Dysfunctional Uterine Bleeding

Leonard J. Levine, MDJonathan R. Pletcher, MD

Dysfunctional Uterine Bleeding - BASICS

Dysfunctional Uterine Bleeding - description

Bleeding beyond the range of normal menses, with normal defined as duration of 2–8 days, occurring every 21–40 days, with blood loss of 20–80 mL/cycle

• May vary in presentation from heavy, long menses followed by long periods of amenorrhea to short, heavy menses occurring every 1–2 weeks
• Most commonly results from anovulatory cycles, which are secondary to an immature hypothalamic-pituitary-ovarian axis

Dysfunctional Uterine Bleeding - epidemiology

• Most commonly occurs within the 1st 2 years of menarche when >50% of cycles are anovulatory
• Later age at menarche results in longer duration of anovulation.
• Most females who experience anovulatory cycles do not develop dysfunctional uterine bleeding (DUB).

Dysfunctional Uterine Bleeding - genetics

• Familial history of anovulatory cycles is common.
• Patients with disorders such as blood dyscrasias and polycystic ovary syndrome (PCOS) usually have familial histories including these disorders.

Dysfunctional Uterine Bleeding - pathophysiology

In most cases presenting within 2 years of menarche, anovulation (failure to ovulate) results in absence of the corpus luteum. Without the secretory effect of progesterone from the corpus luteum, endometrial proliferation continues because of unopposed estrogen.

• The thickened endometrium eventually outgrows support from the basal endometrium, resulting in sloughing of the highest endometrial levels. Alternatively, cyclic estrogen withdrawal may occur, which will lead to sloughing of the endometrium in the absence of progesterone.
• As subsequent levels of endometrium are shed, bleeding increases. Profuse bleeding may result when the basal endometrium is exposed.

Dysfunctional Uterine Bleeding - DIAGNOSIS

Dysfunctional Uterine Bleeding - signs & symptoms

Dysfunctional Uterine Bleeding - history

• Abnormal bleeding:
  • Assessing the amount and site of bleeding will help determine the nature and extent of the problem.
  • Important to know when bleeding began and how much bleeding has occurred to know if the patient is at risk for hemodynamic instability
• The pattern of DUB in relation to the menstrual cycle can help guide the diagnostic workup:
  • Normal cyclic intervals with increased bleeding during each cycle may suggest a bleeding disorder.
  • Normal intervals with bleeding between cycles may suggest infection or foreign body.
  • Abnormal intervals with no cycle regularity may suggest anovulatory cycles, endocrinopathy, or hormonal contraception.
• Cramping suggests ovulation and the presence of progesterone; anovulatory cycles are thus less likely.
• Increased time lapse between menarche and onset of DUB lessens the likelihood of anovulatory cycles.
• Easy bruisability, epistaxis, and/or bleeding gums may be suggestive of a bleeding disorder.
• A family history of thyroid disease, bleeding disorder, PCOS, or DUB will help guide the laboratory workup.
• Ask about sexual abuse when conducting the sexual history. Sexual abuse not only may result in bleeding from trauma but also may be a source of sexually transmitted diseases and pregnancy.

Dysfunctional Uterine Bleeding - physical exam

• Often normal in patients with DUB
• Assess vital signs, including orthostatic BPs, for signs of cardiac instability resulting from severe blood loss.
• Assess sexual maturity rating (SMR, or Tanner stage). Menarche usually does not occur before SMR 3, so bleeding before this stage suggests a nonmenstrual source of bleeding.
• Look for signs of androgen excess (e.g., hirsutism, acne), which may be reflective of disrupted ovulatory function.
• Bitemporal hemianopsia is suggestive of a pituitary adenoma leading to hyperprolactinemia. Only 1/3 of adolescents with hyperprolactinemia will experience galactorrhea.
• Assess for evidence of thyroid disease, hematologic disorder (e.g., bruising, petechiae), or systemic disease (e.g., poor nutritional status).
• Pelvic examination may help determine source of bleeding. Bimanual examination can assess for ovarian or uterine masses, signs of pelvic inflammatory disease (PID), or signs of pregnancy.

