A 35-year-old woman from Mumbai with a history of irregular periods for the past 18 months presents with prolonged menstrual bleeding lasting 10–12 days with heavy flow (soaking 12+ pads per day). She denies dysmenorrhea, pelvic pain, or intermenstrual bleeding. Pelvic examination is unremarkable; uterus is normal size and mobile. Hemoglobin is 8.8 g/dL. Pelvic ultrasound shows a normal uterus and ovaries with no focal lesions. Endometrial thickness is 8 mm in the proliferative phase. Coagulation profile is normal. What is the most likely diagnosis?

Explanation

## Clinical Diagnosis: Dysfunctional Uterine Bleeding (DUB) — Anovulatory Bleeding ### Definition and Pathophysiology **Key Point:** Dysfunctional uterine bleeding is abnormal uterine bleeding in the absence of structural, systemic, or organic pelvic disease. In reproductive-age women, anovulation is the most common mechanism. ### Mechanism of Anovulatory Bleeding 1. **Absent ovulation** → no corpus luteum → no progesterone production 2. **Unopposed estrogen** stimulates continuous endometrial proliferation 3. **Disorganized endometrium** with fragile, immature vessels 4. **Irregular shedding** → prolonged, heavy, irregular bleeding 5. **No hemostatic support** from progesterone-induced secretory changes ### Why This Patient Has Anovulatory DUB | Finding | Interpretation | |---------|----------------| | **Age 35, irregular periods × 18 months** | Reproductive age; anovulation common in this age group | | **Prolonged heavy bleeding (10–12 days)** | Characteristic of anovulatory DUB (not dysmenorrhea-associated) | | **Normal pelvic exam** | Rules out structural disease (fibroids, polyps, adenomyosis) | | **Normal ultrasound** | No focal lesions; endometrial thickness 8 mm is normal for proliferative phase | | **Normal coagulation profile** | Excludes systemic coagulopathy | | **No intermenstrual bleeding** | Suggests anovulation, not organic pathology | **High-Yield:** The **normal structural findings** on ultrasound and **normal coagulation studies** are key to excluding organic and systemic causes, leaving anovulatory DUB as the diagnosis of exclusion. ### Diagnostic Approach: PALM-COEIN Classification ```mermaid flowchart TD A["Abnormal Uterine Bleeding"]:::outcome --> B{"Structural disease?"}:::decision B -->|"Polyp, Adenomyosis, Leiomyoma, Malignancy"| C["PALM causes"]:::outcome B -->|"No structural disease"| D{"Coagulation disorder?"}:::decision D -->|"Yes (von Willebrand, etc.)"|E["Coagulopathy"]:::outcome D -->|"No (normal PT/PTT/INR)"| F{"Ovulatory?"}:::decision F -->|"Anovulatory"| G["DUB — Anovulation"]:::action F -->|"Ovulatory"| H["Ovulatory DUB (rare)"]:::outcome ``` ### Management of Anovulatory DUB **First-line medical therapy:** - **Combined oral contraceptives (COCs):** Suppress FSH → prevent follicular growth → restore ovulation or provide hormonal control - **Progestin-only methods:** Levonorgestrel IUD (LNG-IUD) or medroxyprogesterone acetate (MPA) - **NSAIDs:** Mefenamic acid 500 mg TDS during menses (reduces prostaglandins, decreases flow by 20–30%) - **Tranexamic acid:** 1.3 g TDS for 4 days during menses (antifibrinolytic; reduces flow by 40–50%) **Tip:** Iron supplementation is essential to correct anemia (Hb 8.8 g/dL in this case). **Clinical Pearl:** Anovulatory cycles are common in adolescence (menarche to age 20) and perimenopause (age 40+); in reproductive years (20–40), anovulation suggests PCOS, thyroid disease, hyperprolactinemia, or stress. ### Why Other Options Are Wrong **Coagulopathy (von Willebrand disease):** While this can cause menorrhagia, the **normal coagulation profile** (PT, PTT, fibrinogen) and **normal bleeding time** exclude this. Von Willebrand disease typically presents with a **family history** of bleeding and **mucosal bleeding** (epistaxis, gum bleeding) in addition to menorrhagia. **Endometrial hyperplasia:** This is a pathologic diagnosis requiring endometrial biopsy or hysteroscopy. It is suspected in postmenopausal women with abnormal endometrial thickening (>8 mm) or in reproductive-age women with prolonged unopposed estrogen exposure (obesity, PCOS). This patient's endometrial thickness is normal (8 mm in proliferative phase), and she has no risk factors for hyperplasia. **Pelvic inflammatory disease (PID):** Presents with pelvic pain, fever, cervical discharge, and cervical motion tenderness. This patient has **no pelvic pain** and a **normal pelvic exam**, ruling out PID. [cite:ACOG Practice Bulletin 128 (2012); Munro et al., Fertil Steril 2018; Harrison 21e Ch 50]