Dysfunctional uterine bleeding (DUB) is irregular bleeding that occurs without recognizable causes in the absence of pregnancy. It results from disruptions to the normal hormonal patterns that regulate the uterine lining. Bleeding episodes with DUB can be unpredictable in terms of duration, frequency, and amount. Laboratory tests and imaging studies are used to diagnose DUB and rule out other causes by examining thyroid function, prolactin levels, and pelvic imaging. Treatment involves pharmacologic options like oral contraceptives, estrogen, or progestins to suppress bleeding or reestablish normal cycles. Hysterectomy may be necessary for patients who do not respond to hormone therapy or experience quality of life issues from persistent bleeding.

1. DR FAISAL AL HADDAD
CONSULTANT OF FAMILY MEDICINE &
OCCUPATIONAL HEALTH
Dysfunctional Uterine Bleedin

2. Background
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.

3. Signs and symptoms
DUB 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.

4. Signs and symptoms
Because DUB 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.

5. Signs and symptoms
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

6. Diagnosis
Laboratory studies
 Human chorionic gonadotropin (HCG)
 Complete blood count (CBC)
 Papanicolaou test (Pap smear)
 Endometrial sampling
 Thyroid functions and prolactin
 Liver functions
 Coagulation studies/factors

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

8. 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 DUB 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

9. Management
Hysterectomy may be necessary in patients who :
have failed or declined hormonal therapy,
have symptomatic anemia, and
are experiencing a disruption in their quality of life from
persistent, unscheduled bleeding.
Endometrial ablation is an alternative for patients who
wish to avoid hysterectomy or who are not candidates for
major surgery.

10. THANK YOU