Dysfunctional Uterine Bleeding Clinical Presentation: History, Physical,...

1 of 5

http://emedicine.medscape.com/article/257007-clinical#showall

Dysfunctional Uterine Bleeding Clinical Presentation

Author: Millie A Behera, MD; Chief Editor: Richard Scott Lucidi, MD, FACOG more...
Updated: Sep 29, 2014

History

Suspect dysfunctional uterine bleeding (DUB) when a patient presents with

unpredictable or episodic heavy or light bleeding despite a normal pelvic
examination.
Note the following:

Typically, the usual moliminal symptoms that accompany ovulatory cycles will
not precede bleeding episodes.
Exclude the diagnosis of pregnancy first.
Address the presence of local and systemic disease. Rule out the presence
of signs or symptoms indicative of bleeding disorders. Screening for personal
and family history of easy bruising, bleeding gums, epistaxis, and excessive
bleeding episodes during childbirth, surgery, or dental procedures may be
useful.
Rule out iatrogenic causes of bleeding, including bleeding secondary to
steroid hormone contraception, hormone replacement therapy, or other
hormone treatments, which are common causes.
Most patients are adolescents or are older than 40 years.

Patients who report irregular menses since menarche may have polycystic ovarian
syndrome (PCOS). PCOS is characterized by anovulation or oligo-ovulation and
hyperandrogenism. These patients often present with unpredictable cycles and/or
infertility, hirsutism with or without hyperinsulinemia, and obesity.

Patients with adrenal enzyme defects, hyperprolactinemia, thyroid disease, or other

metabolic disorders also might present with anovulatory bleeding.

Physical

The physical examination can elicit several anatomic and organic causes of
abnormal uterine bleeding.

A complete physical examination should begin with assessment of hemodynamic

stability (vital signs) and proceed with evaluation of the following:

Obesity (BMI)
Signs of androgen excess (hirsutism, acne)
Thyroid enlargement or manifestations of hyperthyroidism or hypothyroidism.
Galactorrhea (may suggest hyperprolactinemia)
Visual field deficits (raise suspicion of intracranial/pituitary lesion)
Ecchymosis, purpura (signs of bleeding disorder)
Signs of anemia or chronic blood loss
A careful gynecologic examination, including Papanicolaou test (Pap smear)
and sexually transmitted disease (STD) screening, is warranted.
The hallmark of DUB is a negative pelvic examination despite the clinical
history. In such cases, management might rest on a clinical diagnosis. Rule
out the presence of uterine fibroids or polyps, as well as rule out endometrial
hyperplasia or carcinoma.

Causes

In ovulatory cycles, progesterone production from the corpus luteum converts

estrogen primed proliferative endometrium to secretory endometrium, which sloughs
predictably in a cyclic fashion if pregnancy does not occur. Heavy but regular uterine
bleeding implies ovulatory bleeding and should not be diagnosed as DUB. Subtle
disturbances in endometrial tissue mechanisms, other forms of uterine pathology, or
systemic causes might be implicated.
Anovulatory cycles are associated with a variety of bleeding manifestations.
Estrogen withdrawal bleeding and estrogen breakthrough bleeding are the most
common spontaneous patterns encountered in clinical practice. Iatrogenically
induced anovulatory uterine bleeding might occur during treatment with oral
contraceptives, progestin-only preparations, or postmenopausal steroid replacement
therapy.
Estrogen breakthrough bleeding\\ Anovulatory cycles have no corpus luteal
formation. Progesterone is not produced. The endometrium continues to proliferate
under the influence of unopposed estrogen.

11/9/2015 9:57 PM

Dysfunctional Uterine Bleeding Clinical Presentation: History, Physical,...

2 of 5

http://emedicine.medscape.com/article/257007-clinical#showall

Eventually, this out-of-phase endometrium is shed in an irregular manner that might

be prolonged and heavy. This pattern is known as estrogen breakthrough bleeding
and occurs in the absence of estrogen decline.

