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This topic is for women who want to learn about or have been diagnosed with dysfunctional uterine bleeding (DUB). It is related to changes in hormone levels. If you don't know what kind of bleeding you have, see the topic Abnormal Vaginal Bleeding.

What is dysfunctional uterine bleeding?

Dysfunctional uterine bleeding is irregular bleeding from the uterus. For example, you may get your period more often than every 21 days or farther apart than 35 days. Your period may last longer than 7 days. It is not serious, but it can be annoying and disrupt your life.

In most cases, this problem is related to changes in hormone levels. It is not caused by other medical conditions, such as miscarriage, fibroids, cancer, or blood clotting problems. Your doctor will rule out these and other causes of vaginal bleeding to confirm that you have dysfunctional uterine bleeding.

What causes dysfunctional uterine bleeding?

Dysfunctional uterine bleeding is usually caused by changes in hormone levels. In some cases the cause of the bleeding isn't known.

Normally one of your ovaries releases an egg during your menstrual cycle. This is called ovulation. Dysfunctional uterine bleeding is often triggered when women don't ovulate. This causes changes in hormone levels and in some cases can lead to unexpected vaginal bleeding.

Women can also get this condition even though they ovulate, although this is less common. Experts don't fully understand this type of vaginal bleeding. It may be caused by changes in certain body chemicals.

What are the symptoms?

You may have dysfunctional uterine bleeding if you have one or more of the following symptoms:

• You get your period more often than every 21 days or farther apart than 35 days. A normal adult menstrual cycle is 21 to 35 days long. A normal teen cycle is 21 to 45 days.
• Your period lasts longer than 7 days (normally 4 to 6 days).
• Your bleeding is heavier than normal. If you are passing blood clots and soaking through your usual pads or tampons each hour for 2 or more hours, your bleeding is considered severe and you should call your doctor.

Talk to your doctor if you have had irregular vaginal bleeding for three or more menstrual cycles, or if your symptoms are affecting your daily life.

How is dysfunctional uterine bleeding diagnosed?

Your doctor must first rule out all other causes of vaginal bleeding before diagnosing dysfunctional uterine bleeding. These causes include miscarriage and problems with pregnancy. Vaginal bleeding may also be caused by common conditions, such as uterine fibroids.

Your doctor will ask how often, how long, and how much you have been bleeding. You may also have a pelvic exam, urine test, blood tests, and possibly an ultrasound. These tests will help your doctor check for other causes of your symptoms. He or she may also take a tiny sample ( biopsy) of tissue from your uterus for testing.

You have dysfunctional uterine bleeding if, after testing, your doctor finds no other diseases or conditions that are causing your symptoms.

How is it treated?

There are many things you can do to treat dysfunctional uterine bleeding. Some are meant to return the menstrual cycle to normal. Others are used to reduce bleeding or to stop monthly periods. Each treatment works for some women but not others. Treatments include:

• Hormones, such as a progestin pill or daily birth control pill (progestin and estrogen). These hormones help control the menstrual cycle and reduce bleeding and cramping.
• A short course of high-dose estrogen. Estrogen is a hormone that is often used to stop dangerously heavy bleeding.
• Use of the levonorgestrel IUD, which releases a progesterone-like hormone into the uterus. This reduces bleeding while preventing pregnancy.
• Rarely used medicines that stop estrogen production and menstruation, such as gonadotropin-releasing hormones. These drugs can cause severe side effects but are used in special cases.
• Surgery, such as endometrial ablation or hysterectomy, when other treatments do not work.

If you also have menstrual pain or heavy bleeding, you can take regular doses of a nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen.

In some cases, doctors use watchful waiting, or a wait-and-see approach. It may be okay for a teen or for a woman nearing menopause. Some teens have times of irregular vaginal bleeding. This usually gets better over time as hormone levels even out. Women in menopause can expect their periods to stop. They may choose to wait and see if this happens before they try other treatments.

Frequently Asked Questions

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	Should I treat dysfunctional uterine bleeding with hormone therapy?

Dysfunctional uterine bleeding (DUB) is irregular vaginal bleeding that is not caused by a serious medical condition.

