Dysfunctional Uterine Bleeding

Definition/diagnostic criteria Dysfunctional uterine bleeding (DUB) is a diagnosis of exclusion characterised by abnormal uterine bleeding without an identifiable organic cause. It typically refers to irregular, non-cyclical bleeding, in the absence of pathology or medical illness, although it is a term that is falling out of fashion because of difficulties in definition.

Epidemiology DUB is a common gynaecological complaint, accounting for a significant proportion of referrals to secondary care. It is most prevalent in adolescents and perimenopausal women, though it can occur at any age during the reproductive years.

Diagnosis
Clinical features: Diagnostically, DUB is characterised by a variation in menstrual cycle intervals, duration, or volume of flow, sometimes leading to anaemia. Symptoms can include heavy menstrual bleeding, prolonged bleeding episodes or bleeding between periods. However, these symptoms are not exclusive to DUB, necessitating thorough investigation.

Investigations: Investigations for DUB include a full blood count (to assess for anaemia), thyroid function tests, and coagulation studies if there is a history suggestive of a bleeding disorder. Swabs and/or a pregnancy test might also be needed.

In the presence of other symptoms suggesting a specific underlying cause (such as intermenstrual bleeding, pelvic pain or pressure symptoms), further investigation such as transvaginal ultrasound and hysteroscopy may be necessary.

Treatment Treatment of DUB is often empirical, guided by the woman’s reproductive plans, symptom severity and response to previous treatments. First-line treatment usually involves hormonal therapies such as combined oral contraceptives or progestogens. Levonorgestrel-releasing intrauterine systems (LNG-IUS) are also highly effective. Non-hormonal options include tranexamic acid and NSAIDs like mefenamic acid for managing menstrual bleeding.

In refractory cases or where pharmacotherapy is contraindicated, surgical options like endometrial ablation or hysterectomy may be considered.

Prognosis The prognosis of DUB varies. Many women experience significant improvement with medical management, although the condition can recur. Surgical interventions, while more definitive, carry risks and are generally considered when medical management fails or is not suitable. The impact of DUB on quality of life should not be underestimated, and a holistic approach to management, considering both physical and psychological aspects, is recommended.