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Abnormal (Dysfunctional) Uterine Bleeding

Practice Essentials

Abnormal uterine bleeding (formerly, dysfunctional uterine bleeding [DUB]
) is irregular uterine bleeding that occurs in the absence of recognizable pelvic pathology, general medical disease, or pregnancy. It reflects a disruption in the normal cyclic pattern of ovulatory hormonal stimulation to the endometrial lining. The bleeding is unpredictable in many ways. It may be excessively heavy or light and may be prolonged, frequent, or random.

About 1-2% of women with improperly managed anovulatory bleeding eventually may develop endometrial cancer.

Signs and symptoms

AUB should be suspected in patients with unpredictable or episodic heavy or light bleeding despite a normal pelvic examination. Typically, the usual moliminal symptoms that accompany ovulatory cycles will not precede bleeding episodes.

Pathologic causes of anovulatory bleeding

Because AUB is considered a diagnosis of exclusion, the presence or absence of signs and symptoms of other causes of anovulatory bleeding must be determined.

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.

Other signs of underlying pathology include the following:

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

See Clinical Presentation for more detail.


Laboratory studies

Studies used to exclude a pathologic source of anovulatory bleeding include the following:

Human chorionic gonadotropin (HCG)

Complete blood count (CBC)

Papanicolaou test (Pap smear)

Endometrial sampling

Thyroid functions and prolactin

Liver functions

Coagulation studies/factors

Other hormone assays, as indicated

Imaging studies

In obese patients with a suboptimal pelvic examination or in patients with suspected ovarian or uterine pathology, pelvic ultrasonographic evaluation may be helpful. Ultrasonography can be used to identify uterine fibroids, as well as endometrial conditions, including hyperplasia, carcinoma, and polyps.


Rule out endometrial carcinoma in all patients at high risk for the condition, including those with the following characteristics:

Morbid obesity

Diabetes or chronic hypertension

Age over 35 years

Longstanding, chronic eugonadal anovulation

Traditionally, carcinoma was ruled out by endometrial sampling via dilation and curettage (D&C). However, endometrial sampling in the office via aspiration, curetting, or hysteroscopy has become popular and is also relatively accurate.


Most endometrial biopsy specimens will show proliferative or dyssynchronous endometrium.

See Workup for more detail.


Pharmacologic treatment

Oral contraceptives: Suppress endometrial development, reestablish predictable bleeding patterns, decrease menstrual flow, and lower the risk of iron deficiency anemia

Estrogen: Prolonged uterine bleeding suggests the epithelial lining of the cavity has become denuded over time; estrogen administered alone will rapidly induce a return to normal endometrial growth

Progestins: Chronic management of AUB requires episodic or continuous exposure to a progestin

Desmopressin: A synthetic analogue of arginine vasopressin, desmopressin has been used as a last resort to treat abnormal uterine bleeding in patients with documented coagulation disorders


Abdominal or vaginal hysterectomy may be necessary in patients who have failed or declined hormonal therapy, who have symptomatic anemia, and who are experiencing a disruption in their quality of life from persistent, unscheduled bleeding.

Endometrial ablation

Endometrial ablation is an alternative for patients who wish to avoid hysterectomy or who are not candidates for major surgery.

See Treatment and Medication for more detail.

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