History

Fact Explanation
Heavy menstrual bleeding (with passage of clots and flooding) This is the commonest presenting symptom in most women. Heavy menstrual bleeding is defined as a menstrual blood loss greater than 80 mL. A crude measure can be made by asking how many blood soaked sanitary napkins are used during a day, whether there is passage of clots, whether there is flooding of blood etc.[1][3][4][5]
Irregular menstrual bleeding Occur in women at extremes of reproductive life i.e. postmenarche and perimenopausal [3]
Dysmenorrhoea May be an associated symptom[3]
Prolonged menstrual bleeding Can be a associated with heavy menstrual bleeding[2]
References
  1. LIVINGSTONE VH. Dysfunctional Uterine Bleeding Can Fam Physician [online] 1987 Nov:2563-2566 [viewed 13 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2218686
  2. FARELL E. Dysfunctional uterine bleeding. Australian Family Physician [online] Vol. 33, No. 11, November 2004 [viewed on 19 May 2014] Available from; http://www.racgp.org.au/afp/200411/14286
  3. NICE Clinical guidelines. Heavy menstrual bleeding: full guideline; CG44 [online]. January 2007.[viewed on 19 May 2014] Available from; http://www.nice.org.uk/nicemedia/live/11002/30401/30401.pdf
  4. COLLINS S. ARULKUMERAN S. HAYES K. JACKSON S. IMPEY L. Dysfunctional uterine bleeding. Oxford handbook of Obstetrics and Gynecology. Second edition. Oxford University press; 492-496
  5. PITKIN J. Dysfunctional uterine bleeding BMJ [online] 2007 May 26, 334(7603):1110-1111 [viewed 19 May 2014] Available from: doi:10.1136/bmj.39203.399502.BE

Examination

Fact Explanation
Pallor Pallor may be seen in women with anemia due to heavy menstrual bleeding. [1][2][3]
Abdominal palpation is normal DUB is a diagnosis of exclusion. There will be abnormalities such as the presence of a mass will lead to a different diagnosis such as an ovarian tumor, uterine fibroid etc. [1][2]
The cervix will appear normal in vaginal speculum examination DUB is diagnosed when all other possible pathologies are excluded. If cervix appears normal cervical causes for bleeding can be clinically excluded[1][2]
Bimanual examination of uterus and adnexiae is normal This excludes the possibility of a uterine or ovarian mass etc. leading to heavy menstrual bleeding.[1][2]
References
  1. FARRELL E. Dysfunctional uterine bleeding. Australian Family Physician [online] Vol. 33, No. 11, November 2004 [viewed on 19 May 2014] Available from; http://www.racgp.org.au/afp/200411/14286
  2. LIVINGSTONE VH. Dysfunctional Uterine Bleeding Can Fam Physician [online] 1987 Nov:2563-2566 [viewed 13 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2218686
  3. COLLINS S. ARULKUMERAN S. HAYES K. JACKSON S. IMPEY L. Dysfunctional uterine bleeding. Oxford handbook of Obstetrics and Gynecology. Second edition. Oxford University press; 492-496

Differential Diagnoses

Fact Explanation
Ectopic pregnancy Should be excluded in a woman in the child bearing age presenting with acute abnormal bleeding particularly if preceded by abdominal pain[1][7]
Abortion Should be excluded in a woman in the child bearing age presenting with acute abnormal bleeding[1][7]
Cervicitis Can present with abnormal menstrual bleeding similar to DUB[1]
Endometritis Can present with abnormal menstrual bleeding similar to DUB[1]
Vaginitis Can present with abnormal menstrual bleeding similar to DUB[1][4]
Pelvic inflammatory disease Can present with menstrual irregularities that are similar to DUB[1][7]
Cervical cancer Is an important differential diagnosis in middle aged females[1][4]
Endometrial cancer Can sometimes present with heavy menstrual bleeding[1][2][3][4]
Gestational trophoblastic disease Is a condition that can present with irregular or heavy vaginal bleeding[1][7]
Uterine fibroids Presents with menorrhagia, particularly submucosal fibroids [1][2][3][4]
Adenomyosis Can cause heavy menstrual bleeding associated with dysmenorrhea [1][2][3]
Cervical Polyps Is benign lesion which can cause menorrhagia[1][5]
Endometrial Polyps Can present with heavy menstrual bleeding and even with intermenstrual bleeding[1][2][3]
Coagulation disorders Is a rare cause of heavy menstrual bleeding, considered mainly in adolescents with heavy menstrual bleeding[1][2][3][4][5]
Hypothyroidism Is associated with heavy menstrual bleeding.[1][2][3]
References
  1. LIVINGSTONE VH. Dysfunctional Uterine Bleeding Can Fam Physician [online] 1987 Nov:2563-2566 [viewed 13 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2218686
  2. COLLINS S. ARULKUMERAN S. HAYES K. JACKSON S. IMPEY L. Dysfunctional uterine bleeding. Oxford handbook of Obstetrics and Gynecology. Second edition. Oxford University press; 492-496
  3. FARRELL E. Dysfunctional uterine bleeding. Australian Family Physician [online] Vol. 33, No. 11, November 2004 [viewed on 19 May 2014] Available from; http://www.racgp.org.au/afp/200411/14286
  4. PITKIN J. Dysfunctional uterine bleeding BMJ [online] 2007 May 26, 334(7603):1110-1111 [viewed 19 May 2014] Available from: doi:10.1136/bmj.39203.399502.BE
  5. CHEN BH, GIUDICE LC. Dysfunctional uterine bleeding. West J Med [online] 1998 Nov, 169(5):280-284 [viewed 19 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1305317
  6. SACKS D. Common menstrual concerns of adolescents Paediatr Child Health [online] 1998, 3(4):231-234 [viewed 19 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851341
  7. COPE E. Dysfunctional bleeding. Br Med J [online] 1971 Jun 12, 2(5762):631-632 [viewed 19 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1796497