Estrogen withdrawal bleeding

This frequently occurs in women approaching the end of reproductive life. In older
women, the mean length of menstrual cycle is shortened significantly due to
aberrant follicular recruitment, resulting in a shortened proliferative phase. Ovarian
follicles in these women secrete less estradiol. Fluctuating estradiol levels might
lead to insufficient endometrial proliferation with irregular menstrual shedding. This
bleeding might be experienced as light, irregular spotting.
Eventually, the duration of the luteal phase shortens, and, finally, ovulation stops.
Dyssynchronous endometrial histology with irregular menstrual shedding and
eventual amenorrhea result.

Oral contraceptives, progestin-only preparations, or

postmenopausal steroid replacement therapy

Treatment with oral contraceptives, progestin-only preparations, or postmenopausal

steroid replacement therapy might be associated with iatrogenically induced uterine
bleeding.
Progesterone breakthrough bleeding occurs in the presence of an unfavorably high
ratio of progestin to estrogen.
Intermittent bleeding of variable duration can occur with progestin-only oral
contraceptives, depo-medroxyprogesterone, and depo-levonorgestrel.

rogesterone withdrawal bleeding can occur if the endometrium initially has been
primed with endogenous or exogenous estrogen, exposed to progestin, and then
withdrawn from progestin. Such a pattern is seen in cyclic hormonal replacement
therapy.

Adolescents

The primary defect in the anovulatory bleeding of adolescents is failure to mount an

ovulatory luteinizing hormone (LH) surge in response to rising estradiol levels.
Failure occurs secondary to delayed maturation of the hypothalamic-pituitary axis.
Because a corpus luteum is not formed, progesterone levels remain low.

The existing estrogen primed endometrium does not become secretory. Instead, the
endometrium continues to proliferate under the influence of unopposed estrogen.
Eventually, this out-of-phase endometrium is shed in an irregular manner that might
be prolonged and heavy, such as that seen in estrogen breakthrough bleeding.

Climacteric

Anovulatory bleeding in menopausal transition is related to declining ovarian

follicular function.

Estradiol levels will vary with the quality and state of follicular recruitment and
growth. Bleeding might be light or heavy depending on the individual cycle
response.

Bleeding disorders

An international expert panel including obstetrician/gynecologists and hematologists

has issued guidelines to assist physicians in better recognizing 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.[2]
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.

An underlying bleeding disorder should be considered when a patient has any of the
following:
Menorrhagia since menarche
Family history of bleeding disorders
Personal history of 1 or more of the following: (1) Notable bruising without
known injury; (2) bleeding of the oral cavity or gastrointestinal tract without
obvious lesion; or (3) epistaxis greater than 10 minutes duration (possibly
necessitating packing or cautery)

If a bleeding disorder is suspected, consultation with a hematologist is suggested.

Differential Diagnoses

Contributor Information and Disclosures

Author
Millie A Behera, MD Assistant Professor (Adjunct), Division of Reproductive Endocrinology and Fertility,

11/9/2015 9:57 PM

Dysfunctional Uterine Bleeding Clinical Presentation: History, Physical,...

3 of 5

http://emedicine.medscape.com/article/257007-clinical#showall

Department of Obstetrics and Gynecology, Duke University Medical Center; Medical Director, Bloom Reproductive
Institute
Millie A Behera, MD is a member of the following medical societies: American College of Obstetricians and
Gynecologists, American Society for Reproductive Medicine, AAGL
Disclosure: Nothing to disclose.

Coauthor(s)
Thomas Michael Price, MD Associate Professor, Division of Reproductive Endocrinology and Infertility,
Department of Obstetrics and Gynecology, Director of Reproductive Endocrinology and Infertility Fellowship
Program, Duke University Medical Center
Thomas Michael Price, MD is a member of the following medical societies: Alpha Omega Alpha, American
College of Obstetricians and Gynecologists, Phi Beta Kappa, Society for Reproductive Investigation, Society for
Reproductive Endocrinology and Infertility, American Society for Reproductive Medicine
Disclosure: Received research grant from: Insigtec Inc<br/>Received consulting fee from Clinical Advisors Group
for consulting; Received consulting fee from MEDA Corp Consulting for consulting; Received consulting fee from
Gerson Lehrman Group Advisor for consulting; Received honoraria from ABOG for board membership.
Specialty Editor Board
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College
of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.

