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.
Diagnosis
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.
Procedures
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.
Histology
Most endometrial biopsy specimens will show proliferative or dyssynchronous endometrium.
See Workup for more detail.
Management
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
Hysterectomy
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.