Dysfunctional Uterine Bleeding - tests

Dysfunctional Uterine Bleeding - lab

• Obtain urine or serum-human chorionic gonadotropin (HCG), regardless of sexual history. Urine-HCG testing can reliably detect pregnancy as early as 2 weeks postconception; however, it may be positive for up to 2 weeks following an abortion.
• CBC: Degree of anemia guides treatment plan. Assess for thrombocytopenia.
• For Clamydia trachomatis and Neisseria gonorrhoeae, obtain cervical cultures or use nucleic acid amplification tests (e.g., polymerase chain reaction) on urine or cervical swabs; also, wet mount to identify Trichomonas or WBCs: To identify presence of STDs
• Consider prolactin level and thyroid function tests: Hyperprolactinemia may have several causes, including pituitary microadenoma and result in amenorrhea or DUB.
• Prothrombin and partial thromboplastin times, von Willebrand factor: To assess for hematologic causes of bleeding
• Luteinizing and follicle-stimulating hormones; androgen levels, including testosterone (total and free); dehydroepiandrosterone sulfate (DHEAS); androstenedione: Abnormal levels are supportive of PCOS.

Dysfunctional Uterine Bleeding - imaging

• Pelvic ultrasound:
  • Indicated when ectopic pregnancy is suspected
  • Consider when a pelvic mass is felt, uterine anomaly is being considered, or bimanual examination cannot be completed.
• MRI of the pelvis: Indicated for patients with a suspected pelvic mass when ultrasonography does not clearly define the anatomy

Dysfunctional Uterine Bleeding - differencial diagnosis

~80% of abnormal uterine bleeding in adolescents can be attributed to anovulatory cycles. However, it is important to rule out other causes of irregular or heavy vaginal bleeding.

• Pregnancy:
  • Should be considered and ruled out in every patient, regardless of patient’s reported sexual history
  • Ectopic pregnancy
  • Threatened abortion, incomplete abortion
  • Placenta previa
  • Hydatidiform mole
• Infection:
  • Vaginitis (e.g., trichomoniasis)
  • Cervicitis or endometritis (e.g., gonorrhea or chlamydia)
  • PID
• Hematologic conditions:
  • Bleeding disorders often present as heavy periods from time of menarche.
  • Thrombocytopenia (e.g., immune thrombocytopenic purpura [ITP], leukemia)
  • Platelet dysfunction
  • Coagulation defect (e.g., von Willebrand disease)
• Endocrinologic disorders:
  • Thyroid disease, especially hypothyroidism
  • Hyperprolactinemia
  • PCOS
  • Adrenal disorders
• Trauma: Laceration to vagina or cervix
• Foreign body: Usually associated with strong, foul odor
• Medications:
  • Direct effect on hemostasis (e.g., Coumadin, chemotherapeutic agents)
  • Hormonal effects (e.g., oral contraceptives, Depo-Provera)
• Systemic disease:
  • Disruption of hypothalamic-pituitary-ovarian axis
  • Other examples include systemic lupus erythematosus and chronic renal failure.
• Primary gynecologic disorders:
  • Endometriosis
  • Uterine polyps, submucosal myomas
  • Hemangioma, arteriovenous malformation

Pitfalls:

• Neglecting to perform pregnancy testing in an adolescent who denies sexual activity
• Neglecting to consider a retained foreign body (e.g., tampon)
• If there is a prolonged course of DUB, consider PCOS, thyroid disease, or other endocrinopathy.

Dysfunctional Uterine Bleeding - TREATMENT

Dysfunctional Uterine Bleeding - initial stabilization

If DUB is attributed to anovulatory cycles, or if a complete workup fails to yield a diagnosis, treatment is guided by the severity of DUB and the presence of active bleeding.