Frances E Casey, MD, MPH Director of Family Planning Services, Department of Obstetrics and Gynecology,
VCU Medical Center
Frances E Casey, MD, MPH is a member of the following medical societies: American College of Obstetricians
and Gynecologists, Association of Reproductive Health Professionals, Society of Family Planning, National
Abortion Federation, Physicians for Reproductive Health
Disclosure: Nothing to disclose.

Chief Editor
Richard Scott Lucidi, MD, FACOG Associate Professor of Reproductive Endocrinology and Infertility,
Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine
Richard Scott Lucidi, MD, FACOG is a member of the following medical societies: American College of
Obstetricians and Gynecologists, American Society for Reproductive Medicine
Disclosure: Nothing to disclose.

Additional Contributors
Anthony Charles Sciscione, DO Professor, Department of Obstetrics and Gynecology, Drexel University College
of Medicine; Director, Maternal and Fetal Medicine, Christiana Care Health System; Director, Delaware Center for
Maternal and Fetal Medicine
Anthony Charles Sciscione, DO is a member of the following medical societies: American College of Obstetricians
and Gynecologists, American Medical Association
Disclosure: Nothing to disclose.

Acknowledgements
The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous
author John T Queenan, Jr, MD, to the development and writing of this article.

References
1. Roach L. Uterine Bleeding: ACOG Updates Guidelines. Medscape Medical News. Jun 21 2013. Available at
http://www.medscape.com/viewarticle/806735. Accessed: July 10, 2013.
2. [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. 2009 May 28. [Medline].
3. Hickey M, Higham JM, Fraser I. Progestogens with or without oestrogen for irregular uterine bleeding
associated with anovulation. Cochrane Database Syst Rev. 2012 Sep 12. 9:CD001895. [Medline].

4. Jick SS, Hernandez RK. Risk of non-fatal venous thromboembolism in women using oral contraceptives
containing drospirenone compared with women using oral contraceptives containing levonorgestrel:
case-control study using United States claims data. BMJ. 2011 Apr 21. 342:d2151. [Medline]. [Full Text].
5. Teichmann A, Apter D, Emerich J, Greven K, Klasa-Mazurkiewicz D, Melis GB, et al. Continuous, daily
levonorgestrel/ethinyl estradiol vs. 21-day, cyclic levonorgestrel/ethinyl estradiol: efficacy, safety and
bleeding in a randomized, open-label trial. Contraception. 2009 Dec. 80(6):504-11. [Medline].

6. Vitagliano A, Bertin M, Conte L, et al. Thermal balloon ablation versus transcervical endometrial resection:
evaluation of postoperative pelvic pain in women treated for dysfunctional uterine bleeding. Clin Exp Obstet
Gynecol. 2014. 41(4):405-8. [Medline].
7. Ash SJ, Farrell SA, Flowerdew G. Endometrial biopsy in DUB. J Reprod Med. 1996 Dec. 41(12):892-6.

11/9/2015 9:57 PM

Dysfunctional Uterine Bleeding Clinical Presentation: History, Physical,...

4 of 5

http://emedicine.medscape.com/article/257007-clinical#showall

[Medline].

8. Bayer SR, DeCherney AH. Clinical manifestations and treatment of dysfunctional uterine bleeding. JAMA.
1993 Apr 14. 269(14):1823-8. [Medline].
9. Bongers MY, Bourdrez P, Heintz AP, et al. Bipolar radio frequency endometrial ablation compared with
balloon endometrial ablation in dysfunctional uterine bleeding: impact on patients' health-related quality of
life. Fertil Steril. 2005 Mar. 83(3):724-34. [Medline].

10. Bongers MY, Mol BW, Brolmann HA. Current treatment of dysfunctional uterine bleeding. Maturitas. 2004
Mar 15. 47(3):159-74. [Medline].

11. Bourdrez P, Bongers MY, Mol BW. Treatment of dysfunctional uterine bleeding: patient preferences for
endometrial ablation, a levonorgestrel-releasing intrauterine device, or hysterectomy. Fertil Steril. 2004 Jul.
82(1):160-6, quiz 265. [Medline].

12. Casablanca Y. Management of dysfunctional uterine bleeding. Obstet Gynecol Clin North Am. 2008 Jun.
35(2):219-34. [Medline].

