Dysfungsion uterine bleeding

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] It affects women's health both medically and socially.
Pathophysiology

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. In 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. If 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:

Menorrhagia - Prolonged (>7 d) or excessive (>80 mL daily) uterine bleeding

occurring at regular intervals

Metrorrhagia - Uterine bleeding occurring at irregular and more frequent than

normal intervals

Menometrorrhagia - Prolonged or excessive uterine bleeding occurring at

irregular and more frequent than normal intervals

Intermenstrual bleeding - Uterine bleeding of variable amounts occurring

between regular menstrual periods

Midcycle spotting - Spotting occurring just before ovulation, typically from

declining estrogen levels

Postmenopausal bleeding - Recurrence of bleeding in a menopausal woman

at least 6 months to 1 year after cessation of cycles

Amenorrhea - No uterine bleeding for 6 months or longer

Dysfunctional uterine bleeding is a diagnosis of exclusion. It 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.
In ovulatory dysfunctional uterine bleeding, bleeding occurs cyclically, and menorrhagia is
thought to originate from defects in the control mechanisms of menstruation. It 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]
Epidemiology
Frequency

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]
International
No cultural predilection is present with this disease state.
Mortality/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.

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. [5]

Abnormal uterine bleeding affects up to 50% of perimenopausal women. In

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. In
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, 6]