Investigations - for Diagnosis

Fact Explanation
Urine Beta-hCG Done to exclude pregnancy [1][5]
Clotting screen (APTT , PT/INR, Clotting time, Bleeding time) Done if a clotting disorder is clinically suspected [1][2][4][5]
Serum TSH and T4 Done to detect hypothyroidism, if it is clinically suspected [1][2][4][5]
Cervical smear Done to detect cervical pathology. But need not be done routinely if smear history is normal [1]
Trans-vaginal ultra sound scan (TVS) Done to detect fibroids, polyps and to determine endometrial thickness particularly in women over the age of 40 years[1][2][4]This is the first line investigation to detect structural abnormalities[3]
Endometrial biopsy Done if the endometrial thickness is increased as seen by TVS [1][2][3][4]
Hysteroscopy and biopsy Done if there is suspicion of endometrial hyperplasia or cancer and when TVS is inconclusive[1][2][3][4]
References
  1. COLLINS S. ARULKUMERAN S. HAYES K. JACKSON S. IMPEY L. Dysfunctional uterine bleeding. Oxford handbook of Obstetrics and Gynecology. Second edition. Oxford University press; 492-496
  2. FARRELL E. Dysfunctional uterine bleeding. Australian Family Physician [online] Vol. 33, No. 11, November 2004 [viewed on 19 May 2014] Available from; http://www.racgp.org.au/afp/200411/14286
  3. NICE Clinical guidelines. Heavy menstrual bleeding: full guideline; CG44 [online]. January 2007.[viewed on 19 May 2014] Available from; http://www.nice.org.uk/nicemedia/live/11002/30401/30401.pdf
  4. PITKIN J. Dysfunctional uterine bleeding. BMJ [online] 2007 May 26, 334(7603):1110-1111 [viewed 19 May 2014] Available from: doi:10.1136/bmj.39203.399502.BE
  5. SACKS D. Common menstrual concerns of adolescents Paediatr Child Health [online] 1998, 3(4):231-234 [viewed 19 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851341

Investigations - Fitness for Management

Fact Explanation
Complete blood count test(CBC) Done to detect presence of anemia as women with heavy menstrual bleeding are at risk to develop anemia.[1][2][3][4]
Serum ferritin Done to detect iron deficiency,if only indicated by CBC[2][3]
References
  1. COLLINS S. ARULKUMERAN S. HAYES K. JACKSON S. IMPEY L. Dysfunctional uterine bleeding. Oxford handbook of Obstetrics and Gynecology. Second edition. Oxford University press; 492-496
  2. NICE Clinical guidelines. Heavy menstrual bleeding: full guideline; CG44 [online]. January 2007.[viewed on 19 May 2014] Available from; http://www.nice.org.uk/nicemedia/live/11002/30401/30401.pdf
  3. FARRELL E. Dysfunctional uterine bleeding. Australian Family Physician [online] Vol. 33, No. 11, November 2004 [viewed on 19 May 2014] Available from; http://www.racgp.org.au/afp/200411/14286
  4. PITKIN J. Dysfunctional uterine bleeding. BMJ [online] 2007 May 26, 334(7603):1110-1111 [viewed 19 May 2014] Available from: doi:10.1136/bmj.39203.399502.BE

