Vaginal bleeding - hormonal

  • Definition
    • Dysfunctional uterine bleeding (DUB) is abnormal bleeding from the vagina that is due to changes in hormone levels. It is bleeding that is NOT caused by:

      • Pregnancy or miscarriage
      • Medical conditions, such as cancer or fibroids
      • Problems with the uterus or vagina from infection or other causes

      Your doctor will rule out other possible causes of irregular bleeding. In most women, abnormal uterine bleeding is caused by a hormone imbalance.

      DUB is more common in teenagers or in women who are approaching menopause.

      DUB is unpredictable. The bleeding may be very heavy or light and can occur often or randomly.

  • Alternative Names
    • Anovulatory bleeding; Bleeding - dysfunctional uterine; DUB; Abnormal uterine bleeding-hormonal; Menorrhagia - dysfunctional; Polymenorrhea - dysfunctional; Metrorrhagia - dysfunctional

  • Causes
    • Every woman's menstrual cycle, or period, is different.

      • On average, a woman's period occurs every 28 days.
      • Most women have cycles between 24 and 34 days apart. It usually lasts 4 to 7 days.
      • Young girls may get their periods anywhere from 21 to 45 days or more apart.
      • Women in their 40s will often notice their period occurring less often.

      About every month, the levels of female hormones in a woman's body rise and fall. Estrogen and progesterone are two hormones that play an important role in ovulation. This is the time when the ovaries release an egg.

      Dysfunctional uterine bleeding most commonly occurs when the ovaries do not release an egg. Changes in hormone levels cause your period to be later or earlier and sometimes heavier than normal.

  • Symptoms
    • Symptoms of dysfunctional uterine bleeding may include:

      • Bleeding or spotting from the vagina between periods
      • Periods that occur less than 28 days apart (more common) or more than 35 days apart
      • Time between periods changes each month
      • Heavier bleeding (such as passing large clots, needing to change protection during the night, soaking through a sanitary pad or tampon every hour for 2 to 3 hours in a row)
      • Bleeding that lasts for more days than normal or for more than 7 days

      Other symptoms caused by changes in hormone levels may include:

      • Excessive growth of body hair in a male pattern (hirsutism)
      • Hot flashes
      • Mood swings
      • Tenderness and dryness of the vagina

      A woman may feel tired or fatigued if she is loses too much blood over time. This is a symptom of anemia.

  • Exams and Tests
    • Your health care provider will do a pelvic exam and may do a Pap test. Other tests that may be done include:

      Your provider may recommend the following:

      • Culture to look for infection
        Biopsy to check for precancer, cancer, or to help decide on hormone treatment
      • Hysteroscopy, performed in the doctor's office, to look into the uterus through the vagina.
      • Ultrasound to look for problems in the uterus or pelvis
  • Treatment
    • Young women up to age 18 may be treated with low-dose combination birth control pills.

      In other women, treatment may include one or more of the following:

      Women over age 40 and older may have the option to receive cyclic progestin or cyclic hormone therapy.

      A health care provider may recommend iron supplements for women with anemia.

      If you want to get pregnant, you may be given medication to stimulate ovulation.

      Women with severe symptoms that do not get better with other treatments may consider the following procedures if they no longer want to have children:

      • Surgical procedure to destroy or remove the lining of the uterus
      • Hysterectomy to remove the uterus
  • Outlook (Prognosis)
    • Hormone therapy usually relieves symptoms. Treatment may not be needed if you do not develop anemia due to blood loss.

  • Possible Complications
    • Complications that may occur:

      • Infertility (inability to get pregnant)
      • Severe anemia due to a lot of blood loss over time
      • Increased risk for endometrial cancer
  • When to Contact a Medical Professional
    • Call your health care provider if you have unusual vaginal bleeding.

  • References
    • ACOG Practice Bulletin No. 110: Noncontraceptive uses of hormonal contraceptives. Obstet Gynecol. 2010 Jan;115(1):206-18. PMID: 20027071

      Committee on Practice Bulletins - Gynecology. Practice bulletin no. 136: management of abnormal uterine bleeding associated with ovulatory dysfunction. Obstet Gynecol. 2013 Jul;122(1):176-85. PMID: 23787936

      Kaunitz AM, Meredith S, Inki P, Kubba A, Sanchez-Ramos L. Levonorgestrel-releasing intrauterine system and endometrial ablation in heavy menstrual bleeding: a systematic review and meta-analysis. Obstet Gynecol. 2009;113:1104-16. PMID: 19384127

      Lobo RA. Abnormal Uterine Bleeding : Ovulatory and Anovulatory Dysfunctional Uterine Bleeding: Management of Acute and Chronic Excessive Bleeding. In: Lentz GM, Lobo RA, Gershenson GM, Katz VL, eds., Comprehensive Gynecology. 6th ed. Philadelphia, PA: Elsevier Mosby; 2012:chap 37.

      Middleton LJ, Champaneria R, Daniels JP, Bhattacharya S, Cooper KG, Hilken NH, et al. Hysterectomy, endometrial destruction, and levonorgestrel releasing intrauterine system (Mirena) for heavy menstrual bleeding: systematic review and meta-analysis of data from individual patients. BMJ. 2010 Aug 16;341:c3929. PMID: 20713583