dysfunctional uterine bleeding

Dysfunctional Uterine Bleeding

Definition

Dysfunctional uterine bleeding is irregular, abnormal uterine bleeding that is not caused by a tumor, infection, or pregnancy.

Description

Dysfunctional uterine bleeding (DUB) is a disorder that occurs most frequently in women at the beginning and end of their reproductive lives. About half the cases occur in women over 45 years of age, and about one fifth occur in women under age 20.Dysfunctional uterine bleeding is diagnosed when other causes of uterine bleeding have been eliminated. Failure of the ovary to release an egg during the menstrual cycle occurs in about 70% of women with DUB. This is probably related to a hormonal imbalance.DUB is common in women who have polycystic ovary syndrome (cysts on the ovaries). Women who are on dialysis may also have heavy or prolonged periods. So do some women who use an intrauterine device (IUD) for birth control.DUB is similar to several other types of uterine bleeding disorders and sometimes overlaps these conditions.

Menorrhagia

Menorrhagia, sometimes called hypermenorrhea, is another term for abnormally long, heavy periods. This type of period can be a symptom of DUB, or many other diseases or disorders. In menorrhagia, menstrual periods occur regularly, but last more than seven days, and blood loss exceeds 3 oz (88.7 ml). Passing blood clots is common. Between 15-20% of healthy women experience debilitating menorrhagia that interferes with their normal activities. Menorrhagia may or may not signify a serious underlying problem.

Metrorrhagia

Metrorrhagia is bleeding between menstrual periods. Bleeding is heavy and irregular as opposed to ovulatory spotting which is light bleeding, in mid-cycle, at the time of ovulation.

Polymenorrhea

Polymenorrhea describes the condition of having too frequent periods. Periods occur more often than every 21 days, and ovulation usually does not occur during the cycle.

Causes and symptoms

Dysfunctional uterine bleeding often occurs when the endometrium, or lining of the uterus, is stimulated to grow by the hormone estrogen. When exposure to estrogen is extended, or not balanced by the presence of progesterone, the endometrium continues to grow until it outgrows its blood supply. Then it sloughs off, causing irregular bleeding. If the bleeding is heavy enough and frequent enough, anemia can result.Menorrhagia is representative of DUB. It is caused by many conditions including some outside the reproductive system. Causes of menorrhagia include:

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
hypothyroidism
blood clotting problems (rare)
lupus erythematosus
pelvic inflammatory disease
steroid therapy
advanced liver disease
renal (kidney) disease
chemotherapy (cancer treatment with chemicals)

To diagnose dysfunctional uterine bleeding, many of the potential causes mentioned above must be eliminated. When all potential causes connected with pregnancy, infection, and tumors (benign or malignant) are eliminated, then menorrhagia is presumed to be caused by dysfunctional uterine bleeding.

Diagnosis

Diagnosis of any menstrual irregularity begins with the patient herself. The doctor will ask for a detailed description of the problem, and take a history of how long it has existed, and any patterns the patient has observed. A woman can assist the doctor in diagnosing the cause of abnormal uterine bleeding by keeping a record of the time, frequency, length, and quantity of bleeding. She should also tell the doctor about any illnesses, including long-standing conditions, like diabetes mellitus. The doctor will also inquire about sexual activity, use of contraceptives, current medications, and past surgical procedures.

Laboratory tests

After taking the woman's history, the gynecologist or family practitioner does a pelvic examination and Pap smear. To rule out specific causes of abnormal bleeding, the doctor may also do a pregnancy test and blood tests to check the level of thyroid hormone. Based on the initial test results, the doctor may want to do tests to determine the level of other hormones that play a role in reproduction. A test of blood clotting time and an adrenal function test are also commonly done.

Imaging

Imaging tests are important diagnostic tools for evaluating abnormal uterine bleeding. Ultrasound examination of the pelvic and abdominal area is used to help locate uterine fibroids, also called uterine leiomyoma, a type of tumor. Visual examination through hysterscopy—where a camera inside a thin tube is inserted directly into the uterus so that the doctor can see the uterine lining—is also used to assess the condition of the uterus.Hystersalpingography can help outline endometrial polyps and fibroids and help detect endometrial cancer. In this procedure an x ray is taken after contrast media has been injected into the cervix. Magnetic resonance imaging (MRI) of the pelvic region can also be used to locate fibroids and tumors.

Invasive procedures

Endometrial biopsy (the removal and examination of endometrial tissue) is the most important testing procedure. It allows the doctor to sample small areas of the uterine lining, while cervical biopsy allows the cervix to be sampled. Tissues are then examined for any abnormalities.Dilation and curettage (D & C), once common is rarely done today for diagnosis of DUB. It is done while the patient is under either general or regional anesthesia. Women over 30 are more likely to need a D & C, as part of the diagnostic procedure, than younger women.Because DUB is diagnosed by eliminating other possible disorders, diagnosis can take a long time and involve many tests and procedures. Older women are likely to need more extensive tests than adolescents because the likelihood of reproductive cancers is greater in this age group, and therefore must be definitively eliminated before treating bleeding symptoms.

