1. Continuity Clinic DYSFUNCTIONAL UTERINE BLEEDING Modified from talk given by Tiffany Meyer, M.D.

2. Continuity Clinic Objectives Identify the primary cause of dysfunctional uterine bleeding (DUB). Characterize the evaluation of DUB. Describe methods for reducing menstrual blood loss. Explain how coagulation disorders can cause menorrhagia. Delineate the most common ovarian cause of DUB.

3. Continuity Clinic Normal Menstrual Bleeding Duration of flow: 2-8 days Cycle length: 21-40 days (up to 45 days normal in adolescents) Blood loss: average blood loss is 20-80 mL 10-15 soaked tampons or pads per cycle

4. Continuity Clinic Normal Menstrual Cycle

5. Continuity Clinic Definitions Hypermenorrhea or menorrhagia = prolonged/ excessive uterine bleeding at regular intervals Metrorrhagia = bleeding at irregular intervals Menometrorrhagia = prolonged/excessive bleeding at irregular intervals

6. Continuity Clinic Definitions con’t Polymenorrhea = uterine bleeding at regular intervals of < 21 days Oligomenorrhea = bleeding at prolonged intervals of 41 days to 3 months but of normal flow, duration, and quantity

7. Continuity Clinic Abnormal Menstrual Bleeding Menstrual cycles < 20 days apart Lasting over 8-10 days Blood loss > 80 mL

8. Continuity Clinic Abnormal Menstrual Bleeding con’t Abnormal bleeding patterns are frequent within first 2-3 years after menarche Caused by immaturity of the hypothalamic-pituitary-ovarian axis

9. Continuity Clinic Dysfunctional Uterine Bleeding (DUB) Abnormal uterine bleeding No demonstrable organic lesion 90% are result of anovulatory cycles

10. Continuity Clinic Etiology of DUB Anovulation (corpus luteum fails to form)  unopposed estrogen secondary to failure of normal cyclical progesterone secretion  without progesterone, inadequate stabilization of thick proliferative endometrium which eventually outgrows its blood supply  heavy, irregular bleeding

11. Continuity Clinic Evaluation of DUB Assess degree of blood loss Assess need for fluid or blood replacement Assess need for hospitalization Assess need for hormonal intervention

12. Continuity Clinic DUB: History Age of menarche? Menstrual pattern? (dates of last 3 cycles) Number of pads or tampons used and amount of saturation? Presence or absence of pain? Sexual activity? STDs? Vaginal d/c? Recent stress? Weight change? Chronic diseases? Bleeding problems? Sports? Medications?

13. Continuity Clinic Taking a Menstrual History

14. Continuity Clinic DUB: Physical General physical exam –R/O thyroid/liver disease, bleeding dyscrasia Breast examination: for galactorrhea Pelvic examination –Indicated if history of sexual activity or painful bleeding –Can be deferred if painless bleeding within 2- 3 years of menarche and no history of sex

15. Continuity Clinic DUB: Laboratory Tests CBC, differential, platelet count, and reticulocyte count Pregnancy test PT, PTT (LFTs if PT elevated) von Willebrand factor antigen and ristocetin cofactor TFTs, LH, FSH, testosterone, DHEAS Tests for GC and CT from endocervix if possibility of sexual activity

16. Continuity Clinic Therapy for DUB Objectives –Control bleeding if necessary –Prevent recurrences –Correct any organic pathology –Education and reassurance (especially if bleeding secondary to anovulatory cycles)

17. Continuity Clinic Mild DUB Characteristics –Menses longer than normal (more than 8-10 days) or cycle shortened (less than 20 days apart) –Hemoglobin > 11 gm/dl

18. Continuity Clinic Therapy For Mild DUB Acute treatment –Observation and reassurance –Keep a menstrual calendar!! –Iron supplements to prevent anemia –NSAIDs to lessen flow Long-term treatment –Monitor iron status (H and H) –Follow-up in 2 months

19. Continuity Clinic Example of Menstrual Calendar

20. Continuity Clinic Moderate DUB Characteristics –Menses moderately prolonged or cycles shortened –Hemoglobin 9-11 gm/dl

21. Continuity Clinic Therapy For Moderate DUB Acute treatment –OCPs (Lo-Ovral or Ovral) taken BID x 3- 4 days until bleeding stops then QD to finish 21-day cycle –May require anti-emetic Long-term treatment –Cycle for 3 months, but length of use depends on resolution of anemia/iron supplementation –Follow-up within 2-3 weeks and Q 3 months

22. Continuity Clinic Therapy For Moderate DUB con’t Another option: –Medroxyprogesterone (Provera) can be used if Patient is not bleeding at time of visit Patient or parent does not want OCPs Medical contraindication to estrogens –Provera is given as 10 mg PO QD x 10- 14 days starting on 14th day of menstrual cycle or starting on first day of each month –Continued for 3-6 months

23. Continuity Clinic Severe DUB Characteristics –Prolonged, heavy bleeding –Hemoglobin < 9 gm/dl or dropping Consider admission if –Initial hemoglobin < 7 gm –Orthostatic signs or tachycardia present –Bleeding is heavy and Hb < 10 gm

24. Continuity Clinic Therapy For Severe DUB Acute treatment –Consider transfusion if very low hematocrit and unstable vital signs –Obtain clotting studies –Consider conjugated estrogens 25 mg IV Q 4-6 hours x 24 hours until bleeding stops

25. Continuity Clinic Therapy for Severe DUB con’t Acute treatment con’t –Can also use Lo-Ovral 1 pill Q 4 hours until bleeding slows or stops then QID x 4 days, TID x 3 days, and BID x 2 weeks –Can also use Ovral or Nordette (monophasic) –May need anti-emetic

26. Continuity Clinic Therapy For Severe DUB con’t Long-term treatment –Iron supplementation to correct anemia –Should take OCPs for 3-6 months –Follow-up within 2-3 weeks and Q 3 months

27. Continuity Clinic Overview of DUB Management

28. Continuity Clinic When to Expect Improvement With DUB Bleeding usually tapers after the first few doses of hormones After 6-12 months, the patient who does not want to remain on OCPs can be given a trial off medication DUB persists for 2 years in 60%, 4 years in 50%, and up to 10 years in 30%

29. Continuity Clinic Coagulation Disorders and DUB Odds of bleeding disorder increase with the severity of bleeding (Canadian study) –1 in 5 patients who require hospitalization –1 in 4 patients with hemoglobin less than 10 –1 in 3 patients requiring transfusion –1 in 2 patients who present with menorrhagia from her very first menses

30. Continuity Clinic Etiology of Acute Adolescent Menorrhagia

31. Continuity Clinic von Willebrand Disease Most common inherited bleeding disorder Many girls diagnosed during childhood with easy bruising, frequent or prolonged nosebleeds, and prolonged bleeding after surgery, injury, or dental work However, often menorrhagia at menarche can be the presenting symptom

32. Continuity Clinic Other Coagulation Disorders Causing Menorrhagia Idiopathic thrombocytopenic purpura (ITP) Platelet dysfunction secondary to medications (NSAIDs) Coagulopathy from systemic illness (liver disease)

33. Continuity Clinic Polycystic Ovarian Syndrome (PCOS) 10% of cases of DUB can occur in an ovulatory cycle PCOS is most common form of ovulatory DUB (but majority with PCOS are anovulatory) About 5-10% of adolescent girls and women have PCOS