ADVANCING
YOUR PRACTICE
Putting
a stop to dysfunctional uterine bleeding
By Denise McEnroe
Ayers, RN, MSN, and Mariann Montgomery, RN, MSN
Doris Lappin, 45, walks
to the ED triage desk and states, “I'm passing
large clots and have soaked two maxi pads within half
an hour. I just don't know what to do to get the bleeding
to stop! I was supposed to see my gynecologist next
week, but this just can't wait until then.”
Most women who menstruate
experience a consistent pattern of menstrual bleeding
from month to month. Uterine bleeding that differs in
quantity, duration, or frequency from a woman's usual
pattern—for example, spotting between menstrual
periods—is considered abnormal, as is any postmenopausal
bleeding (bleeding that occurs 12 months or more after
the woman's last menstrual period).
The term dysfunctional
uterine bleeding (DUB) applies to abnormal bleeding
related to changes in hormones directly affecting the
menstrual cycle in the absence of any identified organic,
systemic, or structural disease. It may occur with or
without ovulation.1-3
Using Mrs. Lappin's case
as an example, we'll discuss the causes of DUB, assessment
pointers, and treatment options. Let's start with a
quick review of normal menstruation.
Menstruation: A
complex event
The menstrual cycle is a series of complex hormonal
events that relies on a balance between hypothalamic,
pituitary, ovarian, and uterine functions. When pregnancy
doesn't occur, menses—sloughing of the endometrial
lining—is an expected result.
A normal menstrual cycle
occurs every 21 to 35 days and lasts 2 to 7 days. On
average, women lose 30 to 80 mL of menstrual blood in
each cycle, with most of that loss occurring during
the first 3 days.1 (See Looking
at a normal menstrual cycle.)
Understanding DUB
By definition, DUB occurs when a woman's normal menstrual
cycle is disrupted, usually due to anovulation (failure
to ovulate). Women who experience cycles that vary in
length by more than 10 days from one cycle to another
are typically anovulatory. Women younger than age 20
and older than age 40 are at particular risk for DUB
because women are most likely to experience hormonal
imbalance and anovulation at the beginning or end of
their reproductive lives. (See Risk
factors for DUB.)
Signs and symptoms of DUB
vary. For instance, a woman may bleed more heavily during
one period and more lightly the next, spot between periods,
or have a shorter or longer interval between periods.
Or she may bleed for less than 2 days or more than 7
days.
Examples of DUB include
the following:
- menorrhagia: blood
flow of more than 80 mL or lasting more than 7 days
- polymenorrhea: menstrual
cycles of less than 21 days
- oligomenorrhea: cycles
lasting longer than 35 days
- metrorrhagia: bleeding
at irregular but frequent intervals
- menometrorrhagia: prolonged
or excessive bleeding at irregular or unpredictable
intervals.
The most common reasons
for abnormal bleeding in women of childbearing age are
pregnancy and pregnancy-related conditions (including
miscarriage). But many other causes are possible, such
as infections of the genital tract, uterine fibroids,
endometrial cancer, certain medications and herbal products
(such as anticoagulants, corticosteroids, and ginkgo),
blood dyscrasias, disorders of the thyroid or adrenal
glands (hypothyroidism or hyperthyroidism and hyperandrogenism),
liver or kidney disease, and even stress. If underlying
pathology is ruled out, the diagnosis is DUB.
Most cases of DUB can be
categorized into one of two types:
- Anovulatory DUB, which
accounts for about 90% of cases,4 is common
in women at the beginning or end of their reproductive
life. In anovulatory DUB, estrogen is continually
secreted but an ovum never ripens in the follicle.
Because an ovum isn't released, the corpus luteum
fails to produce progesterone to counteract uterine
lining proliferation and the patient experiences irregular
and possibly heavy bleeding. In the absence of ovulation,
she won't experience typical menstrual and premenstrual
signs and symptoms, such as cramping, mood changes,
and breast tenderness. However, the effects of unopposed
estrogen on the uterine lining have been directly
linked to endometrial hyperplasia and cancer.
