• Patients often present with complaints of amenorrhea, oligomenorrhea, menorrhagia, or metrorrhagia. Ask patients to compare the amount of pads or tampons used per day in a normal menstrual cycle to the amount used at the time of presentation. The average tampon holds 5 cc of blood; the average pad holds 5-15 cc of blood.

• Occasionally, bleeding is profuse with associated signs and symptoms of hypovolemia, including hypotension, tachycardia, diaphoresis, and pallor. These patients usually do not have pain associated with bleeding episodes, and other systemic symptoms rarely are noted unless vaginal bleeding has an organic cause.

• A reproductive history should always be obtained, including the following:

• Menstrual regularity

• Last menstrual period (LMP), including flow and duration

• Gravida and para

• Previous abortion or recent termination of pregnancy

• Contraceptive use

Physical:

• Initial evaluation should be directed at assessing patient's volume status and degree of anemia. Examine for pallor and absence of conjunctival vessels to gauge anemia.

• Patients who are hemodynamically stable require a pelvic speculum and bimanual examination to define the etiology of vaginal bleeding. The exam should look for the following:

• Trauma

• Foreign body

• Cervical or vaginal laceration

• Bleeding from the os

• Uterine or ovarian structural abnormalities may be noted on bimanual exam.

• Patients with hematologic pathology also may have cutaneous evidence of bleeding diathesis. Physical findings include petechiae, purpura, and mucosal bleeding (eg, gums) in addition to vaginal bleeding.

• Patients with liver disease may manifest additional symptomatology because of abnormal hepatic function. Evaluate patients for spider angioma, palmar erythema, splenomegaly, ascites, jaundice, and asterixis.

• Women with polycystic ovary disease present with signs of hyperandrogenism, including hirsutism, obesity, and palpable enlarged ovaries.

• Hyperactive and hypoactive thyroid can cause menstrual irregularities. Patients may have characteristic eye findings, tremors, changes in skin texture, and weight loss or gain. Goiter may be present.

Causes:

• Multiple organic pathologies can present as abnormal vaginal bleeding, including thrombocytopenia, hypothyroidism, hyperthyroidism, liver disease, hypertension, diabetes mellitus, and adrenal disorders.

• Pregnancy may be associated with abnormal vaginal bleeding.

• Trauma to the cervix, vulva, or vagina may cause abnormal bleeding.

• Carcinomas of the vagina, cervix, uterus, and ovaries always must be considered in patients with the appropriate history and physical exam.

• Other causes of DUB include structural disorders, such as functional ovarian cysts, cervicitis, endometritis, salpingitis, and leiomyomas.

• Polycystic ovary disease, vaginal infection, polyps, ectopic pregnancy, hydatidiform mole, blood dyscrasias, excessive weight gain, increased exercise performance, or stress may also contribute to DUB.

• Breakthrough bleeding may occur in patients taking oral contraceptives that have low doses of estrogen and progestin.

• Intermenstrual bleeding may occur secondary to missed pills, varied ingestion times, and drug interactions.

• The most common drug interactions occur with phenobarbital, carbamazepine, some penicillins, tetracycline, and trimethoprim-sulfamethoxazole.

• Breakthrough bleeding can indicate reduced birth control efficiency; therefore, advise using additional birth control methods until bleeding stops.

• An iatrogenic cause of DUB is the use of progestin-only compounds for birth control. Medroxyprogesterone acetate (Depo-Provera), a long-acting injection given every 3 months, inhibits ovulation. An adverse effect of this drug is prolonged uterine breakthrough bleeding; this may continue after discontinuation of the drug because of persistent anovulation. The Norplant system (surgically implanted levonorgestrel), which acts to block some but not all ovulatory cycles, has the same adverse effects as Depo-Provera.