Normally one of your ovaries releases an egg during your menstrual cycle. This is called ovulation. Most women who have dysfunctional uterine bleeding get it when their ovaries don't release an egg. This can be caused by hormone changes. When your hormone levels are out of balance, they can affect the lining in your uterus, causing bleeding. Dysfunctional uterine bleeding is common before age 20 and after age 40.¹

Some women have dysfunctional uterine bleeding even though they ovulate. Experts don't fully understand this type of vaginal bleeding. It may be caused by changes in certain body chemicals.

For more information about serious causes of vaginal bleeding problems, see the topic Abnormal Vaginal Bleeding.

Symptoms of dysfunctional uterine bleeding (DUB) include:

• Vaginal bleeding that occurs more often than every 21 days or farther apart than 35 days (a normal teen menstrual cycle can last up to 45 days).
• Vaginal bleeding that lasts longer than 7 days (normally lasts 4 to 6 days).
• Blood loss of more than 80 mL (2.7 fl oz) each menstrual cycle [normally about 30 mL (1 fl oz)]. If you are passing blood clots and soaking through your usual pads or tampons each hour for 2 or more hours, your bleeding is considered severe.

Most menstrual blood is lost in the first 3 days of the period. Therefore, excessive blood loss is possible without having exceptionally long periods.

The symptoms of DUB can also be signs of another, more serious condition with similar symptoms. If your abnormal vaginal bleeding is undiagnosed, see your health professional. For more information, see the topic Abnormal Vaginal Bleeding.

Dysfunctional uterine bleeding (DUB) occurs most often before age 20 and after age 40.¹

• Teen years. Some teens have times of irregular vaginal bleeding. This usually gets better over time as hormone levels even out and the menstrual cycle becomes more regular. If you need treatment, your doctor may give you hormones to help regulate your menstrual cycle. He or she may also prescribe medicine to reduce bleeding.
• Reproductive years. Some women in their 20s and 30s have dysfunctional uterine bleeding. Sometimes it's because of changing hormone levels. And sometimes the reason is not known. If your doctor rules out serious causes of vaginal bleeding, he or she may diagnose you with dysfunctional uterine bleeding without knowing why it is happening. Your treatment depends on whether you are planning to have children.
• After age 40: Perimenopausal and menopausal years. After age 40, women tend to have changing hormone levels. During this time before your period stops (perimenopause), you may not always ovulate. This can lead to irregular vaginal bleeding. You can expect this bleeding to go away on its own when menopause is complete. Your treatment options depend on your childbearing plans and how much your symptoms are impacting your daily life. Your doctor may recommend a wait-and-see approach, hormones, or a surgical procedure.

No matter what your age, see your health professional if you have irregular vaginal bleeding.

Factors that increase your risk of developing dysfunctional uterine bleeding (DUB) include:

• Your age. Dysfunctional uterine bleeding is more common in teens, at the beginning of the reproductive years, and in perimenopausal women at the end of their reproductive years.
• Your weight. Overweight women more commonly develop dysfunctional uterine bleeding.¹

Some women have dysfunctional uterine bleeding even though they have no risk factors.

For more information about medical factors that can increase a woman's risk of vaginal bleeding problems, such as disease, infection, or pregnancy complications, see the topic Abnormal Vaginal Bleeding.

If you have not been diagnosed with dysfunctional uterine bleeding (DUB), see the topic Abnormal Vaginal Bleeding to determine whether you should see your health professional.

Any significant change in menstrual pattern or amount of bleeding that affects your daily life requires evaluation by a health professional. This includes menstrual bleeding for three or more menstrual cycles that:

• Occurs more frequently than every 21 days or farther apart than 35 days (a normal teen menstrual cycle can last up to 45 days).
• Lasts longer than 7 days.
• Consists of more than 80 mL of blood lost or involves passing blood clots and soaking through your usual pads or tampons each hour for 2 or more hours.

Watchful Waiting

Watchful waiting is a wait-and-see approach. If you have been diagnosed with dysfunctional uterine bleeding, you may consider watchful waiting when:

• A careful examination has revealed no underlying physical problem or disease.
• Blood loss is not severe enough to cause anemia.
• You prefer to wait and see if your symptoms get better on their own. If you are a teen, you can expect your cycles to even out with time. If you are nearing the age of menopause, you can expect menstrual cycles to stop eventually.

Talk to your doctor if you have not had a menstrual period for more than 3 months. He or she may give you medicine to start your menstrual period, so your uterine lining doesn't become too thick.