- Ovulatory DUB is more
likely to occur during peak reproductive years. Associated
with prolonged progesterone secretion or inadequate
prostaglandin release, it typically leads to heavy
but predictable bleeding. Ovulatory DUB may also coexist
with tumors or polyps that can contribute to excessive
bleeding. Women with ovulatory DUB experience menstrual
and premenstrual signs and symptoms, which are linked
to ovulation and progesterone.5
History lessons
Mrs. Lappin reports that she's had three viable pregnancies
without complications. In between pregnancies, she was
on a low-dose oral contraceptive. After her last pregnancy,
she had a tubal ligation performed and now takes no
medications routinely. She has no history of bleeding
disorders or thyroid or other endocrine disease and
has no personal or family history of cancer.
Mrs. Lappin says her menstrual
periods started when she was 13 and were regular until
last year, when she began having periods of heavy blood
flow lasting 7 to 10 days. She reports using at least
“two boxes of pads” per cycle and says she
passes many large clots. She also has breakthrough bleeding,
with this event being the worst so far. Under further
questioning, she reveals that she's frequently tired
and just “doesn't feel well overall.”
Getting a detailed obstetric
and gynecologic history is the first step to identifying
the underlying cause of your patient's excessive uterine
bleeding. This includes investigating whether she has
any vaginal discharge, abdominal pain, or pain during
intercourse (dyspareunia) or urination (dysuria). When
obtaining her health history, specifically explore whether
she has a clotting or bleeding disorder (such as von
Willebrand disease), chronic liver disease, renal disease,
or endocrine disease. Ask about a family history of
cancer, endocrine disorders, or bleeding diseases that
could be associated with abnormal uterine bleeding.
Also ask if she's taking any over-the-counter or prescription
drugs or if she uses herbal remedies. Explore her diet
and exercise patterns and find out if she's under any
unusual stress and if she's gained or lost weight recently.
To help evaluate your patient's
hemodynamic status, ask if she ever feels light-headed,
fatigued, short of breath, or dizzy, which can signal
anemia related to blood loss. Take her baseline vital
signs and assess orthostatic BP if she has signs and
symptoms of hypovolemia.
During your physical assessment,
inspect your patient's skin, noting the color and any
signs of bleeding disorders, including bruising and
petechiae. Also check for clinical or lab evidence of
hyperandrogenism, including acne, hirsutism, or abdominal
striae. Examine her thyroid gland for enlargement and
check her abdomen for tenderness, rigidity, and masses.
Record her height and weight and calculate her body
mass index. To track her menstrual cycles and related
signs and symptoms, teach her to use a menstruation
calendar. (See Tracking signs and symptoms,
day by day.)
Upon initial assessment,
the nurse finds Mrs. Lappin to be pale and diaphoretic.
Mrs. Lappin says she feels dizzy. Vital signs are: temperature,
99.0° F (37.2° C); thready pulse of 110; and
respirations, 24. Orthostatic BP results: supine, 110/78
and pulse 110; standing, 82/60 and pulse 130. The patient
says she's “feeling faint” with the position
change. The nurse notes that she has no bruising, petechiae,
or signs of hyperandrogenism. Based on her history and
clinical findings, including orthostatic hypotension,
the practitioner admits Mrs. Lappin to the hospital.
The nurse inserts an I.V.
catheter and administers 1,000 mL of 0.9% sodium chloride
over 4 hours, as ordered. The practitioner orders a
complete blood cell count, coagulation studies, and
a pregnancy test. The nurse prepares Mrs. Lappin for
a pelvic examination with Pap test and an ultrasound.
Delving deeper
A thorough pelvic examination, lab work, and imaging
studies will reveal more about your patient's problem.
Pelvic examination.
With a bimanual pelvic examination, the practitioner
assesses for ovarian and uterine masses and signs of
pelvic inflammatory disease. He'll also take specimens
to screen for cervical cancer (Pap test) and for Neisseria
gonorrhoeae and Chlamydia trachomatis, even when bleeding
is present.
The practitioner will examine
the patient's urethra, vagina, cervix, and uterus for
lesions and evaluate the endometrium for polyps. He
should also assess the rectal area and perform a fecal
occult blood test to determine if the gastrointestinal
tract is the source of bleeding.
