dysfunctional uterine bleeding
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Dysfunctional Uterine Bleeding
Causes and symptoms
- adenomyosis (a benign condition characterized by growths in the area of the uterus)
- imbalance between the hormones estrogen and progesterone
- fibroid tumors
- pelvic infection
- endometrial cancer (cancer of the inner mucous membrane of the uterus)
- endometrial polyps
- endometriosis (a condition in which endometrial or endrometrial-like tissue appears outside of its normal place in the uterus)
- use of an intrauterine device (IUD) for contraception
- blood clotting problems (rare)
- lupus erythematosus
- pelvic inflammatory disease
- steroid therapy
- advanced liver disease
- renal (kidney) disease
- chemotherapy (cancer treatment with chemicals)
dys·func·tion·al u·ter·ine bleed·ing
dysfunctional uterine bleeding (DUB)
dysfunctional uterine bleedingGynecology Excess menstrual hemorrhage of hormonal origin, related to 'breakthrough bleeding' or estrogen withdrawal, often occurring in anovulatory cycles Etiology No cause is found in 75% of cases, although adolescent DUB is attributed to immaturity of the hypothalamic-pituitary-ovarian axis; peri- and post-menopausal DUB often occurs in endometria that are deaf to the ovary's curtain call; DUB in ♀ elderly requires curettage to exclude malignancy. See Dysmenorrhea.
Dysfunctional Uterine Bleeding
|Mean LOS:||5.9 days|
|Description:||SURGICAL: Dilation and Curettage, Conization, Laparoscopy and Tubal Interruption With CC or Major CC|
|Mean LOS:||3.6 days|
|Description:||MEDICAL: Menstrual and Other Female Reproductive System Disorders With CC or Major CC|
Dysfunctional uterine bleeding (DUB) is abnormal uterine bleeding, or menorrhagia, with no discernible organic cause. It is a leading cause of outpatient visits in the healthcare system in the United States. The normal menstrual cycle is dependent on the influence of four hormones: estrogen, which predominates during the proliferative phase (generally days 1 to 14); progesterone, which predominates during the secretory phase (generally days 15 to 28); and follicle-stimulating hormone (FSH) and luteinizing hormone (LH), both of which stimulate the ovarian follicle to mature. Disrupting the balance of these four hormones usually results in anovulation and DUB, which is an abnormal amount, duration, or timing of bleeding.
During an anovulatory cycle, the corpus luteum does not form and thus progesterone is not secreted. Failure of progesterone secretion allows continuous unopposed production of estradiol, which stimulates the overgrowth of the endometrium. This results in an overproduction of the uterine blood flow. Complications of DUB include anemia, infection from prolonged use of tampons, and in rare situations, hemorrhagic shock. As many as 10% of women with normal ovulatory cycles experience DUB. One in every 20 women ages 30 to 49 consults a practitioner for DUB.
The cause of DUB is unknown. The term DUB indicates that abnormal bleeding is occurring without an organic cause; thus, it is a diagnosis of exclusion. It is associated with polycystic ovarian disease and obesity; in both of these conditions, the endometrium is chronically stimulated by estrogen. Other possible associated factors are cancer of the vagina, cervix, ovaries, and uterus; fibroids, polyps, ectopic pregnancy, or molar pregnancy; and excessive weight gain, stress, and increased exercise performance. DUB may also occur from the use of progestin-only compounds for birth control or from contraceptive intrauterine devices (IUDs), which can cause variable vaginal bleeding for the first few cycles after placement.
Excessive menstrual bleeding is a common clinical problem in women of reproductive age. Hereditary bleeding disorders, such as von Willebrand disease, factor X deficiency, or factor VII deficiency, are among the genetic causes of menorrhagia.
Gender, ethnic/racial, and life span considerations
DUB can occur from menarche to postmenopause. DUB occurs in teenagers as the result of anovulatory cycles that are related to the immaturity of the hypothalamic-pituitary-gonadal axis. DUB is most common in the perimenopausal woman as the result of changing hormonal levels. Older women approaching menopause possibly suffer from DUB because of a decreased sensitivity of the ovary to FSH and LH. While DUB has no predilection for race, black women have a higher incidence of leiomyomas and higher levels of estrogen and, as a result, are prone to experiencing more episodes of abnormal vaginal bleeding.
Global health considerations
Countries that have a large population of female athletes have a higher prevalence of DUB. Global prevalence data are not available.
Determine the duration of the present bleeding, the amount of blood loss, and the presence of associated symptoms such as cramping, nausea and vomiting, fever, abdominal pain, or passing of blood clots. Ask the patient to compare the amount of pads or tampons used in a normal period with the amount they are presently using. Obtain a menstrual and obstetric history. Recent episodes of easy bruising or prolonged, heavy bleeding may indicate abnormal clotting times. Take a birth control history to determine if the woman is using contraceptives or an IUD. Other possible causative factors, such as pregnancy, pelvic inflammatory disease, or other medical conditions, can be ruled out through a complete history.
The most common symptom is irregular vaginal bleeding. A complete examination is essential to eliminate organic causes of bleeding. A pelvic speculum and bimanual examination should be done, with particular attention paid to the presence of cervical erosion, polyps, presumptive signs of pregnancy, masses, tenderness or guarding, or other signs of pathology that may cause abnormal uterine bleeding. Assess for petechiae, purpura, and mucosal bleeding (gums) to rule out hematological pathology. Check for pallor and absence of conjunctival vessels to gauge anemia.