Dysfunctional Uterine Bleeding - general measures

• For mild DUB (inconvenient, unpredictable bleeding, and the patient has a normal hemoglobin):
  • Reassurance until ovulatory cycles resume. Encourage maintenance of a menstrual calendar, with follow-up in 3–6 months.
  • Iron supplementation
  • If inconvenience and anxiety are unresponsive to reassurance, hormonal therapy with a daily combined oral contraceptive pill (OCP) should be considered to regulate menstrual cycle. If estrogen is contraindicated, may use medroxyprogesterone acetate (Provera), 10 mg daily for 7 days every 35–40 days
• For moderate DUB (irregular, prolonged, heavy bleeding with a hemoglobin >10 g/dL):
  • Hormonal therapy, as described previously
  • Menstrual calendar with follow-up every 1–3 months
• For severe DUB (heavy, prolonged bleeding with a hemoglobin <10 g/dL), treatment depends on the presence of active bleeding:
  • If no active bleeding, hemodynamically stable patients can be started on OCPs and iron supplementation, with follow-up in 1–2 months.
  • In the presence of active bleeding: Hormonal therapy, using combined OCP containing higher dose of estrogen (50 ์g ethinyl estradiol)—1 pill q.i.d. until bleeding stops, followed by pill taper (q.i.d. for 4 days, t.i.d. for 3 days, b.i.d. for 2 weeks, then 1 pill daily); switch to lower-dose pill (30–35 ์g) after taper complete—antiemetic therapy necessary for high doses of estrogen. Hospitalization of patient during treatment if severe anemia (hemoglobin <7 g/dL), if hemodynamically unstable, or compliance concerns. Blood transfusion as necessary. If patient is unstable and unable to tolerate oral pill regimen, can give IV conjugated estrogen q4h for 24 hours to stop bleeding. Add OCP with progesterone as soon as patient is able to tolerate oral regimen to prevent excessive withdrawal bleed.
  • Iron supplementation
  • Dilatation and curettage rarely necessary, although may be needed if hormonal therapy fails
• Possible side effects:
  • Estrogen, given in high doses, will cause nausea and/or vomiting. An appropriate antiemetic should be used for prophylaxis against these symptoms.
  • High-dose estrogen may have vascular side effects and should be used with caution in patients particularly at risk for vascular events (e.g., patients with a history of lupus, strokes, or thrombotic phenomena; and those who smoke cigarettes). In these cases, consult a gynecologist for an alternative progesterone-only therapy.

Dysfunctional Uterine Bleeding - FOLLOW UP

Dysfunctional Uterine Bleeding - prognosis

DUB persists for 2 years in 60% of patients, 4 years in 50%, and up to 10 years in 30%.

Dysfunctional Uterine Bleeding - complications

Mild to severe anemia resulting from blood loss

Dysfunctional Uterine Bleeding - patient monitoring

When to expect improvement:

• Bleeding usually tapers after the 1st few doses of hormone therapy.
• After 6–12 months, if patient does not wish to remain on OCPs, a trial off medication might reveal normal ovulatory cycles.

Dysfunctional Uterine Bleeding - bibliography

1. Bravender T, Emans SJ. Menstrual disorders: Dysfunctional uterine bleeding. Pediatr Clin North Am. 1999;46:545–553.
Emans SJ, Laufer MR, Goldstein DP. Pediatric and Adolescent Gynecology. 4th ed. Philadelphia: Lippincott-Raven; 1998.
2. Levine LJ, Catallozzi M, Schwarz DF. An adolescent with vaginal bleeding. Pediatr Case Rev. 2003;3: 83–90.
Mitan LA, Slap GB. Dysfunctional uterine bleeding. In: Neinstein LS, ed. Adolescent Health Care: A Practical Guide. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2002.
3. Rimsza ME. Dysfunctional uterine bleeding [erratum appears in Pediatr Rev. 2002;23]. Pediatr Rev. 2002;23:227–233.

Dysfunctional Uterine Bleeding - CODES

Dysfunctional Uterine Bleeding - icd9

• 626.1 Metrorrhagia
• 626.2 Menometrorrhagia
• 626.8 Dysfunctional uterine bleeding

Dysfunctional Uterine Bleeding - FAQ

• Q: If most girls have anovulatory cycles, why do only some present with DUB?
• A: Most girls do have an irregular menstrual cycle during the 1st 2 years after menarche. However, in most of those girls, the negative-feedback system of estrogen will lead to cyclic endometrial shedding in an anovulatory pattern.
• Q: If DUB from anovulatory cycles is caused by lack of progesterone, why does the initial treatment of severe DUB with active bleeding involve large doses of estrogen?
• A: Estrogen has procoagulation effects that promote hemostasis (e.g., effects on platelet aggregation and levels of fibrinogen and clotting factors). In addition, severe DUB may lead to an exposed endometrial base that bleeds profusely; for progesterone to exhibit its secretory effects, the endometrium in that area must be restored by estrogen.
• Q: When hormonal therapy fails, and the basal endometrium continues to bleed, how does a dilation and curettage act as the final treatment?
• A: The curettage removes any remaining bleeding vessels and stimulates local prostaglandins to create a uterine contracture that inhibits bleeding. This is rarely needed in adolescent patients, as they usually respond to hormonal therapy.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

Other Book Chapters Related to Vaginal bleeding

Read excerpts from these other book chapters related to Vaginal bleeding:

Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Williams & Wilkins.

More About Causes of Vaginal bleeding

• Back to symptom: Vaginal bleeding: Introduction (review 134 causes)
• Next Book Extract About Vaginal bleeding: Medications causing Vaginal bleeding
• All Book Extracts: All Online Book Extracts for Vaginal bleeding

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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