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Dysfunctional Uterine Bleeding

by JoAnn V. Pinkerton, MD

Dysfunctional uterine bleeding is abnormal bleeding resulting from changes in the hormonal control of menstruation.

  • Bleeding occurs frequently or irregularly, lasts longer, or is heavier.

  • This disorder is diagnosed when the physical examination, ultrasonography, and other tests have ruled out the usual causes of vaginal bleeding.

  • An endometrial biopsy is usually done.

  • The bleeding can usually be controlled with estrogen plus a progestin (a synthetic female hormone) or sometimes with either alone.

  • If the biopsy detects abnormal cells, treatment involves high doses of a progestin and sometimes removal of the uterus.

Dysfunctional uterine bleeding occurs most commonly at the beginning and end of the reproductive years: 20% of cases occur in adolescent girls, and more than 50% occur in women older than 45. In about 90% of cases, the ovaries do not regularly release an egg (ovulate). Thus, pregnancy is less likely. However, because the ovaries may occasionally release an egg, these women should use contraception if they do not wish to become pregnant.

Dysfunctional uterine bleeding commonly results when thelevel of estrogen remains high instead of decreasing as it normally does after an egg is released and is not fertilized. The high estrogen level is not balanced by an appropriate level of progesterone . In such cases, no egg is released, and the lining of the uterus (endometrium) may continue to thicken (instead of breaking down and being shed normally as a menstrual period). This abnormal thickening is called endometrial hyperplasia. Periodically, the thickened lining is shed incompletely and irregularly, causing bleeding. Bleeding is irregular, prolonged, and sometimes heavy. This type of bleeding is common among women who have polycystic ovary syndrome and occurs in some women with endometriosis. If this cycle of abnormal thickening and irregular shedding continues, precancerous cells may develop, increasing the risk of cancer of the uterine lining (endometrial cancer), even in young women.

Dysfunctional uterine bleeding is often an early sign of menopause.

Symptoms

Bleeding may differ from typical menstrual periods in the following ways:

  • Occur more frequently (fewer than 21 days apart—polymenorrhea)

  • Occur frequently and irregularly between periods (metrorrhagia)

  • Involve more blood loss (loss of more than about 3 ounces of blood or periods that last more than 7 days) but occur at regular intervals (menorrhagia)

  • Involve more blood loss and occur frequently and irregularly between menses (menometrorrhagia)

Bleeding during regular menstrual cycles may be abnormal, or bleeding may occur at unpredictable times. Some women have symptoms associated with menstrual periods, such as breast tenderness, cramping, and bloating, but many do not.

If bleeding continues, women may develop iron deficiency and sometimes anemia.

Whether infertility develops depends on the cause of the bleeding.

Diagnosis

Dysfunctional uterine bleeding is suspected when bleeding occurs at irregular times or in excessive amounts. It is diagnosed when all other possible causes of vaginal bleeding have been excluded. These causes include disorders of the reproductive organs (such as polycystic ovary syndrome), inflammation, blood clotting disorders, thyroid disorders, pregnancy, complications of pregnancy, and use of contraceptives or certain drugs.

To establish that bleeding is abnormal, doctors ask questions about the pattern of bleeding. To exclude other possible causes, they ask about other symptoms and possible causes (such as use of drugs, the presence of other disorders, fibroids, and complications during pregnancies). A physical examination is also done. A complete blood count can help doctors estimate how much blood has been lost and whether anemia is present. A pregnancy test is also done.

Tests to check for possible causes of vaginal bleeding may be done based on the findings during the interview and physical examination. For example, doctors may do blood tests to determine how fast blood clots (to check for clotting disorders) or to measure hormone levels (to check for polycystic ovary syndrome, thyroid disorders, or other disorders).

Transvaginal ultrasonography (using a small handheld device inserted through the vagina and into the uterus) is often used to check for growths in the uterus and to determine whether the uterine lining is thickened.

If the risk of endometrial cancer is increased, doctors take a sample of tissue from the lining of the uterus (an endometrial biopsy). Risk is increased in women with the following:

  • Age 35 or older

  • Obesity

  • Polycystic ovary syndrome

  • High blood pressure

  • Diabetes

  • Bleeding that is persistent, irregular, or heavy despite treatment

  • Thickening of the uterine lining (detected by ultrasonography)

  • Inconclusive findings during ultrasonography

Treatment

Treatment depends on how old the woman is, how heavy the bleeding is, whether the uterine lining is thickened, and whether the woman wishes to become pregnant. It focuses on controlling the bleeding and, if needed, preventing endometrial cancer. Bleeding can be controlled using drugs, which may be hormones or not. Drugs that are not hormones are often used first, especially in younger women, because they have fewer side effects. These drugs include

  • NSAIDs

  • Tranexamic acid

When the uterine lining is thickened but its cells are normal (endometrial hyperplasia), hormones may be used to control bleeding.Often, a birth control pill that contains estrogen and a progestin (a combination oral contraceptive) is used. Besides controlling bleeding, oral contraceptives decrease the breast tenderness and cramping that may accompany bleeding. They also decrease the risk of endometrial cancer. Bleeding usually stops in 12 to 24 hours. Sometimes high doses are needed to control the bleeding. After bleeding stops, low doses of the oral contraceptive may then be prescribed for at least 3 months to prevent the bleeding from recurring.

Some women should not take estrogen , including that in combination oral contraceptives (see Hormone therapy). Such women include postmenopausal women and women with significant risk factors for a heart or blood vessel disorder or for blood clots. For these women, a progestin may be used alone. It can be given by mouth for 21 days a month. When a progestin is taken this way, it may not prevent pregnancy. Thus, if women did not wish to become pregnant, they must use another method of contraception. A progestin may also be given through an intrauterine device (IUD) or by injection every few months. Progestin may also be used alone when treatments that include estrogen are ineffective.

If women are trying to become pregnant and bleeding is not too heavy, they may be given clomiphene (a fertility drug) by mouth instead of hormones. It stimulates ovulation.

If the uterine lining remains thickened or the bleeding persists despite treatment with hormones,dilation and curettage (D and C) is usually needed. In this procedure, tissue from the uterine lining is removed by scraping.This procedure may reduce bleeding. However, in some women, it causes scarring of the endometrium (Asherman syndrome), which can cause menstrual bleeding to stop (amenorrhea).

If bleeding continues after a D and C, a procedure that destroys or removes the lining of the uterus (endometrial ablation) can often help control bleeding. This procedure may use burning, freezing, or other techniques.

If bleeding continues to be substantial after other treatments have been tried, doctors may recommend removal of the uterus (hysterectomy).

If the uterine lining contains abnormal cells (particularly in women who are older than 35 and who do not want to become pregnant), treatment begins with a high dose of a progestin. A biopsy is done after 3 to 6 months of treatment. If it detects abnormal cells, a hysterectomy is done because the abnormal cells may become cancerous. If women are postmenopausal, treatment does not begin with a progestin. Hysterectomy may be required.

Rarely, very heavy bleeding requires emergency measures. They may include fluids given intravenously and blood transfusions. Occasionally, doctors insert a catheter with a deflated balloon at its tip through the vagina and into the uterus. The balloon is inflated to put pressure on the bleeding vessels and thus stop the bleeding. Very rarely, estrogen is given intravenously until the bleeding stops.

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