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Dysfunctional Uterine Bleeding (DUB)

The term ‘dysfunctional uterine bleeding’ refers to any form of abnormal vaginal bleeding during the reproductive years. Vaginal bleeding occurring after the menopause falls outside this category.

Dysfunctional uterine bleeding can take many forms including:

 Irregular and frequent ‘periods’. In this, the pattern of bleeding is unpredictable and, usually, there are more episodes of vaginal bleeding than would be seen in a normal pattern. The bleeding is not necessarily heavier than normal. The medical term for irregular frequent bleeding is ‘metrorrhagia’. These Latin based terms are now being slowly abandoned in favour of descriptive terminology. However, they are still in widespread use and predominate the medical literature. It is therefore worthwhile knowing them.

 When the pattern described above occurs with prolonged and heavy periods, it is then called ‘menometrorrhagia’.

 Infrequent irregular periods. In this, a woman can go for several weeks or even months without a period. It becomes impossible to predict when a period might arrive. This is a common feature of polycystic ovarian syndrome but it is also seen in the absence of this condition. The medical term for infrequent irregular periods is ‘oligomenorrhoea’.

 Bleeding in between the periods is also a common problem. Inter-menstrual bleeding can take the form of mere spotting but can also be as heavy as a normal period, sometimes occurring more than once in between the normal periods.

Causes of dysfunctional uterine bleeding (DUB)

There are many potential causes of an abnormal pattern of vaginal bleeding. It is important therefore that the attending doctor takes a careful history; performs a careful examination and, on the basis of the findings from the history and examination, requests appropriate tests to confirm the diagnosis.

Ovulation pattern: A normal menstrual cycle depends on a normal interplay of the hormones that control the cycle. When there is a disruption in the production of any of the numerous hormones involved, the result could be failure of ovulation and subsequent disorganised menstrual cycles. Failure of ovulation is called ‘anovulation’.

Anovulation is common at either end of the reproductive age range. It is therefore quite common to have dysfunctional uterine bleeding soon after menarche in the early teens as well as in the years leading to menopause, typically the mid to late 40s.  Anovulation is also a common feature of Polycystic Ovarian Syndrome (PCOS). Women with this condition often report erratic periods with prolonged phases lasting several months without a period. Anovulation can also be caused by hormone producing small tumours (usually benign) in the pituitary gland in the brain. Anovulation is therefore the single commonest underlying cause of dysfunctional uterine bleeding.

Systemic conditions: Disease conditions not directly related to the genital tract could also cause a disruption in the menstrual pattern. These include diseases of the thyroid. Both an underactive thyroid (hypothyroidism) and an overactive thyroid (hyperthyroidism) can manifest in irregular menstrual periods among other things. A doctor should always be aware of these and be on the lookout for the possibility. Other less common causes of dysfunctional uterine bleeding are liver disease, diseases of the adrenal glands (Cushing’s disease) and even diabetes.

Local conditions: When there is bleeding in between the periods and/or the bleeding is usually provoked by sexual intercourse, the problem could be local. Inflammation of the cervix (cervix), cervical polyps and cervical ectropion (‘erosion’) are some of the local causes of inter-menstrual bleeding. Another possible cause to be ruled out is cancer in the lower genital tract especially the cervix but also, much less common, cancer of the vagina or vulva. Other causes of dysfunctional uterine bleeding could be polyps inside the womb cavity and, rarely, ovarian malignancy.

Looking at this long list of possible causes of dysfunctional uterine bleeding is a powerful reminder of why doctors always need to be meticulous in dealing with this common problem. In the overwhelming majority of cases, the underlying cause is hormonal and non-sinister. However, getting the diagnosis right is key to getting effective treatment.

Investigations that can be done will depend largely on the history and examination findings. Treatment will depend on the final diagnosis. For the majority who have anovulatory cycles, if the woman wants to have regular monthly periods, the easiest option to achieve this is to go on the combined pill. This will of course depend on whether she is not actively trying to conceive and that she does not have the risk factors that will contra-indicate the use of the pill.  If a systemic condition such as thyroid disease is discovered, treating this will normally lead to a resolution of the accompanying menstrual irregularities. Local conditions such as cervical polyps are easily dealt with (removal).

Last Updated on August 22, 2012