The American College of
Obstetricians and Gynecologists recommends endometrial
evaluation, including biopsy, for women over age 35
and those at high risk for endometrial cancer.6 Risk
factors for endometrial cancer include morbid obesity,
diabetes, hypertension, and long-standing anovulation.
Lab work.
All women of childbearing potential should have a pregnancy
test and a complete blood cell count. Depending on the
patient's history and physical, the practitioner may
order additional blood work, such as a platelet count,
coagulation studies, and levels of ferritin and hormones
such as thyroid-stimulating hormone, progesterone, testosterone,
and prolactin.
Imaging studies.
Your patient may undergo a pelvic ultrasound to rule
out tumors, cysts, and polyps. A transvaginal ultrasound
helps the practitioner evaluate structural abnormalities,
such as the position and size of fibroid tumors, and
determine endometrial thickness. If he detects uterine
abnormalities, he may order sonohysterography to aid
in diagnosis. This involves infusing saline into the
endometrial cavity during a pelvic or transvaginal ultrasound
examination.
After diagnosis, a patient
like Mrs. Lappin needs treatment to stop the bleeding,
restore and maintain hemodynamic stability, and restore
a normal menstrual cycle. See Responding
to hemodynamic instability for details on treating acute
bleeding.
Treatment goals include
treating any underlying cause, controlling excessive
bleeding, preventing recurrence, and preserving fertility
in women of childbearing age. Most cases of DUB are
successfully managed with medication. Let's consider
treatment options, which vary depending on the type
of DUB the patient is experiencing.
Treating anovulatory
DUB
The mainstay of treatment for anovulatory DUB is combination
oral contraceptives that contain estrogen and progesterone
or cyclical progesterone. Very effective in controlling
excessive anovulatory bleeding, oral contraceptives
are available in various doses to meet individual patient
needs.
Oral contraceptive therapy
is generally prescribed for at least 3 months before
other diagnostic or treatment options are considered.
The following regimens are common:
- Mild bleeding. The
patient may be put on a normal contraceptive regimen,
starting with her next menstrual cycle.
- Moderate to heavy bleeding.
The patient may take progestin for 10 to 21 days,
then start on a normal contraceptive regimen with
the next cycle. Alternatively, she may take a monophasic
oral contraceptive (delivering the same amount of
estrogen and progestin every day) four times daily
for 5 to 7 days, then reduce to daily dosing.7
If combination hormones
are contraindicated in a patient with anovulatory DUB,
the practitioner may order progestin, such as medroxyprogesterone
(Provera) or norethindrone acetate (Aygestin) to be
taken for 5 to 12 days a month beginning on day 11 or
14 of the menstrual cycle to oppose estrogen's effect
on the endometrium. When the patient stops taking the
progestin each month, she'll have controlled withdrawal
bleeding.
Some women benefit from
an intrauterine device that contains progesterone. This
method works well because it directly counteracts the
effects of estrogen on the endometrium and decreases
blood loss. At the same time, it provides contraception
while preserving the woman's childbearing ability. Because
little of the progesterone is absorbed, most women have
few systemic effects and tolerate therapy well.
Medroxyprogesterone acetate
(Depo-Provera), a long-acting injectable progestin,
has become increasingly popular because it requires
just one injection every 3 months. It's contraindicated
in patients with undiagnosed vaginal bleeding. Teach
the patient to notify the practitioner immediately if
abnormal bleeding becomes severe, so she can be evaluated
further.
To treat some cases of
anovulatory DUB, the gonadotropin-releasing hormone
leuprolide (Lupron) is prescribed to trigger chemical
menopause. Leuprolide reduces follicle-stimulating hormone
and luteinizing hormone levels to cause amenorrhea,
usually within 3 months of starting therapy. Interrupting
the anovulatory cycle prepares the body for further
intervention. A woman is typically on this therapy for
6 months or less; during that time, she should be monitored
for osteoporosis and signs and symptoms of menopause,
such as hot flashes, night sweats, and vaginal dryness.