Who To See

Health professionals who can do an initial evaluation of a vaginal bleeding problem include:

• Nurse practitioners.
• Physician assistants.
• Family medicine doctors.
• Internists.
• Gynecologists.

If you need to be seen for further evaluation or surgery, your doctor may refer you to a gynecologist.

To prepare for your appointment, see the topic Making the Most of Your Appointment

Your health professional must first rule out all other medical causes of vaginal bleeding before diagnosing dysfunctional uterine bleeding (DUB).

First, your health professional will:

• Review your history of symptoms and menstrual periods. (If possible, bring with you a record of the days you had your period, how heavy or light the flow was, and how you felt each day.)
• Conduct a routine pelvic exam.
• Determine whether you are ovulating regularly. This is evaluated using one or more of the following:
  • A daily record of your symptoms (menstrual calendar)
  • A daily basal body temperature chart, if you have been keeping track at home
  • A progesterone test, because low levels during the third week of a menstrual cycle suggest an ovulation problem
  • An endometrial biopsy for perimenopausal women, because abnormal endometrial tissue is common in this age group

If your symptoms are severe, your health professional suspects a serious medical problem, or you are considering a certain treatment, you may also have one or more other tests, such as:

• Blood tests, which may include:
  • Pregnancy test (human chorionic gonadotropin, or hCG).
  • Complete blood count (CBC), to check for signs of disease, infection, and anemia.
  • Thyroid-stimulating hormone (TSH) to check for a thyroid gland problem, which can cause menstrual irregularity.
  • Serum prolactin level, to check for a pituitary gland problem, which can interfere with or stop the menstrual cycle.
  • Serum ferritin, to check for anemia, a symptom of heavy blood loss.
• Pap smear and cultures to check for infection or abnormal cervical cells.
• Urine test to screen for infection, disease, and other signs of poor health.
• Transvaginal pelvic ultrasound, to check for any abnormalities in the pelvic area. After the pelvic exam, a transvaginal ultrasound is often the next step in diagnosing a vaginal bleeding problem. If a pelvic mass is found, ultrasound results are useful for making further testing and treatment decisions.
• Sonohysterogram, which uses ultrasound to monitor the movement of a salt solution (saline), which is injected into the uterus. This test may be done to look for uterine polyps or fibroids.
• Endometrial biopsy, usually for women older than 35 or who are postmenopausal, to learn whether the lining of the uterus (endometrium) is healthy and functioning normally.
• Hysteroscopy, if no cause is apparent but a problem condition is suspected; to check for and treat a suspected condition, such as uterine fibroids; or if bleeding continues despite treatment.

Early Detection

Endometrial cancer risk increases with age. Also known as uterine cancer, it is most common in women over age 50, after menopause. However, endometrial cancer can also develop earlier, during perimenopause or in women who have had abnormal bleeding for many years.

• If you have heavy or unusual vaginal bleeding after menopause, your doctor will do tests, usually either ultrasound or endometrial biopsy, to look for cancerous cell changes.
• If you are perimenopausal, have not responded to other treatment for uterine bleeding, or have risk factors for endometrial cancer, your doctor may recommend an endometrial biopsy.

Dysfunctional uterine bleeding (DUB) can usually be managed with medicine to reduce bleeding and/or hormone therapy to either stop or regulate menstrual periods. Surgical treatment is reserved for bleeding that can't be controlled with medicine or hormone therapy.

Acute, severe uterine bleeding

Severe uterine bleeding is usually treated on an emergency basis with a short course of high-dose estrogen therapy. If that isn't effective in rare cases, a dilation and curettage (D&C) may be done to clear the uterus of tissue. When necessary, a blood transfusion is used to quickly restore needed blood volume.

If you are treated for severe uterine bleeding, you and your health professional can then choose a treatment that is safe for the longer term.

Ongoing uterine bleeding

Your age, the cause of your condition, and any future plans for pregnancy will impact the treatment choices available to you.

