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| '''For patient information, click [[Dysfunctional uterine bleeding (patient information)|here]]''' | | '''For patient information, click [[Dysfunctional uterine bleeding (patient information)|here]]''' |
| {{SI}} | | {{Dysfunctional uterine bleeding}} |
| {{CMG}} | | '''Editor(s)-in-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]; '''Associate Editor(s)-In-Chief:''' [[User:AroojNaz|Arooj Naz, M.B.B.S]], {{VVS}} |
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| | '''''Synonyms and Keywords:''''' Anovulatory bleeding; DUB; Abnormal uterine bleeding |
| | ==[[Dysfunctional uterine bleeding overview|Overview]]== |
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| ==Overview== | | ==[[Dysfunctional uterine bleeding historical perspective|Historical Perspective]]== |
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| '''Dysfunctional Uterine Bleeding''' (DUB) is the most common cause of functional abnormal uterine bleeding, which is [[vaginal bleeding|abnormal genital tract bleeding]] based in the [[uterus]] and found in the absence of demonstrable organic [[pathology]].
| | ==[[Dysfunctional uterine bleeding classification|Classification]]== |
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| Diagnosis must be made by exclusion, since organic pathology must first be ruled out. It can be classified as ''ovulatory'' or ''anovulatory'', depending on whether [[ovulation]] is occurring or not.
| | ==[[Dysfunctional uterine bleeding pathophysiology|Pathophysiology]]== |
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| * Uterine bleeding is deemed abnormal when there is an irregular amount or an irregular pattern of bleeding.
| | ==[[Dysfunctional uterine bleeding causes|Causes]]== |
| * Menometrorrhagia: Excessive and irregular bleeding between cycles and during menstruation
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| * Metrorrhagia: Irregular and more frequent bleeding
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| * Menorrhagia: Excessive, but regular bleeding
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| == Ovulatory == | | ==[[Dysfunctional uterine bleeding differential diagnosis|Differentiating Dysfunctional uterine bleeding from other Diseases]]== |
| Ovulatory DUB happens with the involvement of ovulation, and may represent a possible [[endocrine]] dysfunction, resulting in [[menorrhagia]] or [[metrorrhagia]].
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| Mid-cycle bleeding may indicate a transient [[estrogen]] decline, while late-cycle bleeding may indicate [[progesterone]] deficiency.
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| == Anovulatory == | | ==[[Dysfunctional uterine bleeding epidemiology and demographics|Epidemiology and Demographics]]== |
| [[Anovulatory cycle]] DUB happens without the involvement of [[ovulation]].
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| The etiology can be [[psychological]] stress, weight ([[obesity]], [[anorexia nervosa|anorexia]], or a rapid change), [[exercise]], [[endocrinopathy]], [[neoplasm]], [[medication|drugs]], or it may be otherwise [[idiopathic]].
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| Assessment of anovulatory DUB should always start with a good [[medical history]] and [[physical examination]].
| | ==[[Dysfunctional uterine bleeding risk factors|Risk Factors]]== |
| Laboratory assessment of [[hemoglobin]], [[luteinizing hormone]] ([[LH]]), [[follicle stimulating hormone]] ([[FSH]]), [[prolactin]], T<sub>4</sub>, [[thyroid stimulating hormone]] ([[TSH]]), [[pregnancy]] (by [[human chorionic gonadotropin|βhCG]]), and [[androgen]] profile should also happen.
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| More extensive testing might include an [[ultrasound]] and [[Endometrium|endometrial]] sampling.
| | ==[[Dysfunctional uterine bleeding natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| ==Diagnosis== | | ==Diagnosis== |
| | [[Dysfunctional uterine bleeding history and symptoms|History and Symptoms]] | [[Dysfunctional uterine bleeding physical examination|Physical Examination]] | [[Dysfunctional uterine bleeding laboratory findings|Laboratory Findings]] | [[Dysfunctional uterine bleeding CT|CT]] | [[Dysfunctional uterine bleeding MRI|MRI]] | [[Dysfunctional uterine bleeding ultrasound|Ultrasound]] | [[Dysfunctional uterine bleeding other imaging findings|Other Imaging Findings]] | [[Dysfunctional uterine bleeding other diagnostic studies|Other Diagnostic Studies]] |
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| === History and Symptoms === | | ==Treatment== |
| * History taking is an important part of diagnosis of DUB.
| | [[Dysfunctional uterine bleeding medical therapy|Medical Therapy]] | [[Dysfunctional uterine bleeding surgery|Surgery]] | [[Dysfunctional uterine bleeding primary prevention|Primary Prevention]] | [[Dysfunctional uterine bleeding secondary prevention|Secondary Prevention]] | [[Dysfunctional uterine bleeding cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Dysfunctional uterine bleeding future or investigational therapies|Future or Investigational Therapies]] |
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| === Physical Examination ===
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| * Complete physical exam, including pelvic and rectal examinations.
