Diagnostic Investigation:
The history should include a detailed menstrual pattern in terms of intervals, duration and amount of the flow; a list of medications; obstetric history; sexual and contraceptive histories; and a general medical history. It should also include recent surgical and gynecologic disorders. Physical examination focuses on general medical conditions that might cause DUB. Examination of the thyroid, breast, liver, and skin is essential. Evaluation of the presence and absence of ecchymotic lesions, obesity, and hirsutism is essential. Pelvic examination of external and internal organs, the source and degree of bleeding, the size and shape of the uterus and any adnexal abnormalities are checked for the diagnosis. A complete blood count, Pap smear, coagulation profile, serum HCG, iron concentration and binding capacity, ovulation detection, thyroid function tests, serum androgens, hepatic function tests, endometrial biopsy, hysteroscopy and hysterogram, pelvic ultrasound, and MRI are usually done depending on the clinical findings and to make an accurate diagnosis.

Treatment:
It is individualized according to the patient's age, her desire for contraception or fertility, and the severity and chronicity of the bleeding. The goals of treatment are to arrest the acute episode of bleeding, to prevent recurrences, and to induce ovulation in the patient desiring to conceive. If the pelvic examination shows a normal uterus and no systemic diseases are suspected, hormonal therapy is usually effective in managing DUB.

Acute, Profuse Bleeding: When a patient presents with acute, profuse, and uncontrollable hemorrhage, the usual steps taken for any other serious hemorrhage must be instituted immediately. High-dose estrogen therapy or injectable progesterone is sometimes helpful to control the bleeding. Emergency dilatation and curettage or hysterectomy might be needed in some occasions to control the bleeding and save the patient's life.

Chronic, Recurrent Bleeding: Treatment is based on the patient's complaint, age, and desire for fertility. Observation only is a reasonable approach for adolescent girls without any evidence of anemia. However, if the patient is sexually active, combination oral contraceptives is offered.

Surgical Therapy: Although most of the patients with DUB can be managed by hormonal therapy, a D & C can be effective both diagnostically and therapeutically. For those older than age 35, histology evaluation of the endometrium is essential either by an endometrial biopsy or a D & C to rule out endometrial hyperplasia and endometrial cancer. Endometrial ablation either by thermal balloon or by Nd: YAG laser or electrocoagulations through the hysteroscope are surgical options. Hysterectomy is regarded as the definitive treatment. Please discuss with your healthcare provider to decide what the right treatment for you is.

Clinical Considerations and Suggested Approach:
Adolescents (13-18 Years): Anovulatory bleeding is a normal physiologic process in the perimenarchal years of the reproductive cycle. Ovulatory menstrual cycles may not be established until a year or more after menarche. This phenomenon is attributed to immaturity or hypothalamic-pituitary-gonadal axis. Occasionally, adolescents with blood dyscrasias, including Von Willebrand's disease and prothrombin deficiency, have heavy vaginal bleeding at menarche. Disorders such as leukemia, idiopathic thrombocytopenic purpura, and hypersplenism can all produce platelet dysfunction and cause excessive bleeding. These conditions require specific treatments, and routine screening for coagulation disorders is suggested in adolescents.
For chronic anovulation, treatment with low-dose oral contraceptives is the treatment of choice. Oral contraceptives suppress both ovarian and adrenal androgen production and increase sex hormone binding globulins.

Women of Reproductive Age (19-39): Although anovulation may be considered physiologic in adolescents, adult women of reproductive age who have menorrhagia, metrorrhagia, or amenorrhoea require evaluation for the specific cause. The laboratory tests should include a pregnancy test, thyroid stimulating hormone (TSH) level, and prolactin level. Chronic anovulation that results from hypothalamic dysfunction, as diagnosed by a low follicular stimulating hormone (FSH) level, may be the result of excessive psychologic stress, exercise, or weight loss. A history of rapidly progressing hirsutism accompanied by virilization suggests a tumor. In most cases, tumors can be ruled out by testing testosterone and dehydroepinandrostetrone sulfate levels in serum. The incidence of endometrial carcinoma increases with age. Therefore, based on age alone, endometrial assessment to exclude cancer is indicated in any woman older than 35 years who is suspected of having anovulatory uterine bleeding. Adult women of reproductive age with anovulatory uterine bleeding can be treated safely with either a cyclic progestrogen or oral contraceptives. If pregnancy is desired, induction of ovulation with clomiphene citrate is the initial treatment of choice.

Women of Later Reproductive Age (40 Years to Menopause): The incidence of anovulatory uterine bleeding increases as women approach the end of their reproductive years. In perimenopausal women, the onset of anovulatory cycles represents a continuation of declining ovarian function. These patients need to be educated regarding the specific health risks associated with menopause so that an early proactive approach toward the prevention of menopause associated conditions such as osteoporosis can be initiated. In addition to the use of hormone replacement therapy for cycle control, important lifestyle changes include exercise, dietary modification, and smoking cessation. The incidence of endometrial carcinoma in women ages 40-49 years was 36.2 per 100,000 in 1995. Therefore, all women older than 40 years who present with suspected anovulatory uterine bleeding should be evaluated with endometrial assessment (after pregnancy has been excluded). Women who have failed medical therapy and no longer desire future childbearing are candidates for endometrial ablation, which appears to be an efficient and cost-effective treatment to hysterectomy for anovulatory uterine bleeding. However, endometrial ablation may not be definite therapy.