Treating ovulatory
DUB
In ovulatory DUB, continuous estrogen secretion unopposed
by progesterone stimulates buildup of the endometrium
and leads to a prostaglandin imbalance. Heavy bleeding
related to ovulatory DUB may respond well to a nonsteroidal
anti-inflammatory drug (NSAID) such as naproxen or ibuprofen.
These NSAIDs decrease prostaglandin production, reduce
blood flow by causing vasoconstriction, and ease cramping
pain. They're most effective in decreasing the quantity
of blood flow in patients with cyclic ovulatory bleeding,
fibroids, and intrauterine devices. In some cases NSAIDs
are combined with oral contraceptives. Therapy with
NSAIDs is contraindicated in patients with bleeding
disorders or platelet dysfunction.
If your patient is on NSAID
therapy, teach her to start taking the drug 1 to 2 days
before she expects the start of her period and to continue
taking it throughout her menses, as prescribed.
Beyond medications
If DUB can't be managed medically, the practitioner
may consider several invasive options.
Hysteroscopy allows visualization
of the inside of the uterus when bleeding persists.
If the practitioner detects fibroids or endometrial
polyps during the procedure, he can remove them.
Uterine artery embolization
stops direct blood flow to fibroids that are causing
excessive bleeding. Losing their blood source, the fibroids
become ischemic and necrotic and shrink.
Dilation and curettage
(D & C) doesn't cure underlying problems but it
will control acute bleeding that hasn't responded to
medication. The effects of a D & C last only until
the onset of the next menstrual period. A D & C
may be done to find out the cause of the bleeding and
to help the practitioner decide how to best treat the
bleeding process.
Endometrial ablation is
an option if the patient doesn't want to have children.
The technique uses microwaves, radiofrequency energy,
or cryoblation to destroy the uterine lining. Ablation
is very successful at decreasing or completely stopping
menstrual cycles and DUB, but it leaves the patient
infertile.
Hysterectomy is the definitive
treatment for women with endometrial cancer. However,
it's now used only as a last resort for DUB related
to other causes.
Treatment, teaching,
and support
During a pelvic exam, the practitioner identifies many
large fibroids in the uterus. Because of Mrs. Lappin's
severe, acute bleeding and hypovolemia, he performs
a D & C immediately to curtail the bleeding. She
continues on I.V. replacement therapy (125 mL/hour)
and receives one unit of packed red blood cells to treat
her low hemoglobin level (7.6 mg/dL). She's given a
single dose of conjugated estrogens (Premarin) and started
on a combination oral contraceptive. She responds well
to treatment and is discharged the next day with instructions
to continue the oral contraceptives and see her gynecologist
in 1 week.
A patient with DUB may
experience considerable distress, including social embarrassment.
The disorder may make her unwilling to engage in sexual
activity, particularly if her bleeding is frequent or
excessive. Until the cause of the bleeding is determined,
she may worry about a diagnosis of cancer or another
serious condition. She may also have feelings of fear
or grief about the potential for infertility.
Give your patient and her
family information to help them better understand DUB,
including the causes, treatments, long-term effects,
and prognosis. Then spell out these measures to help
minimize the effects of DUB on her daily functioning:
- Call your healthcare
provider if you pass clots the size of a half-dollar
or larger, if you soak a pad or tampon at least every
hour, or if you develop severe abdominal pain.
- Take your medications
as prescribed. (Tell the patient what adverse reactions
she might experience and when to contact her healthcare
practitioner.)
- If you experience cramps
or discomfort, take ibuprofen or naproxen as directed.
Avoid aspirin products because they can increase bleeding.
- To get plenty of iron
in your diet, eat foods such as liver, beans, and
spinach. (If the practitioner prescribes an iron supplement,
teach the patient about side effects such as constipation
and a darker stool color.)
- Rest frequently to
manage fatigue.
- If you feel dizzy or
have heart palpitations, which may signal excessive
blood loss, contact your healthcare practitioner right
away.
- You may engage in sexual
activity and other activities of daily living, including
swimming and exercise, during menstruation.
By helping your patient
understand the reasons for DUB and supporting her as
she takes steps to manage it, you help her return to
her normal routines.
