1. 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:
© 2008 by Lippincott Williams & Wilkins. All world rights reserved.

2. 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)

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. Signs and symptoms
Metrorrhagia - bleeding at irregular but frequent intervals
Menometrorrhagia - prolonged or excessive bleeding at irregular or unpredictable intervals

11. 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

12. Causes of abnormal bleeding
- Certain medications (anticoagulants, corticosteroids)
- Herbals (ginkgo)
- Blood dyscrasias
- Thyroid or adrenal disorders
- Liver or kidney disease
- Stress

13. 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

14. 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

15. 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

16. 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

17. Risk factors Age under 20 or over 40
Overweight/extreme weight loss or gain
Excessive exercise
High stress levels
Polycystic ovarian syndrome

18. Diagnosis Obtain detailed gynecologic/obstetric history
Medication history
Physical assessment to include vital signs, height and weight, thyroid gland
Past medical history

19. 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

20. 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

21. 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

22. 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

23. 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

24. Common treatment regimens
Depo-Provera may be used (contraindicated in undiagnosed vaginal bleeding)
Gonadotropin releasing hormone - leuprolide (Lupron)

25. 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

26. NSAID therapy
Teach patient to take drug 1 to 2 days before she expects her period
Continue taking it throughout her menses as prescribed

27. 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

28. 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

29. 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

30. 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