For many women, DUB results in distress related to the uncertainty of the timing, duration, and amount of bleeding. Pain is one of the most commonly reported symptoms of DUB. A woman may feel that her usual activities need to be curtailed, a situation that may contribute to feelings of loss of control. Assess the severity of the symptoms as well as the woman’s concerns and coping patterns to establish a framework for determining appropriate interventions.
General Comments: Diagnosis of DUB is made by ruling out organic causes.
|Test||Normal Result||Abnormality With Condition||Explanation|
|Pelvic ultrasonography or transvaginal ultrasonography||Normal uterine and ovarian structures||Abnormal structures such as ovarian cysts, fibroids, pregnancy, structural lesions||Identifies structure of uterus and ovaries|
|Endometrial biopsy||Presence of a “secretory-type” endometrium 3–5 days before normal menses; no pathological conditions||Hyperplastic proliferative polyps are found with DUB (polyps stimulate estrogen); with anovulation, no secretory changes are noted; adenocarcinoma indicates uterine cancer||Other organic conditions must be ruled out before a diagnosis of DUB is made|
|Hysteroscopy||No pathology visualized||Polyps indicate DUB; other tumors or structural variations may be seen with other conditions||Direct visualization of the uterus with biopsy|
Other Tests: Pelvic examination, uterine ultrasound, complete blood count, cultures for sexually transmitted infections; prothrombin time, activated partial thromboplastin time, human chorionic gonadotropin (to rule out pregnancy), thyroid tests
Primary nursing diagnosis
DiagnosisFluid volume deficit related to blood loss
OutcomesFluid balance; Hydration; Circulation status
InterventionsBleeding reduction; Blood product administration; Intravenous therapy; Shock management
Planning and implementation
The patient may be confronted with a prolonged evaluation and a variety of treatments before uterine bleeding resumes a more normal pattern or stops completely. Activities are not restricted and can be continued as the woman tolerates them. If infection or anemia is identified, appropriate pharmacologic therapy is initiated. Hormonal manipulation may be indicated, requiring careful dosing and attention to compliance with the treatment plan. Surgical management typically begins with dilation and curettage to remove excessive endometrial buildup, but may include intrauterine cryosurgery; laser ablation of the endometrium; or, as a last resort, a hysterectomy. Hysteroscopic tubal sterilization can be performed along with the endometrial ablation if the patient desires permanent contraception.
|Medication or Drug Class||Dosage||Description||Rationale|
|Levonorgestrel intrauterine system||Release of 20 µg/day; system lasts for 5 yr||Intrauterine contraceptive with synthetic female hormone, levonorgestrel, which is released slowly into the uterus||Progesterone agonist|
|Oral contraceptives||Varies with drug||Combination (estrogen and progestin) oral contraceptives||Suppresses endometrial development, reestablishes predictable menstrual patterns and decreases flow, and lowers the risk of anemia|
|Medroxyprogesterone acetate (Provera)||10 mg PO daily, for 10 days (days 16–25 of the menstrual cycle)||Synthetic progestin||Will transform proliferative endometrium into secretory endometrium|
|Conjugated estrogen (Premarin)||25 mg IV q 4 hr for 3 doses or until bleeding stops||Natural estrogen||Emergency treatment for severe bleeding, follow with progestins|
Important interventions include strategies to assist the woman in maintaining normal activities during the evaluation. Instruct the woman about the signs and symptoms of toxic shock syndrome (fever, joint and muscle aches, malaise, weakness) if she continues to use tampons; more frequent than normal changes of the tampon may be indicated. The use of incontinence pads may be more beneficial than the standard feminine napkin in the presence of heavy bleeding.
Issues related to sexuality, especially if hysterectomy is indicated, require an accepting, open attitude of the nurse. The woman may feel her femininity is threatened but may have difficulty expressing these feelings. You may need to initiate discussions regarding the impact of evaluation and treatment on the woman. If appropriate, consider the effect on the woman’s partner and include the partner in all discussions.
Evidence-Based Practice and Health Policy
Matteson, K.A., Raker, C.A., Pinto, S.B., Scott, D.M., & Frishman, G.N. (2012). Women presenting to an emergency facility with abnormal uterine bleeding: Patient characteristics and prevalence of anemia. The Journal of Reproductive Medicine, 57(1-2), 17–25.
- Women with DUB are at risk for severe anemia; however, comorbidities may prohibit the use of standard treatment options to stop the bleeding, such as hormonal therapy with estrogen and progestin.
- A retrospective cohort study among 378 women treated in the emergency room for abnormal uterine bleeding revealed mild anemia (hemoglobin between 10 to 12 g/dL) in 35% of the women and moderate to severe anemia (hemoglobin < 10 g/dL) in 13.7% of the women. Clinical symptoms including tachycardia and hypotension were present in 9.1% and 12.9% of the women, respectively.
- Among the women in this study, 49.2% had comorbidities that affected their treatment options, including smoking in 21.4% and cardiovascular disease in 17.9%.
- Findings on history and physical examination; complete blood count
- Records of the bleeding patterns kept by the woman
- Presence of symptoms from complications such as anemia
Discharge and home healthcare guidelines
Provide a list of prescribed medications, if any, that includes the name, dosage, route, and side effects and the signs and symptoms of potential complications, including hypotensive episodes. Explain the need for careful monitoring and follow-up of the bleeding. Encourage the patient to keep a menstrual calendar and record daily bleeding patterns. Teach the patient to have appropriate laboratory follow-up of the complete blood count if indicated.