13. Chullapram T, Song JY, Fraser IS. Medium-term follow-up of women with menorrhagia treated by rollerball
endometrial ablation. Obstet Gynecol. 1996 Jul. 88(1):71-6. [Medline].
14. Claessens EA, Cowell CA. Dysfunctional uterine bleeding in the adolescent. Pediatr Clin North Am. 1981
May. 28(2):369-78. [Medline].

15. Crosignani PG, Rubin B. Dysfunctional uterine bleeding. Hum Reprod. 1990 Jul. 5(5):- Rubin B. [Medline].
16. Demers C, Derzko C, David M, et al. Gynaecological and obstetric management of women with inherited
bleeding disorders. Int J Gynaecol Obstet. 2006 Oct. 95(1):75-87. [Medline].
17. DeVore GR, Owens O, Kase N. Use of intravenous Premarin in the treatment of dysfunctional uterine
bleeding--a double-blind randomized control study. Obstet Gynecol. 1982 Mar. 59(3):285-91. [Medline].

18. Dodson MG. Use of transvaginal ultrasound in diagnosing the etiology of menometrorrhagia. J Reprod Med.
1994 May. 39(5):362-72. [Medline].
19. Daz S, Croxatto HB, Pavez M, et al. Clinical assessment of treatments for prolonged bleeding in users of
Norplant implants. Contraception. 1990 Jul. 42(1):97-109. [Medline].
20. Edlund M, Blomback M, von Schoultz B, et al. On the value of menorrhagia as a predictor for coagulation
disorders. Am J Hematol. 1996 Dec. 53(4):234-8. [Medline].
21. Ely JW, Kennedy CM, Clark EC, et al. Abnormal uterine bleeding: a management algorithm. J Am Board
Fam Med. 2006 Nov-Dec. 19(6):590-602. [Medline]. [Full Text].
22. Falcone T, Desjardins C, Bourque J, et al. Dysfunctional uterine bleeding in adolescents. J Reprod Med.
1994 Oct. 39(10):761-4. [Medline].
23. Ferenczy A, Gelfand M. The biologic significance of cytologic atypia in progestogen-treated endometrial
hyperplasia. Am J Obstet Gynecol. 1989 Jan. 160(1):126-31. [Medline].

24. Ferenczy A, Gelfand MM, Tzipris F. The cytodynamics of endometrial hyperplasia and carcinoma. A review.
Ann Pathol. 1983 Sep. 3(3):189-201. [Medline].
25. Franks S, Adams J, Mason H, et al. Ovulatory disorders in women with polycystic ovary syndrome. Clin
Obstet Gynaecol. 1985 Sep. 12(3):605-32. [Medline].

26. Gervaise A, de Tayrac R, Fernandez H. Contraceptive information after endometrial ablation. Fertil Steril.
2005 Dec. 84(6):1746-7. [Medline].
27. Hopkins MP, Androff L, Benninghoff AS. Ginseng face cream and unexplained vaginal bleeding. Am J
Obstet Gynecol. 1988 Nov. 159(5):1121-2. [Medline].

28. Jayasinghe Y, Moore P, Donath S, et al. Bleeding disorders in teenagers presenting with menorrhagia. Aust
N Z J Obstet Gynaecol. 2005 Oct. 45(5):439-43. [Medline].
29. Kadir RA, Economides DL, Sabin CA, et al. Frequency of inherited bleeding disorders in women with
menorrhagia. Lancet. 1998 Feb 14. 351(9101):485-9. [Medline].

30. LaCour DE, Long DN, Perlman SE. Dysfunctional uterine bleeding in adolescent females associated with
endocrine causes and medical conditions. J Pediatr Adolesc Gynecol. 2010 Apr. 23(2):62-70. [Medline].

31. Lethaby A, Augood C, Duckitt K, et al. Nonsteroidal anti-inflammatory drugs for heavy menstrual bleeding.
Cochrane Database Syst Rev. 2007 Oct 17. CD000400. [Medline].
32. Lethaby A, Farquhar C, Cooke I. Antifibrinolytics for heavy menstrual bleeding. Cochrane Database Syst
Rev. 2000. CD000249. [Medline].

