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Emergency And Acute Medicine – Dysfunctional Uterine Bleeding
Basics Description
Abnormal uterine bleeding refers to an alteration in the pattern or volume of normal menses. Typical menstrual blood loss is 30–80 mL, with a normal cycle interval of 28 ± 7 days. Abnormal uterine bleeding is classified into dysfunctional uterine bleeding (DUB) and organic uterine bleeding. Dysfunctional uterine bleeding is hormonally mediated, divided into anovulatory and ovulatory categories, is not due to organic or iatrogenic causes, and is therefore a diagnosis of exclusion. Organic uterine bleeding is related to systemic illness or disease of the reproductive tract.
Etiology
Anovulatory bleeding, the most common cause, results from unopposed estrogen stimulation of the proliferative endometrium. Neuroendocrine dysfunction may be associated with polycystic ovarian syndrome, very low-calorie diets, rapid weight changes, intense exercise, anorexia, psychological stress, obesity, medications, hypothyroidism, or primary hypothalamic dysfunction. Ovulatory bleeding is caused by inadequate uterine prostaglandin F2α, increased uterine contractility, or excessive prostacycline production, which diminishes platelet function and increases uterine vasodilation.
Pediatric Considerations
Anovulatory bleeding is common during adolescence due to immaturity of the hypothalamic–pituitary–ovarian axis.
Diagnosis Signs And Symptoms
Patients present with abnormal uterine bleeding in the absence of systemic or structural disease. It is most common in perimenarcheal and perimenopausal women and is typically painless. Anovulatory patterns include metrorrhagia with irregular bleeding between periods, menorrhagia with regular cycles and excessive flow greater than 80 mL or lasting more than 7 days, oligomenorrhea with cycles longer than 35 days, and menometrorrhagia with heavy and irregular bleeding.
History
History focuses on bleeding pattern, duration, volume, associated symptoms, medication use, and risk factors for pregnancy or systemic disease.
Physical-Exam
Acne, hirsutism, and obesity suggest polycystic ovarian syndrome. Pelvic examination typically reveals mild to moderate bleeding. Pallor, tachycardia, hypotension, and orthostasis indicate severe blood loss. Evaluate for trauma or foreign bodies.
Alert
Hemodynamic instability is rare in dysfunctional uterine bleeding; if present, consider ectopic pregnancy or another cause of acute hemorrhage.
Essential Workup
A pregnancy test is mandatory.
Diagnosis Tests And Interpretation
Laboratory evaluation includes pregnancy test, complete blood count, and coagulation studies. Iron studies, thyroid-stimulating hormone, luteinizing hormone, follicle-stimulating hormone, prolactin, and cervical cultures are typically deferred for outpatient follow-up. Pelvic ultrasound may identify uterine, tubal, or ovarian pathology and help exclude organic causes. Dilation and curettage may be required for heavy bleeding unresponsive to therapy. Endometrial biopsy is recommended for patients older than 35 years.
Differential Diagnosis
Pregnancy-related causes include threatened, incomplete, or spontaneous abortion, ectopic pregnancy, and molar pregnancy. Infectious causes include vaginitis, cervicitis, and pelvic inflammatory disease. Coagulopathies include von Willebrand disease, idiopathic thrombocytopenic purpura, platelet disorders, and thalassemia. Medication-related causes include warfarin, aspirin, oral contraceptives, tricyclic antidepressants, and antipsychotics. Systemic illnesses include adrenal, hepatic, renal, thyroid disease, diabetes, and other endocrinopathies. Anatomic causes include fibroids, endometriosis, polyps, endometrial hyperplasia, malignancy, intrauterine devices, and trauma.
Treatment Pre Hospital
Administer intravenous crystalloids as needed for hypotension or tachycardia secondary to heavy bleeding.
Initial Stabilization And Therapy
Follow ABCs. Transfuse packed red blood cells for significant bleeding unresponsive to crystalloid resuscitation.
Emergency Department Treatment And Procedures
Observation is usually sufficient for mild bleeding. Administer intravenous fluids or packed red blood cells for continued bleeding or hemodynamic instability. Obtain gynecology consultation for severe bleeding unresponsive to medical therapy. Dilation and curettage may be necessary for instability. Endometrial ablation or hysterectomy is reserved for refractory cases.
Medication
Conjugated estrogen is indicated for heavy bleeding with hemodynamic instability at 2.5 mg orally every 6 hours or 25 mg intravenously, repeatable after 3 hours if needed. Ibuprofen 400–800 mg orally every 8 hours reduces prostaglandin synthesis. Medroxyprogesterone acetate 5–10 mg orally daily is added once bleeding subsides. Combined oral contraceptives containing ethinyl estradiol 35 μg and norethindrone 1 mg may be given four times daily for one week. Tranexamic acid 1,300 mg orally three times daily for five days may be used, though limited by gastrointestinal side effects and allergy risk. Medications may be deferred in mild cases with outpatient gynecology referral.
Follow-Up And Disposition
Admission is required for significant blood loss, continued bleeding, or hemodynamic instability requiring aggressive resuscitation or operative intervention. Most patients may be discharged once bleeding is controlled and vital signs are stable, with gynecology follow-up arranged.
Issues For Referral
Endometrial biopsy is indicated for patients older than 35 years. Follow-up with gynecology or primary care is essential to evaluate for ongoing blood loss or malignancy.
Pearls And Pitfalls
Dysfunctional uterine bleeding is a diagnosis of exclusion. Only 2% of endometrial carcinomas occur before age 40. Hemodynamic instability makes DUB an unlikely primary diagnosis.
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