Management - General Measures

Fact Explanation
Iron tablets (Ferrous sulphate) Oral iron replacement therapy is given when iron deficiency anemia is present[1][2][3]
References
  1. FARRELL E. Dysfunctional uterine bleeding. Australian Family Physician [online] Vol. 33, No. 11, November 2004 [viewed on 19 May 2014] Available from; http://www.racgp.org.au/afp/200411/14286
  2. NICE Clinical guidelines. Heavy menstrual bleeding: full guideline; CG44 [online]. January 2007.[viewed on 19 May 2014] Available from; http://www.nice.org.uk/nicemedia/live/11002/30401/30401.pdf
  3. COLLINS S. ARULKUMERAN S. HAYES K. JACKSON S. IMPEY L. Dysfunctional uterine bleeding. Oxford handbook of Obstetrics and Gynecology. Second edition. Oxford University press; 492-496

Management - Specific Treatments

Fact Explanation
Nonsteroidal anti-inflammatory drugs Mefenamic acid is given to reduce menstrual blood loss in patients with heavy menstrual bleeding and it also reduces dysmenorrhoea[1][2][3][4]
Antifibrinolytics Tranexamic acid is prescribed to reduce the menstrual blood loss in heavy menstrual bleeders[1][2][3][4]
Levonorgestrel ­releasing intrauterine system (LNG­-IUS) This treatment method reduces the menstrual blood loss significantly. Can be used in both ovulatory and anovulatory DUB. Provides contraception.[1][2][3][7]
Combined oral contraceptives (COCs) COCP pills reduce menstrual blood loss and improves dysmenorrhoea and also provides contraception[1][2][3][5]
Oral progestogen (norethisterone) Cyclical treatment with noresthisterone or medroxyprogesterone acetate regulates menstrual cycles. It can also be given for emergency suppression of heavy menstrual bleeding.[1][2][3]
Gonadotrophin ­releasing hormone analogue (GnRH­-a) This treatment is given when first line medical treatment has failed and there are are contraindications to surgery. GnRH analogues induce medical menopause and cause bone demineralisation.Therefore this treatment is limited to 6 months.[1][2][3]
Endometrial ablation Done if the patients fails to respond to medical management and only if she has completed her family. Radiofrequency ablation, thermal balloon endometrial ablation(TBEA), microwave endometrial ablation (MEA) are methods currently used for endometrial ablation. [1][2][3][6][7]
Hysterectomy This is the only definitive cure for DUB. But has higher complications and morbidity. Therefore is done as the last option when all other treatment fails in a woman who has no future fertility wishes.[1][2][3][7]
References
  1. NICE Clinical guidelines. Heavy menstrual bleeding: full guideline; CG44 [online]. January 2007.[viewed on 19 May 2014] Available from; http://www.nice.org.uk/nicemedia/live/11002/30401/30401.pdf
  2. FARRELL E. Dysfunctional uterine bleeding. Australian Family Physician [online] Vol. 33, No. 11, November 2004 [viewed on 19 May 2014] Available from; http://www.racgp.org.au/afp/200411/14286
  3. COLLINS S. ARULKUMERAN S. HAYES K. JACKSON S. IMPEY L. Dysfunctional uterine bleeding. Oxford handbook of Obstetrics and Gynecology. Second edition. Oxford University press; 492-496
  4. PITKIN J. Dysfunctional uterine bleeding. BMJ [online] 2007 May 26, 334(7603):1110-1111 [viewed 19 May 2014] Available from: doi:10.1136/bmj.39203.399502.BE
  5. DELALE O.M. GUPTA A. ABRAHAM C. CHANDRAREDDY A. BOWERS C.H. Jr. CUTLER J.B. Management of dysfunctional uterine bleeding based on endometrial thickness. International Journal of Women’s Health[online] 2010:2 297–302 [viewed on 19 May 2014]Available from; http://www.dovepress.com/management-of-dysfunctional-uterine-bleeding-based-on-endometrial-thic-peer-reviewed-article-IJWH-recommendation1
  6. GEPING YIN, TONGYU ZHU, JUAN LI, MING CHEN, SHUJUN YANG and XIAOLI ZHAO. Decreased expression of survivin, estrogen and progesterone receptors in endometrial tissues after radio-frequency treatment of dysfunctional uterine bleeding. World Journal of Surgical Oncology[online] 2012, 10:100 [Viewed on 19 May 2014] Available from; http://link.springer.com/article/10.1186%2F1477-7819-10-100
  7. ROBERTS TE, TSOURAPAS A, MIDDLETON LJ, CHAMPANERIA R, DANIELS JP, COOPER KG, BHATTACHARYA S, BARTON PM. Hysterectomy, endometrial ablation, and levonorgestrel releasing intrauterine system (Mirena) for treatment of heavy menstrual bleeding: cost effectiveness analysis BMJ [online] 2011:d2202 [viewed 19 May 2014] Available from: doi:10.1136/bmj.d2202