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 symptomsUse 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