Dysfunctional Uterine Bleeding
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- Dysfunctional uterine bleeding (DUB) is irregular menstrual bleeding (usually heavy, prolonged, or frequent); it is a diagnosis of exclusion after establishment of normal anatomy and the absence of other medical illnesses.
- Commonly associated with anovulation
Adolescent and perimenopausal women are affected most often.
5% of reproductive age women will see a doctor in any given year for DUB.
10–30% of reproductive age women have DUB.
Etiology and Pathophysiology
- Anovulation accounts for 90% of DUB:
- Loss of cyclic endometrial stimulation
- Elevated estrogen levels stimulate endometrial growth.
- No organized progesterone withdrawal bleed
- Endometrium eventually outgrows blood supply, breaks down, and sloughs from uterus.
- Adolescent DUB is usually due to an immature hypothalamic-pituitary-ovarian (HPO) axis that leads to anovulatory cycles.
- DUB can be broadly divided into anovulatory bleeding (usually irregular and unpredictable menses) or ovulatory bleeding (usually heavy regular menses) after pathologic causes of abnormal bleeding have been ruled out:
- Pregnancy: Ectopic pregnancy, threatened or incomplete abortion, or hydatidiform mole
- Reproductive pathology and structural disorders:
- Uterus: Leiomyomas, endometritis, hyperplasia, polyps, trauma
- Adnexa: Salpingitis, functional ovarian cysts
- Cervix: Cervicitis, polyps, STIs, trauma
- Vagina: Trauma, foreign body
- Vulva: Lichen sclerosis, STIs
- Malignancy of the vagina, cervix, uterus, and ovaries
- Systemic diseases:
- Inflammatory bowel disease
- Hematologic disorders (e.g., Von Willebrand disease, thrombocytopenia)
- Advanced or fulminant liver disease
- Chronic renal disease
- Diseases causing anovulation:
- Adrenal disorders
- Pituitary disease (prolactinoma)
- Polycystic ovarian syndrome (PCOS)
- Eating disorders
- Medications (iatrogenic causes):
- Hormonal medications: Intrauterine devices
- Antipsychotic medications
- Other causes of abnormal uterine bleeding:
- Excessive weight gain
- Increased exercise
Unclear, but can include inherited disorders of hemostasis
Risk factors for endometrial cancer (which can cause DUB):
- Age >40
- Diabetes mellitus
- Early menarche or late menopause (>55 years)
- Chronic anovulation or infertility
- Unopposed estrogen therapy
- History of breast cancer or endometrial hyperplasia
- Tamoxifen use
- Family history: Gynecologic, breast, or colon cancer