Looking at
a normal menstrual cycle
The menstrual cycle is regulated by a complex
interaction of the hypothalamus, the anterior
pituitary gland, the ovaries, and various target
tissues, such as the endometrium. Normal menstrual
function consists of two distinct phases, with
estrogen and progesterone, hormones produced by
the ovaries, playing key roles:
- In the proliferative
phase, estrogen levels predominate. Several
ovarian follicles containing immature ova grow
in this phase of the menstrual cycle. These
follicles release estrogens that act on the
uterus and cause the endometrium to become thick
and vascular and proliferate. The corpus luteum
develops from an ovarian follicle during midcycle,
using estrogens and progesterone it produces
to maintain its structure.
- The secretory
phase begins when an increase in progesterone
triggers ovulation. If the ovum isn't fertilized,
the corpus luteum will atrophy and estrogen
and progesterone production will decline. The
endometrium breaks down and menstruation occurs.
|
Risk
factors for DUB
- Age under 20
or over 40
- Overweight (because
hormones involved in ovulation aren't readily
available from fat stores) or extreme weight
loss or gain
- Excessive exercise,
which decreases body fat to a degree that's
inadequate to maintain the menstrual cycle
- High stress levels
- Polycystic ovarian
syndrome
|
Tracking
signs and symptoms, day by day
The use of a menstruation calendar or menstrual
flow diary can help your patient compare how her
current menstrual cycle differs from her normal
cycles in duration, frequency, and intensity.
Teach her to record the following:
- 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
- the amount of
bleeding (number of saturated pads or tampons)
- her 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.
Your patient should
also note if menstruation causes her social embarrassment
or inconvenience, compromises her sexual activity,
or requires her to change her lifestyle. |
Responding
to hemodynamic instability
For a woman experiencing severe acute bleeding,
the primary consideration is her hemodynamic status.
She needs hospitalization to support the ABCs, monitor
signs and symptoms of hypovolemia, and possibly
to replace fluids with volume expanders or blood
products. If her hemodynamic status is unstable
because of severe acute bleeding, she may receive
conjugated estrogens I.V. every 4 to 6 hours until
bleeding stops or for 12 hours. To promote rapid
regrowth of the endometrial tissue over the denuded
epithelial surfaces, she'll also receive I.V. infusions
of high-dose estrogen preparations such as Premarin,
followed by therapy with oral contraceptives. |
References
1. Fazio SB, Ship AN. Abnormal uterine bleeding. South
Med J. 2007; 100(4):376-382.
2. Bradley LD. Abnormal uterine bleeding. Nurse
Pract. 2005;30(10):38-49.
3. Vilos GA, Lefebvre G, Graves GR. Guidelines for the
management of abnormal uterine bleeding. J Obstet
Gynaecol Can. 2001;23(8):704-709.
4. Dodds NR. Dyfunctional uterine bleeding. eMedicine
from WebMd. http://www.emedicine.com/emerg/TOPIC155.htm.
5. Association of Reproductive Health Professionals.
What you need to know: Abnormal uterine bleeding. http://www.arhp.org/Publications-and-Resources/Clinical-Fact-Sheets/Abnormal-Uterine-Bleeding.
6. ACOG practice bulletin. Management of anovulatory
bleeding. Int J Gynaecol Obstet. 2001;72:263-271.
7. Albers JR, Hull SK, Wesley RM. Abnormal uterine bleeding.
Am Fam Physician. 2004;69(8):1915-1926.
Resources
Ayers DM, Lappin JE, Liptok LM. Abnormal vs. dysfunctional
uterine bleeding: What's the difference? Nursing.
2004;34(suppl):11-14.
Koeplin PL, Burke KM, eds. Medical-Surgical Nursing:
Critical Thinking in Client Care. 4th ed. Upper
Saddle River, N.J.: Prentice Hall, Inc.; 2008.
Pitkin J. Dysfunctional uterine bleeding. Brit Med
J. 2007;334:1110-1111.
Quint EH, Smith YR. Abnormal uterine bleeding in adolescents.
J Midwifery Women's Health. 2003;48(3):186–191.
Stemler KA, Stegbauer CC. Abnormal uterine bleeding:
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Source:
Nursing2009. January 2009. |