33. Lethaby A, Irvine G, Cameron I. Cyclical progestogens for heavy menstrual bleeding. Cochrane Database
Syst Rev. 2008 Jan 23. CD001016. [Medline].
34. Lethaby AE, Cooke I, Rees M. Progesterone or progestogen-releasing intrauterine systems for heavy
menstrual bleeding. Cochrane Database Syst Rev. 2005 Oct 19. CD002126. [Medline].
35. March CM. Hysteroscopy. J Reprod Med. 1992 Apr. 37(4):293-311; discussion 311-2. [Medline].

36. Margolis MT, Thoen LD, Boike GM, et al. Asymptomatic endometrial carcinoma after endometrial ablation.
Int J Gynaecol Obstet. 1995 Dec. 51(3):255-8. [Medline].

11/9/2015 9:57 PM

Dysfunctional Uterine Bleeding Clinical Presentation: History, Physical,...

5 of 5

http://emedicine.medscape.com/article/257007-clinical#showall

37. Meyer WR, Walsh BW, Grainger DA, et al. Thermal balloon and rollerball ablation to treat menorrhagia: a
multicenter comparison. Obstet Gynecol. 1998 Jul. 92(1):98-103. [Medline].
38. Munro MG. Dysfunctional uterine bleeding: advances in diagnosis and treatment. Curr Opin Obstet
Gynecol. 2001 Oct. 13(5):475-89. [Medline].

39. Ravn SH, Rosenberg J, Bostofte E. Postmenopausal hormone replacement therapy--clinical implications.
Eur J Obstet Gynecol Reprod Biol. 1994 Feb. 53(2):81-93. [Medline].

40. Rodeghiero F. Management of menorrhagia in women with inherited bleeding disorders: general principles
and use of desmopressin. Haemophilia. 2008 Jan. 14 Suppl 1:21-30. [Medline].

41. Rogers PA, Martinez F, Girling JE, et al. Influence of different hormonal regimens on endometrial
microvascular density and VEGF expression in women suffering from breakthrough bleeding. Hum Reprod.
2005 Dec. 20(12):3341-7. [Medline].
42. Rose EH, Aledort LM. Nasal spray desmopressin (DDAVP) for mild hemophilia A and von Willebrand
disease. Ann Intern Med. 1991 Apr 1. 114(7):563-8. [Medline].
43. Sagiv R, Ben-Shem E, Condrea A, et al. Endometrial carcinoma after endometrial resection for
dysfunctional uterine bleeding. Obstet Gynecol. 2005 Nov. 106(5 Pt 2):1174-6. [Medline].

44. Schneider LG. Causes of abnormal vaginal bleeding in a Family Practice Center. J Fam Pract. 1983 Feb.
16(2):281-3. [Medline].
45. Smith CB. Dysfunctional uterine bleeding. Am Fam Physician. 1987 Sep. 36(3):161-8. [Medline].

46. Solnik JM, Guido RS, Sanfilippo JS, et al. The impact of endometrial ablation technique at a large university
women's hospital. Am J Obstet Gynecol. 2005 Jul. 193(1):98-102. [Medline].
47. Speroff L, Glass R, Kase N. Dysfunctional uterine bleeding. Clinical Gynecologic Endocrinology & Infertility.
1999. 575-591.
48. Strickland JL. Management of abnormal bleeding in adolescents. Mo Med. 2004 Jan-Feb. 101(1):38-41.
[Medline].
49. van Bogaert LJ. Diagnostic aid of endometrium biopsy. Gynecol Obstet Invest. 1979. 10(6):289-97.
[Medline].

50. Van Zon-Rabelink IA, Vleugels MP, Merkus HM, et al. Efficacy and satisfaction rate comparing endometrial
ablation by rollerball electrocoagulation to uterine balloon thermal ablation in a randomised controlled trial.
Eur J Obstet Gynecol Reprod Biol. 2004 May 10. 114(1):97-103. [Medline].
51. Wathen PI, Henderson MC, Witz CA. Abnormal uterine bleeding. Med Clin North Am. 1995 Mar.
79(2):329-44. [Medline].

52. Wilansky DL, Greisman B. Early hypothyroidism in patients with menorrhagia. Am J Obstet Gynecol. 1989
Mar. 160(3):673-7. [Medline].
53. Wren BG. Dysfunctional uterine bleeding. Aust Fam Physician. 1998 May. 27(5):371-7. [Medline].

Medscape Reference 2011 WebMD, LLC

11/9/2015 9:57 PM