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| '''''Synonyms and Keywords:''''' Anovulatory bleeding; DUB; Abnormal uterine bleeding | | '''''Synonyms and Keywords:''''' Anovulatory bleeding; DUB; Abnormal uterine bleeding |
| ==Overview==
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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]].
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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.
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| * Uterine bleeding is deemed abnormal when there is an irregular amount or an irregular pattern of bleeding.
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| * 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 ==
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| 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 ==
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| [[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]].
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| 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.
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| ==Diagnosis==
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| === History and Symptoms ===
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| * History taking is an important part of diagnosis of DUB.
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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==
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| {{Reflist|2}}
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| == Resources == | | == Resources == |