• If you are a teen, you can expect your periods to become more regular as your body matures. You may choose to wait and see if your periods become more regular. If you need treatment, your doctor may prescribe progestin or birth control pills to regulate your cycle.
• If you are not ovulating regularly, it's difficult to predict how long your irregular bleeding will last until you stop having periods completely (menopause). If you need treatment, your doctor may give you hormone therapy (progestin or birth control pills) to regulate your cycle. If you have no future childbearing plans and have severe symptoms, you can opt for surgical treatment to remove your uterus ( hysterectomy) or to destroy the uterine lining ( endometrial ablation).
• If you are ovulating regularly, have irregular vaginal bleeding, and plan to become pregnant in the future, talk to your doctor about your treatment options. He or she may recommend oral progestin and/or birth control pills until your bleeding becomes more regular. If you have no future pregnancy plans, you can consider endometrial ablation or hysterectomy if medical treatment is ineffective.

Gonadotropin-releasing hormone analogues (GnRH-As) are rarely used now. These drugs reduce estrogen production, making your body think it is in menopause. This reduces or stops menstrual periods for as long as you take the medicine. After you stop taking the medicine, your symptoms will come back unless you are close to menopause. Side effects with GnRH-As are common.

For more information about treatment options, see:

Should I use hormone therapy to treat dysfunctional uterine bleeding?

What To Think About

When considering treatment for dysfunctional uterine bleeding, evaluate the following:

• Has irregular menstrual bleeding caused a significant change in your lifestyle?
• Do you plan to become pregnant in the future?
• Do you have anemia caused by irregular menstrual bleeding?
• Do you want a treatment that will also provide birth control?
• Do you prefer to avoid medical treatment if possible?
• Will you be starting menopause soon? If you are approaching menopause, you can expect uterine bleeding to naturally cease without treatment.

The answers to these questions will help you and your health professional select the treatment plan that is best for you.

Usually, dysfunctional uterine bleeding (DUB) results from unpredictable hormonal changes and therefore cannot be prevented. However, being overweight can impact your hormone production, increasing your risk of developing irregular menstrual bleeding. If you are overweight, losing weight may help prevent dysfunctional uterine bleeding from developing.

You can use home treatment for some problems related to dysfunctional uterine bleeding (DUB).

For menstrual pain and heavy bleeding, you can use a nonsteroidal anti-inflammatory drug (NSAID), such as over-the-counter ibuprofen. This type of medicine lowers prostaglandins, which cause menstrual pain, and reduces bleeding during your period. An NSAID works best when you start taking it 1 to 2 days before you expect pain to start. If you don't know when your period will start next, take your first dose of an NSAID as soon as bleeding or premenstrual pain starts. Take regular doses of the NSAID, as directed.

Irregular menstrual bleeding can lead to low levels of iron in the blood. This condition is known as anemia. You can take the following steps to prevent anemia:

• Increase the amount of iron in your diet. Your body needs iron to make new blood cells, and your diet is the best source. Get 18 mg to 20 mg of iron per day. Red meats, shellfish, eggs, beans, green leafy vegetables, and iron-enriched breads and cereals are the best sources of iron.
• It is better to eat a well-balanced diet than it is to take dietary supplements, but if you are unable to meet your need for iron through diet alone, consider taking a nonprescription iron supplement (such as ferrous sulfate) or a multivitamin. You may become constipated when you are taking an iron supplement. To avoid constipation, eat more fiber, eat plenty of fruits, and drink at least 2 to 4 extra glasses of water per day.
• Be sure your diet includes 250 mg of vitamin C per day. Vitamin C helps your body absorb iron more effectively.

Treating dysfunctional uterine bleeding (DUB) with medicines has fewer risks but is not always as effective as surgical treatment. If you plan to become pregnant in the future, or if you are nearing the time when your menstrual periods will stop ( menopause), you may want to try medicines first.

Goals of medical treatment

The goal of medication treatment for dysfunctional uterine bleeding is to reduce or eliminate blood loss. This can be accomplished in one or both of the following ways:

• Reducing the endometrium's rate of blood loss
• Regulating or eliminating the menstrual cycle by changing hormonal levels

Medication Choices

There are several hormone therapies for managing dysfunctional uterine bleeding. These treatments help reduce bleeding and regulate the menstrual cycle:

