Understanding Dysfunctional Uterine Bleeding

What is Dysfunctional Uterine Bleeding (DUB)?

Dysfunctional uterine bleeding (DUB) refers to any irregular changes in a woman’s menstrual cycle. This includes changes in how often it happens (frequency), its regularity, how long it lasts (duration), and the amount of blood lost, when not pregnant. A typical menstrual cycle lasts between 24 to 38 days, bleeding occurs for 2 to 7 days, and the amount of blood lost ranges from 5ml to 80ml. Any variations in these four aspects are considered DUB:

• The frequency of menses can be described as:
  • frequent – less than 24 days
  • normal – 24 to 38 days
  • infrequent – more than 38 days
• The regularity can be described as:
  • absent
  • regular – with a variation of +/- 2 to 7 days
  • irregular – variation greater than 20 days
• The length of your period/duration can be described as:
  • prolonged – greater than 8 days
  • normal – 4 to 8 days
  • shortened – less than 4 days
• The volume of flow can be described as:
  • heavy – greater than 80ml
  • normal – 5 to 80ml
  • light – less than 5ml of blood loss

DUB is often when you bleed between your monthly periods (anovulatory bleeding) or when your periods are extremely heavy and/or prolonged. DUB can be chronic – it happens often, or for the past 6 months – or acute, when it occurs in unusual or sudden episodes.

Symptoms

When is bleeding dysfunctional?

Irregular bleeding patterns include:

• bleeding or spotting between periods (spotting appears lighter than a normal menstrual period and is often brown, pink, or light red)
• extremely heavy bleeding during your period, i.e. bleeding that soaks through one or more tampons or pads every hour
• bleeding or spotting after sex
• bleeding that lasts for more than 8 days
• menstrual cycles that are shorter than 24 days or longer than 38 days
• irregular periods in which cycle length varies by more than 7 to 9 days
• not having a period for 3 to 6 months
• bleeding after menopause

When DUB is more common:

Dysfunctional bleeding can occur at any age, however, there are certain times in a woman’s life when it’s more common for bleeding to be irregular:

• when a girl starts her period (around age 9 to 14)
• during perimenopause (around age 50). The number of days between periods may change; it’s common to skip periods or for bleeding to get lighter or heavier at this time.

Although these changes may be normal, speak to your doctor if you have any concerns about DUB.

Causes

Dysfunctional uterine bleeding has many possible causes, including:

• Hormonal imbalances: If you do not ovulate for several menstrual cycles, areas of the endometrium (the tissue that lines the uterus) can become too thick. This is more common amongst girls when they start their period and during perimenopause. It’s also associated with certain medical conditions, such as polycystic ovary syndrome (PCOS) and hypothyroidism.
• Structural abnormalities in the uterus:
  • Fibroids are noncancerous growths that form from the muscle tissue of the uterus.
  • Polyps are another type of noncancerous growth. They can be found inside the uterus or on the cervix.
  • Adenomyosis (the endometrium grows into the wall of the uterus); symptoms include heavy menstrual bleeding and menstrual pain that worsens with age.
• Hormonal birth control: Birth control pills, injectables, and the IUD.
• Medications: Blood thinners and aspirin, hormone replacement therapy, and tamoxifen (a breast cancer drug).
• Problems related to the endometrium – This includes endometriosis, ectopic pregnancy, miscarriage, pelvic inflammatory disease (PID), and endometrial intraepithelial neoplasia (EIN).
• Precancer and cancer: Endometrial intraepithelial neoplasia (EIN) is a precancerous lesion of the endometrium and significantly increases the risk for endometrial cancer. Other cancers include uterine cancer, cervical cancer, vaginal cancer, ovarian cancer, and endometrial hyperplasia.
• Infections: Trichomoniasis, cervicitis, chlamydia, gonorrhea, endometriosis, and vaginitis.
• Retained foreign bodies and trauma: Forgetting to remove an IUD and injury to the uterus.
• Other medical conditions: Bleeding disorders such as platelet disorders, leukemia, Von Willebrand disease, liver disease, and kidney disease.

Complications

Anemia is one of the main complications of heavy bleeding. Other complications are related to the conditions which cause DUB.

Diagnosis

Before visiting a doctor, it’s helpful to track your bleeding for a few weeks. Note the dates of bleeding, the type of flow (heavy, medium, light), and the length of the bleeding. Smartphone apps have period trackers that can assist with this.

DUB is diagnosed following a full medical history (your personal and family health history, past and present illnesses, surgical procedures, pregnancy history, medications, birth control method, and so forth) and a physical exam (pelvic exam, cervical exam, and a pap smear).

Depending on your age and symptoms, your doctor may order the following tests:

• Blood tests, for anemia, infections, blood disorders, thyroid function, and hormone levels
• A pregnancy test
• Tests for sexually transmitted infections (STIs)
• An ultrasound of the pelvic organs
• A hysteroscopy, to view the inside of the uterus
• Endometrial biopsy, for a sample of the endometrium
• Sonohysterography, to get ultrasound images of the uterus using a fluid
• Magnetic resonance imaging (MRI), to create images of the internal organs
• Computed tomography (CT), to X-ray internal organs and structures in cross-section

Treatment

Treatment depends on the underlying cause of the dysfunctional uterine bleeding. In the case of puberty, no treatment is given as the hormones start balancing themselves. Medication is used as the first line of treatment, and if that does not stop the dysfunctional bleeding, then surgery would be needed.

Medication

• Hormonal birth control methods are used for problems with ovulation, PCOS, and fibroids:
  • Combined hormonal birth control pills, the skin patch, and the vaginal ring contain both estrogen and progesterone. They lighten menstrual flow, regulate periods, can reduce the number of periods you have or stop them completely.
  • Progesterone-only hormonal methods, including the hormonal IUD, pills, and injection, also reduce bleeding.
• Hormone therapy is given to women during perimenopause; it can also treat other perimenopausal symptoms, such as hot flashes, night sweats, and vaginal dryness.
• Gonadotropin-releasing hormone (GnRH) agonists stop the menstrual cycle and reduce the size of fibroids.
• Tranexamic acid is used for heavy menstrual bleeding.
• Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may help control heavy bleeding and relieve menstrual cramps.
• Medication to help the blood to clot is prescribed if you have a bleeding disorder.
• Antibiotics are used for infections.

The type of surgery needed depends on your condition, age, and whether you want to conceive in the future. Surgical procedures include:

• Endometrial ablation destroys the lining of the uterus, and therefore stops or reduces the bleeding. This is for women who don’t plan on falling pregnant.
• Fibroid treatments keep the uterus intact and preserve the ability to fall pregnant:
  • Uterine artery embolization, which blocks blood flow to the uterus and causes them to shrink.
  • MRI-guided ultrasound surgery uses ultrasound waves to destroy fibroids.
  • A myomectomy only removes the fibroids, not the uterus (fibroids may grow back after this surgery).
• A hysterectomy is the removal of the uterus, and is used to treat fibroids, adenomyosis, and endometrial cancer.

Prevention

While it’s impossible to prevent all causes of abnormal uterine bleeding, you can lower the risk of specific conditions causing it, e.g.

• Maintaining a healthy weight can help regulate hormones.
• A diet low in animal fats can decrease cancer risks.
• Safer sex practices can also reduce the likelihood of STIs that may lead to abnormal uterine bleeding.