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