Dysfunctional Uterine Bleeding: Symptoms, Types, Causes and Treatment

Dysfunctional uterine bleeding (DUB) is a common but often misunderstood gynecological concern that can dramatically affect a woman's quality of life. Whether you are experiencing unexpected heavy periods, irregular cycles, or disruptive spotting, understanding DUB is the first step toward effective management. In this comprehensive guide, we will walk through the key symptoms, types, causes, and treatments for DUB, drawing on the latest research and clinical guidelines.

Symptoms of Dysfunctional Uterine Bleeding

DUB can manifest in many different ways, making it a challenging condition to recognize and diagnose. It's essential to pay attention to any changes in your menstrual pattern, as these could signal underlying hormonal imbalances or other health concerns.

Symptom	Description	Frequency/Pattern	Source(s)
Menorrhagia	Excessive or prolonged menstrual bleeding	Most common presentation	3 4 5 6 8
Metrorrhagia	Irregular, often unpredictable bleeding	Between periods	6
Menometrorrhagia	Heavy and irregular bleeding	Both heavy and erratic	6
Intermenstrual Bleeding	Spotting between periods	Unpredictable	2 6

Table 1: Key Symptoms

Recognizing the Symptoms

The hallmark of DUB is abnormal uterine bleeding that cannot be attributed to an identifiable organic, systemic, or iatrogenic cause. Most women notice:

• Menorrhagia: This means menstrual bleeding that is unusually heavy or lasts longer than normal. In clinical studies, menorrhagia is the most common symptom, reported in around half of DUB cases, especially among women aged 41-50 years 3 4 5 8.
• Metrorrhagia: This refers to bleeding that occurs at irregular intervals, outside the expected menstrual period 6.
• Menometrorrhagia: Here, bleeding is both excessively heavy and occurs at unpredictable times 6.
• Intermenstrual Bleeding: Spotting or bleeding between periods, which can be especially disruptive and worrisome 2.

Other symptoms can include anemia (from blood loss), fatigue, and, in some cases, anxiety or distress due to the unpredictability of the bleeding.

When to Seek Help

If you notice any of these symptoms—particularly if they disrupt your day-to-day activities or lead to symptoms of anemia, such as fatigue or shortness of breath—it’s important to seek medical evaluation. DUB is a diagnosis of exclusion, meaning other causes must be ruled out first 1 3 10.

Types of Dysfunctional Uterine Bleeding

Not all cases of DUB are the same. The type of bleeding often reflects the underlying hormonal or endometrial changes. Understanding the types helps tailor treatment and set realistic expectations.

Type	Bleeding Pattern	Age Prevalence	Source(s)
Anovulatory	Irregular, unpredictable	Adolescents, Perimenopause	1 3 4 7 8 9
Ovulatory	Regular cycles, heavy flow	Reproductive years	5 6 11
Acute	Sudden, severe bleeding	Any	1 13 16
Chronic	Persistent abnormal bleeding	Most common DUB cases	1 12 16

Table 2: Types of Dysfunctional Uterine Bleeding

Anovulatory Dysfunctional Uterine Bleeding

This is the most frequent type of DUB, especially in adolescents (just after menarche) and perimenopausal women. In anovulatory cycles, the ovary does not release an egg, resulting in unopposed estrogen stimulation of the endometrium without progesterone balance. This leads to unpredictable, often heavy bleeding 1 3 4 7 8 9.

Ovulatory Dysfunctional Uterine Bleeding

In contrast, ovulatory DUB features regular menstrual cycles with consistently heavy bleeding. The underlying mechanism may involve subtle disturbances in endometrial repair or vascular function, but the precise causes are less well understood 5 6 11.

Acute vs. Chronic Bleeding

• Acute DUB: Refers to a sudden episode of severe bleeding requiring immediate medical attention 1 13 16.
• Chronic DUB: Persistent or recurrent abnormal bleeding over several months, which is more common and forms the bulk of DUB cases 1 12 16.

Age and Life Stage Considerations

• Adolescents: Most often experience anovulatory cycles as their hormonal system matures.
• Reproductive-aged women: May experience either type, but ovulatory DUB is more frequent.
• Perimenopausal women: Often have anovulatory cycles due to hormonal fluctuations as menopause approaches 3 4 8.

Causes of Dysfunctional Uterine Bleeding

Understanding what causes DUB is critical for both diagnosis and management. DUB is fundamentally a diagnosis made only after excluding identifiable organic, systemic, and iatrogenic causes of abnormal uterine bleeding.

Cause Category	Examples/Details	Diagnostic Approach	Source(s)
Hormonal	Anovulation, ovulatory dysfunction	Menstrual history, labs	1 3 4 7 9
Structural	Should be excluded: polyps, fibroids, etc	Imaging, biopsy	2 10
Systemic	Coagulopathy, thyroid, liver disease	Blood tests, history	10
Iatrogenic	Medications, IUD, hormone therapy	Medication review	10 16

Table 3: Causes of DUB

Hormonal and Functional Causes

Most DUB cases are linked to hormonal imbalances, particularly anovulation. Without ovulation, there is no progesterone production, leading to prolonged exposure of the endometrium to estrogen. The result is an overgrown, unstable endometrial lining prone to irregular shedding and heavy bleeding 1 3 7 9.

