Dysfunctional Uterine Bleeding
Dysfunctional uterine bleeding is abnormal bleeding resulting from changes in the normal hormonal control of menstruation.
Dysfunctional uterine bleeding occurs most commonly at the beginning and end of the reproductive years: 20% of cases occur in adolescent girls, and more than 50% occur in women older than 45.
Dysfunctional uterine bleeding commonly results when the level of estrogen remains high. The high level of estrogen is not balanced by an appropriate level of progesterone, and release of an egg (ovulation) does not occur. As a result, the lining of the uterus (endometrium) thickens. This condition is called endometrial hyperplasia. The lining is then shed incompletely and irregularly, causing bleeding. Bleeding is irregular, prolonged, and sometimes heavy. This type of bleeding is common among women who have polycystic ovary syndrome.
Diagnosis and Treatment
Dysfunctional uterine bleeding is diagnosed when all other possible causes of vaginal bleeding have been excluded. The results of a blood test can help doctors estimate the extent of the blood loss. Transvaginal ultrasonography may be used to determine whether the uterine lining is thickened. If the risk of cancer of the uterine lining (endometrial cancer) is high, an endometrial biopsy is performed before drug treatment is started. Women at risk include those who are 35 or older, those who are substantially overweight, and those who have polycystic ovary syndrome, high blood pressure, or diabetes.
Treatment depends on how old the woman is, how heavy the bleeding is, whether the uterine lining is thickened, and whether the woman wishes to become pregnant.
When the uterine lining is thickened but its cells are normal, hormones may be used. Women who have heavy bleeding may be treated with an oral contraceptive containing estrogen and a progestin. When bleeding is very heavy, estrogen may be given intravenously until the bleeding stops. Sometimes a progestin is given by mouth at the same time or started 2 or 3 days later. Bleeding usually stops in 12 to 24 hours. Low doses of the oral contraceptive may then be prescribed for at least 3 months.
Treatment with an oral contraceptive or estrogen given intravenously is inappropriate for some women (such as postmenopausal women and women with significant risk factors for heart or blood vessel disease). These women may be given a progestin alone by mouth for 10 to 14 days each month. For women who wish to become pregnant, clomiphene may be given by mouth instead. It stimulates ovulation.
If the uterine lining remains thickened or the bleeding persists despite treatment with hormones, dilation and curettage (D and C) is usually needed. In this procedure, tissue from the uterine lining is removed by scraping. When the uterine lining is thickened and contains abnormal cells (particularly in women who are older than 35 and do not want to become pregnant), treatment begins with a high dose of a progestin. If the cells continue to be abnormal after treatment, a hysterectomy is performed, because the abnormal cells may become cancerous.
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