Transcript Putting a Stop to Dysfunctional Uterine Bleeding

Putting a Stop to Dysfunctional
Uterine Bleeding
By Denise McEnroe-Ayers, RN, MSN
and Mariann Montgomery, RN, MSN
Nursing2009, January 2009
2.3 ANCC/AACN contact hours
Online: www.nursingcenter.com
© 2008 by Lippincott Williams & Wilkins. All world rights reserved.
Abnormal uterine bleeding

Any uterine bleeding that differs in quantity,
duration, or frequency

Examples include:
- spotting between menstrual periods
- postmenopausal bleeding (occurs 12 months
or more after woman’s last menstrual period)
Dysfunctional uterine bleeding (DUB)

Relates to abnormal bleeding as a result of
hormonal changes directly affecting the
menstrual cycle in the absence of any identified
organic, systemic, or structural disease

May occur with or without ovulation
Normal menstrual cycle

Menstrual cycle is regulated by a complex
interaction of hypothalamus, anterior pituitary
gland, ovaries, and various target tissues (e.g.,
endometrium)

Normal menstrual function consists of two
distinct phases; estrogen and progesterone play
key roles
Normal menstrual cycle
Proliferative phase
 Estrogen levels predominate
 Ovarian follicles containing immature ova grow
and release estrogens that act on the uterus and
cause endometrium to become thick, vascular,
and proliferate
 Corpus luteum develops from ovarian follicle
during midcycle; uses estrogens and
progesterone it produces to maintain its
structure
Normal menstrual cycle
Secretory phase
 Begins when an increase in progesterone
triggers ovulation
 If ovum isn’t fertilized, corpus luteum will atrophy
and estrogen and progesterone production
decline
 Endometrium breaks down and menstruation
occurs
Menstruation: A complex event

When pregnancy doesn’t occur, sloughing of the
endometrial lining (menses) is expected result

Normal menstrual cycle occurs every 21 to 35
days and lasts 2 to 7 days

On average, women lose 30 to 80 mLs of fluid,
most occurring in first 3 days
Understanding DUB

When normal menstrual cycle is disrupted,
usually due to anovulation (failure to ovulate)

Women whose cycle vary in length by more than
10 days are usually anovulatory

Women under 20 and over 40 are at risk due to
hormonal imbalances and anovulation at
beginning and end of reproductive lives
Signs and symptoms

Menorrhagia - blood flow more than 80 mLs or
lasting more than 7 days

Polymenorrhagia - menstrual cycle less than 21
days

Oligomenorrhea – menstrual cycle lasting longer
than 35 days
Signs and symptoms

Metrorrhagia - bleeding at irregular but frequent
intervals

Menometrorrhagia - prolonged or excessive
bleeding at irregular or unpredictable intervals
Causes of abnormal bleeding

Most common cause in women of child-bearing
age is pregnancy (and pregnancy-related
conditions, e.g., miscarriage)

Other causes:
- Infection of genital tract
- Uterine fibroids
- Endometrial cancer
Causes of abnormal bleeding
- Certain medications (anticoagulants,
corticosteroids)
- Herbals (ginkgo)
- Blood dyscrasias
- Thyroid or adrenal disorders
- Liver or kidney disease
- Stress
Categories of DUB
Anovulatory (90% of cases)
 Common in women at beginning/end of
reproductive life

Estrogen secreted, but ovum doesn’t ripen

Progesterone not produced to counteract
uterine lining proliferation
Anovulatory DUB

Patient has irregular, possibly heavy bleeding

In absence of ovulation will not experience
typical signs: cramping, mood changes, breast
tenderness

Unopposed estrogen has been linked to
endometrial hyperplasia and cancer
Categories of DUB
Ovulatory
 More likely to occur during peak reproductive
years

Associated with prolonged progesterone
secretion or prostaglandin release

Leads to heavy but predictable bleeding
Ovulatory DUB

May also coexist with tumors or polyps that
contribute to excessive bleeding

Women with ovulatory DUB experience
premenstrual and menstrual signs and
symptoms

Symptoms linked to ovulation and progesterone
Risk factors

Age under 20 or over 40

Overweight/extreme weight loss or gain

Excessive exercise

High stress levels

Polycystic ovarian syndrome
Diagnosis

Obtain detailed gynecologic/obstetric history

Medication history

Physical assessment to include vital signs,
height and weight, thyroid gland

Past medical history
Tracking signs and symptoms
Use of menstruation calendar or menstrual flow
diary can help patient compare how her current
menstrual cycle differs from her normal cycles in
duration, frequency, and intensity. Teach her to
record:
 Daily temperatures, taken each morning before
she gets out of bed; an elevation in body
temperature can indicate ovulation
 When her periods start and stop
Tracking signs and symptoms




Amount of bleeding (number of saturated pads
or tampons)
Contraceptive use and sexual activity
Any problems such as pain, clots, postcoital
bleeding, or bleeding that requires more than
one pad or tampon every hour
If menstruation causes social embarrassment or
inconvenience, compromises sexual activity, or
requires her to change her lifestyle
Delving deeper

Pelvic examination. American College of
Obstetricians recommends endometrial
evaluation/biopsy for all women over 35 and at
high risk of cancer

Lab work. Should include pregnancy test/CBC

Imaging studies. May nclude pelvic ultrasound
to rule out tumors, cysts, polyps
Treatment

Mainstay for DUB is combination oral
contraceptive therapy containing estrogen and
progesterone or cyclical progesterone

Generally prescribed for at least 3 months
before other options are considered
Common treatment regimens

Mild bleeding - contraceptive started with next
menstrual cycle

Moderate to heavy bleeding - patient may take
progestin for 10 to 21 days followed by normal
contraceptive regimen with next menstrual cycle

Intrauterine device containing progesterone
Common treatment regimens

Depo-Provera may be used (contraindicated in
undiagnosed vaginal bleeding)

Gonadotropin releasing hormone - leuprolide
(Lupron)
Treating ovulatory DUB

Continuous estrogen secretion unopposed by
progesterone causes buildup of endometrium
and prostaglandin imbalance

NSAIDs decrease prostaglandin production,
reduce blood flow, ease cramping

NSAIDs are contraindicated in bleeding and
platelet disorders
NSAID therapy

Teach patient to take drug 1 to 2 days before
she expects her period

Continue taking it throughout her menses as
prescribed
Beyond medication

Hysteroscopy. Allows for visualization if
bleeding persists, removal of polyps if found

Uterine artery embolization. Causes loss of
blood flow to fibroids, causing them to shrink

Dilation and curettage. Controls acute bleeding
that doesn’t respond to medication
Beyond medication

Endometrial ablation. Uses microwave
radiofrequency to destroy uterine lining, done in
patient who doesn’t want children (renders
patient infertile)

Hysterectomy. Last resort in DUB related to
other causes such as cancer
Patient teaching and support

Call healthcare provider if you pass clots, soak a
pad every hour, or develop severe abdominal
pain

Take medications as prescribed

Take NSAIDs for pain (avoid aspirin)

Get plenty of iron in your diet
Patient teaching and support

Rest frequently to manage fatigue

Contact healthcare provider right away if you
experience dizziness or heart palpitations

May engage in activities of daily living:
swimming, sexual intercourse, exercise