, infection, and foreign bodies.
O The cervix should be visualized and inspected for lesions, polyps, infection, or intrauterine device
(UD).
O Bleeding from the cervical os
O A rectovaginal examination should be performed to evaluate the cul-de-sac, posterior wall of the
uterus, and uterosacral ligaments.
O Uterine or ovarian structural abnormalities, including leiomyoma or fibroid uterus, may be noted on
bimanual examination.
O Patients with hematologic pathology may also have cutaneous evidence of bleeding diathesis.
Physical findings include petechiae, purpura, and mucosal bleeding (eg, gums) in addition to vaginal
bleeding.
O Patients with liver disease that has resulted in a coagulopathy may manifest additional
symptomatology because of abnormal hepatic function. Evaluate patients for spider angioma, palmar
erythema, splenomegaly, ascites, jaundice, and asterixis.
O Women with polycystic ovary disease present with signs of hyperandrogenism, including hirsutism,
obesity, acne, palpable enlarged ovaries, and acanthosis nigricans (hyperpigmentation typically seen
in the folds of the skin in the neck, groin, or axilla)
O Hyperactive and hypoactive thyroid can cause menstrual irregularities. Patients may have varying
degrees of characteristic vital sign abnormalities, eye findings, tremors, changes in skin texture, and
weight change. Goiter may be present.
auses
O Systemic disease, including thrombocytopenia, hypothyroidism,hyperthyroidism, Cushing disease,
liver disease, diabetes mellitus, and adrenal and other endocrine disorders, can present as abnormal
uterine bleeding.
O Pregnancy and pregnancy-related conditions may be associated with vaginal bleeding.
O Trauma to the cervix, vulva, or vagina may cause abnormal bleeding.
O Carcinomas of the vagina, cervix, uterus, and ovaries must always be considered in patients with the
appropriate history and physical examination findings. Endometrial cancer is associated with obesity,
diabetes mellitus, anovulatory cycles, nulliparity, and age older than 35 years.
O Other causes of abnormal uterine bleeding include structural disorders, such as functional ovarian
cysts, cervicitis, endometritis, salpingitis, leiomyomas, and adenomyosis. Cervical dysplasia or other
genital tract pathology may present as postcoital or irregular bleeding.
O Polycystic ovary disease results in excess estrogen production and commonly presents as abnormal
uterine bleeding.
O Primary coagulation disorders, such as von Willebrand disease,myeloproliferative disorders,
and immune thrombocytopenia, can present with menorrhagia.
O Excessive exercise, stress, and weight loss cause hypothalamic suppression leading to abnormal
uterine bleeding due to disruption along the hypothalamus-pituitary-ovarian pathway.
O Bleeding disturbances are common with combination oral contraceptive pills as well as progestin-only
methods of birth control. However, the incidence of bleeding decreases significantly with time.
Therefore, only counseling and reassurance are required during the early months of use.
O Contraceptive intrauterine devices (UDs) can cause variable vaginal bleeding for the first few cycles
after placement and intermittent spotting subsequently. The progesterone impregnated UD (Mirena)
is associated with less menometrorrhagia and usually results in secondary amenorrhea.
[2]