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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.
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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
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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: A case study
of menorrhagia. Nurse Pract. 2004;29(12):8–23.
Source: Nursing2009.
January 2009.
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