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| === Laboratory Findings ===
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| * Pap smear
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| * Peripheral smear
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| * [[Complete blood count]] ([[CBC]]) with differential
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| * [[Prolactin]]
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| * Clotting factor assays
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| * [[human chorionic gonadotropin]]
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| * [[Dehydroepiandrosterone-sulfate]] ([[DHEA-S]])
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| * [[Testosterone]]
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| * [[Estradiol]]
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| * [[Follicle stimulating hormone]] ([[FSH]])
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| * [[Luteinizing hormone]] ([[LH]])
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| * [[Thyroid stimulating hormone]] ([[TSH]])
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| * [[LFT]]s ([[liver function test]]s)
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| * [[Blood urea nitrogen]] ([[BUN]]) / [[creatinine]]
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| * Serum [[progesterone]]
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| ===Ultrasound ===
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| * [[Transvaginal ultrasound]] more accurate than [[pelvic ultrasound]]
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| * [[Pelvic ultrasound]] may be indicated to reveal certain pathologies, as well as uterine masses, adnexal masses.
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| === MRI and CT ===
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| * If malignancy is suspected, a [[CT]] scan can be helpful
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| === Other Diagnostic Studies ===
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| * Diagnostic dilatation and curettage provides more information than [[biopsy]], but is more invasive
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| * [[Prothrombin time]] / [[partial thromboplastin time]] (PT/PTT)
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| * Biopsy of endometrial and [[progesterone]] challenge test reveal [[estrogen]] excess
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| * The uterine cavirty and endometrium may be evaluated by [[hysteroscopy]].
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| == Differential Diagnosis of Causes of {{PAGENAME}}==
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| * Anatomic or structural lesions
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| *:* Uterine or [[cervical polyp]]s
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| *:* [[Uterine leiomyoma]]
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| *:* Foreign body
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| * Coagulation disorders
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| *:* Clotting factor disorder: [[Hemophilia]], hepatic disease, anticoagulant use, renal disease, [[Von Willebrand's Disease]]
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| *:* Platelet dysfunction: [[Leukemia]], [[Thrombocytopenia]], and related medications
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| * Pregnancy complications
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| *:* Placental abruption
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| *:* [[Ectopic Pregnancy]]
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| *:* Miscarriage
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| *:* Spontaneous abortion
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| *:* [[Placenta previa]]
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| * Endometrial cancer
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| *:* Risk Factors:
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| *:*:* [[Diabetes Mellitus]]
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| *:*:* Unopposed estrogen
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| *:*:* [[Obesity]]
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| *:*:* Older age
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| *:*:* Chronic anovulation
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| *:*:* [[Ddx:Hypertension|Hypertension]]
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| * Endometrial hyperplasia
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| *:* Exogenous extrogen
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| *:* Excess of endogenous estrogen
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| *:* DUB (dysfunctional uterine bleeding) is a diagnosis of exclusion
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| * Endometrioma
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| * Hyperprolactinemia
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| * Hypo- or [[Hyperthyroidism]]
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| * Hypothalamic lesion
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| * Medications (e.g., [[Norepinephrine]])
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| * Nonuterine bleeding
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| *:* Rectal
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| *:* Urinary
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| *:* Vaginal
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| *:* Cervical
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| * Other malignancy
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| * Pelvic infection
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| * [[Polycystic Ovarian Syndrome]] ([[Stein Leventhal Syndrome]])
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| * Systemic disease
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| * [[Anorexia Nervosa]]
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| * Immature hypothalamic-pituitary-ovarian axis
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| * Intense exercise
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| * Nutritional status (Very low calorie diets)
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| * Peri-menopause
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| * Psychologic stress <ref>Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016</ref>
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| == Treatment ==
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| Management of dysfunctional uterine bleeding predominantly consists of reassurance, though mid-cycle [[estrogen]] and late-cycle [[progestin]] can be used for mid- and late-cycle bleeding respectively.
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| Also, non-specific [[hormone|hormonal]] therapy such as combined [[estrogen]] and [[progestin]] can be given.
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| The goal of therapy should be to arrest bleeding, replace lost [[iron]] to avoid [[anemia]], and prevent future bleeding.
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| In general;
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| *IV [[estrogen]], blood transfusion, IV fluids, curettage, hysterectomy or ligation of uterine artery are used to treat acute life-threatening bleeds.
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| *Treatment of underlying etiologies.
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| == Pharmacotherapy ==
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| === Acute Pharmacotherapies ===
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| * Oral contraceptives are used to treat nonacute bleeding.
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| *:* Cyclic progesterone
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| *:* Estrogen/progesterone
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| *:* Other:
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| *:*:* Fibrinolytic agents
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| *:*:* Danazol
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| *:*:* Tranexamic acid
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| *:*:* Megestrol
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| *:*:* GnRH analogs (Gonadotropin-releasing hormone)
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| *:*:* Intrauterine progesterone
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| == Surgery and Device Based Therapy ==
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| * Hysterectomy
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| * Endometrial ablation
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| === Indications for Surgery ===
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| * Anatomic causes
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| * If fertility is not desired
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| ==References== | | ==Case Studies== |
| {{Reflist|2}}
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| == Resources ==
| | [[Dysfunctional uterine bleeding case study one|Case #1]] |
| *[http://www.merck.com/mrkshared/mmanual/home.jsp Merck Manual]: [http://www.merck.com/mrkshared/mmanual/section18/chapter235/235e.jsp Abnormal Uterine Bleeding]
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| [[Category:Primary care]]
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| [[Category:Gynecology]] | | [[Category:Gynecology]] |