In ovulatory DUB, the cause is less clear but may involve local endometrial or vascular factors, or subtle hormonal disturbances 5 11.

Structural Causes: Always Exclude First

Before DUB can be diagnosed, clinicians must rule out structural lesions such as:

• Uterine fibroids
• Endometrial polyps
• Adenomyosis
• Endometrial hyperplasia or cancer

This is typically done using pelvic ultrasound, endometrial biopsy, and sometimes hysteroscopy 2 10.

Systemic and Iatrogenic Causes

Other medical conditions—such as thyroid disorders, liver disease, or bleeding disorders (e.g., von Willebrand disease)—can cause abnormal uterine bleeding and must be considered 10. Medications like anticoagulants, hormone therapies, and devices such as IUDs may also be responsible 10 16.

The Role of the PALM-COEIN System

Modern guidelines recommend using the PALM-COEIN classification to systematically evaluate causes of abnormal uterine bleeding, with DUB falling under "non-structural" etiologies after organic causes are excluded 2 7.

Treatment of Dysfunctional Uterine Bleeding

Once other causes have been excluded and DUB is diagnosed, the focus shifts to individualized treatment. Most women respond well to medical therapy, but surgical options are available for those who do not.

Treatment Option	Indication/Use	Advantages	Source(s)
Medical (Hormonal)	First-line, acute/chronic bleeding	Non-invasive, effective	1 12 13 16
Non-hormonal Medical	Tranexamic acid, NSAIDs	Fewer hormonal side effects	16
IUD (LNG-IUS)	Chronic heavy bleeding	Long-term, reversible	15 16
Endometrial Ablation	Failed medical treatment	Minimally invasive	14 15
Hysterectomy	Refractory, completed childbearing	Definitive, curative	9 12 14 15

Table 4: Treatment Options

Medical Management

Hormonal therapies are the mainstay:

• Progestins: Used to regulate cycles and prevent endometrial overgrowth, especially in anovulatory DUB 1.
• Combined oral contraceptives: Regulate bleeding and provide contraception 16.
• Levonorgestrel-releasing IUD (LNG-IUS): Highly effective for chronic heavy menstrual bleeding, with many women preferring it over surgery 15 16.
• Estrogen therapy: In acute severe bleeding, intravenous estrogen may rapidly stop bleeding 13.

Non-hormonal options:

• Tranexamic acid: Reduces menstrual blood loss by stabilizing blood clots 16.
• NSAIDs: Reduce menstrual bleeding and pain 16.

Surgical Options

• Endometrial Ablation: Destroys the lining of the uterus to reduce or stop bleeding. It is less invasive than hysterectomy and can be highly effective, though some women may eventually need further procedures 14 15.
• Hysterectomy: Complete removal of the uterus provides a definitive cure for DUB but is reserved for women who do not desire future fertility and have failed less invasive treatments 9 12 14 15. Hysterectomy is associated with higher risks and longer recovery.

Deciding on the Right Treatment

The choice between medical and surgical management depends on:

• Severity and pattern of bleeding
• Patient’s age and desire for future fertility
• Presence of anemia or other complications
• Response to prior therapies
• Patient preference (many women prefer less invasive options when possible) 15

Monitoring and Follow-Up

Regular follow-up is essential to ensure treatment effectiveness and to monitor for underlying pathology, especially in perimenopausal women or those with risk factors for endometrial hyperplasia or cancer 1 4 8.

Conclusion

Dysfunctional uterine bleeding is a complex but manageable condition when approached systematically and empathetically. Here’s a summary of the key takeaways:

• DUB is a diagnosis of exclusion: All structural, systemic, and iatrogenic causes must be ruled out before labeling bleeding as dysfunctional 1 3 10.
• Most common in perimenopausal women: Especially those aged 41-50 years, with menorrhagia as the predominant symptom 3 4 8.
• Anovulatory cycles are the usual culprit: Leading to unpredictable, often heavy bleeding due to hormonal imbalances 1 3 7 9.
• Diagnosis requires careful history, examination, and sometimes biopsy: To exclude other pathologies 2 4 8.
• Medical therapy is first-line: Progestins, combined oral contraceptives, LNG-IUS, tranexamic acid, and NSAIDs are all options; most women respond well 1 12 16.
• Surgical options exist for refractory cases: Endometrial ablation and hysterectomy can be considered when medical therapy fails or is contraindicated 14 15.
• Patient preference matters: Many women value less invasive treatments and are willing to try them even with moderate success rates 15.

By partnering with your healthcare provider and staying informed, you can find an effective, personalized strategy to manage DUB and reclaim your quality of life.