Treatment

Treatment of DUB depends on the cause of the bleeding and the age of the patient. When the underlying cause of the disorder is known, that disorder is treated. Otherwise the goal of treatment is to relieve the symptoms to a degree that uterine bleeding does not interfere with a woman's normal activities or cause anemia.Generally the first approach to controlling DUB is to use oral contraceptives that provide a balance between the hormones estrogen and progesterone. Oral contraceptives are often very effective in adolescents and young women in their twenties. NSAIDs (nonsteroidal anti-inflammatory drugs), like Naprosyn and Motrin, are also used to treat DUB.When bleeding cannot be controlled by hormone treatment, surgery may be necessary. Dilation and curettage sometimes relieves the symptoms of DUB. If that fails, endometrial ablation removes the uterine lining, but preserves a woman's uterus. This procedure is sometimes be used instead of hysterectomy. However, as it affects the uterus, it can only be used when a woman has completed her childbearing years. The prescription of iron is also important to decrease the risk of enemia.Until the 1980s, hysterectomy often was used to treat heavy uterine bleeding. Today hysterectomy is used less frequently to treat DUB, and then only after other methods of controlling the symptoms have failed. A hysterectomy leaves a woman unable to bear children, and, therefore, is limited largely to women who are unable to, or uninterested in, bearing children. Still, hysterectomy is a common treatment for long-standing DUB in women done with childbearing.

Alternative treatment

Alternative practitioners concentrate on good nutrition as a way to prevent heavy periods that are not caused by uterine fibroids, endometrial polyps, endometriosis, or cancer. Iron supplementation (100 mg per day) not only helps prevent anemia, but also appears to reduce menorrhagia in many women. Other recommended dietary supplements include vitamins A and C. Vitamin C improves capillary fragility and enhances iron uptake.Vitamin E and bioflavonoid supplements are also recommended. Vitamin E can help reduce blood flow, and bioflavonoids help strengthen the capillaries. Vitamin K is known to play a role in clotting and is helpful in situations where heavy bleeding may be due to clotting abnormalitiesBotanical medicines used to assist in treating abnormal bleeding include spotted cranesbill (Geranium maculatum), birthroot (Trillium pendulum), blue cohosh (Caulophyllum thalictroides), witch hazel (Hamamelis virginiana), shepherd's purse (Capsella bursa-pastoris), and yarrow (Achillea millifolia). These are all stiptic herbs that act to tighten blood vessels and tissue. Hormonal balance can also be addressed with herbal formulations containing phytoestrogens and phytoprogesterone.

Prognosis

Response to treatment for DUB is highly individual and is not easy to predict. The outcome depends largely on the woman's medical condition and her age. Many women, especially adolescents, are successfully treated with hormones (usually oral contraceptives). As a last resort, hysterectomy removes the source of the problem by removing the uterus, but this operation is not without risk, or the possibility of complications.

Prevention

Dysfunctional uterine bleeding is not a preventable disorder.

Resources

Other

"Menorrhagia." The Wellness Web. http://wellweb.com/INDEX/MENORRHAGIA.htm.

Key terms

Dilation and curettage (D & C) — A procedure performed under anesthesia during which the cervix is dilated, and tissue lining the uterus is scraped out with a metal spoon-shaped instrument or a suction tube. The procedure can be either diagnostic, or to remove polyps.Endometrial biopsy — The removal of tissue either by suction or scraping of samples of tissue from the uterus. The cervix is not dilated. The procedure has a lower rate of diagnostic accuracy than a D & C, but can be done as an office procedure under local anesthesia.Endometrial cancer — Cancer of the inner mucous membrane of the uterus.Fibroids, or fibroid tumors — Fibroid tumors are non-cancerous (benign) growths in the uterus. They occur in 30-40% of women over age 40, and do not need to be removed unless they are causing symptoms that interfere with a woman's normal activities.Hypothyroidism — A disorder in which the thyroid gland produces too little thyroid hormone causing a decrease in the rate of metabolism with associated effects on the reproductive system.Lupus erythematosus — A chronic inflammatory disease in which inappropriate immune system reactions cause abnormalities in the blood vessels and connective tissue.Progesterone — A hormone naturally secreted by the ovary, or manufactured synthetically, that prepares the uterus for implantation of a fertilized egg.Prostaglandins — A group of chemicals that mediate, or determine the actions of other chemicals in the cell or body.

bleeding

[blēd´ing] 1. escape of blood from an injured vessel; see also hemorrhage.2. phlebotomy.dysfunctional uterine bleeding bleeding from the nonmenstruating uterus when no organic lesions are present.implantation bleeding that occurring at the time of implantation of the zygote in the decidua.occult bleeding escape of blood in such small quantity that it can be detected only by chemical tests or by microscopic or spectroscopic examination.bleeding time the time required for a standardized wound to stop bleeding. The bleeding time test is used as a screening procedure to detect both congenital and acquired platelet disorders; it measures the ability of platelets to arrest bleeding and hence gives an estimate of platelet number and level of functioning. There are several methods of performing the bleeding time. In Ivy's test, incisions are made on the forearm, a sphygmomanometer is inflated to a standard of 40 mm around the upper arm, and the time until cessation of bleeding is recorded. The template method is a variation in which a template with a slit in it is laid on the forearm, and the slit and the knife making the skin incision are both standardized. The most widely used template is the Simplate. Normally bleeding will cease in 2 to 9 minutes. Qualitative platelet disorders, thrombocytopenia (platelet count of less than 100,000/mm³), and the use of aspirin will prolong the bleeding time.

dys·func·tion·al u·ter·ine bleed·ing

uterine bleeding due to a benign endocrine abnormality rather than to any organic disease.

dysfunctional uterine bleeding

Gynecology 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

DRG Category:	744
Mean LOS:	5.9 days
Description:	SURGICAL: Dilation and Curettage, Conization, Laparoscopy and Tubal Interruption With CC or Major CC
DRG Category:	760
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.

Causes

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.

Genetic considerations

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.

Assessment

History

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.

Physical examination

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.

Psychosocial

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.

Diagnostic highlights

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

Diagnosis

Fluid volume deficit related to blood loss

Outcomes

Fluid balance; Hydration; Circulation status

Interventions

Bleeding reduction; Blood product administration; Intravenous therapy; Shock management

Planning and implementation

Collaborative

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.

Pharmacologic highlights

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

Independent

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%.

Documentation guidelines

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.