• Progestins (synthetic progesterone). In some women, progestins can control endometrial growth and bleeding. You usually take progestins 10 to 12 days every month.
• Birth control pills (synthetic estrogen and progesterone). Daily birth control pills prevent pregnancy. They also reduce the amount of heavy menstrual bleeding by about half.² In other words, when you take birth control pills, your menstrual bleeding can be half as heavy as it was before you took the pills. But when you stop taking the pills, irregular bleeding or perimenopausal symptoms may return.
• The levonorgestrel intrauterine device (IUD). A doctor inserts this birth control device into your uterus through your vagina. It stays in your body for up to 5 years and releases levonorgestrel, a form of progesterone, into the uterus. For more information, see intrauterine device (IUD) for birth control.
• Estrogen. Most dysfunctional uterine bleeding is treated with birth control pills or progestin. But in other cases, estrogen may be used to reduce bleeding.¹
• Hormone suppressors such as gonadotropin-releasing hormone analogues (GnRH-As). GnRH-As are rarely used now. These drugs reduce estrogen production, making your body think it is in menopause. This reduces or stops menstrual periods for as long as you take the medicine. Side effects with GnRH-As are common.

What To Think About

Intravenous estrogen therapy is generally used on an urgent basis, when severe blood loss must be quickly stopped. After bleeding subsides, a week or so of progestin or estrogen-progestin therapy is added to help return the menstrual cycle to normal.

Surgery is generally reserved for treating dysfunctional uterine bleeding (DUB) that can't be controlled with medicine.

Surgery Choices

The following procedures are used to treat dysfunctional uterine bleeding.

• Hysteroscopy can be used to diagnose and treat dysfunctional uterine bleeding at the same time. A lighted viewing instrument called a hysteroscope is inserted through the vagina and cervix and into the uterus. When areas of bleeding are located, biopsies can be taken and then the areas of bleeding can be treated with either a laser beam or electric current (electrocautery).
• Hysterectomy is the removal of the uterus. It may be done when a sample of the uterine lining (endometrial biopsy) shows abnormal cell changes or cancer, when uterine bleeding is uncontrollable, or when the cause of chronic bleeding cannot be found and treated. A hysterectomy is a major surgery with risks of complications. Recovery from surgery can take 4 to 8 weeks, depending on the type of hysterectomy performed. If the ovaries are also removed, you may need to take long-term estrogen replacement therapy after surgery.
• Endometrial ablation is a minimally invasive alternative to hysterectomy when other medical treatments fail or when you or your doctor have reasons for not using other treatments. Endometrial ablation scars the uterine lining, so it is not a treatment option if you are planning to become pregnant.

What To Think About

Hysteroscopy may be done to rule out serious uterine conditions:

• Before long-term treatment with medicines or surgical treatment for dysfunctional uterine bleeding.
• When uterine bleeding has continued despite nonsurgical treatment.

There is no other treatment for dysfunctional uterine bleeding. But your doctor may prescribe medicine for related conditions, such as heavy bleeding or cramping during your period.

Organizations

• Abnormal Vaginal Bleeding
• Birth Control
• Menopause and Perimenopause
• Normal Menstrual Cycle

Citations

1. Speroff L, Fritz MA (2005). Dysfunctional uterine bleeding. In L Speroff, MA Fritz, eds., Clinical Gynecologic Endocrinology and Infertility, 7th ed., pp. 548–571. Philadelphia: Lippincott Williams and Wilkins.

2. Lobo RA (2007). Abnormal uterine bleeding: Ovulatory and anovulatory dysfunctional uterine bleeding, management of acute and chronic excessive bleeding. In VL Katz et al., eds., Comprehensive Gynecology, 5th ed., pp. 915–931. Philadelphia: Mosby Elsevier.

Other Works Consulted

• American College of Obstetricians and Gynecologists (2007). Endometrial ablation. ACOG Practice Bulletin No. 81. Obstetrics and Gynecology, 109(5): 1233–1248.

• Elward K (2006). Dysfunctional uterine bleeding (DUB). In MR Dambro, ed., Griffith's 5-Minute Clinical Consult, pp. 346–347. Philadelphia: Lippincott Williams and Wilkins.

• Hillard P (2007). Benign diseases of the female reproductive tract. In JS Berek, ed., Berek and Novak's Gynecology, 14th ed., pp. 431–504. Philadelphia: Lippincott Williams and Wilkins.

Author:	Kathe Gallagher, MSW Debby Golonka, MPH	Last Updated: February 12, 2008
Medical Review:	Kathleen Romito, MD - Family Medicine Liisa Honey, MD, FRCSC - Obstetrics and Gynecology
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