Download Dysfunctional uterine bleeding (DUB)

Gynaecological Nursing
NUR 352
Lecture 6
Mr. Othman Ta’ani
Definition

Abnormal bleeding from the uterus in the absence of
organic disease of the genital tract.
OR

Abnormal bleeding from the uterus unassociated with
tumors, inflammation or pregnancy.
The term may be applied to any abnormal pattern of uterine
bleeding but it is commonly applied to bleeding which is
excessive in amount, duration or frequency.

Occurs during the reproductive years (between menarche
and menopause).
Bleeding patterns

Excessive or heavy menstrual loss (menorrhagia)

Irregular bleeding (metrorrhagia)

Frequent bleeding with shortened cycle (polymenorrhoea).

Prolonged bleeding
Classification

Primary:
No detectable disease in genital tract. No
intrauterine contraceptive device (IUCD) present.
No prior administration of sex steroids or other
hormones. Due to dysfunction arising within the
genital tract or reproductive system.
Classification

Secondary:
No detectable disease of the genital tract but a
known disorder outside the genital tract e.g.
leukaemia,thrombocytopenia.

Iatrogenic:
Abnormal bleeding is associated with IUCD, depot
medrxyprogesterone acetate (depo-provera) or
estrogen administration.
Classification According to Etiology and Common
Symptoms Disorders with Normal Ovulation

Ovulatory oligomenorrhoea:
- Proliferative phase is prolonged
- Secretive phase is normal
- Common in adolescents
- May be a normal feature of menarche
- May be a forerunner of polycystic ovarian disease
* From Up to Date: “The Normal Menstrual Cycle” 2008
Classification According to Etiology and Common
Symptoms Disorders with Normal Ovulation

Ovulatory polymenorrhoea:
- Proliferative phase is shortened especially in
adolescence
- Shortened secretive phase may also occur especially
in older women
- Due to premature degeneration of the corpus luteum
Dysfunctional uterine bleeding with corpus
luteum abnormality

Failure in the development of corpus luteum

Decreased secretion of progesterone

Occurs mainly in the adult reproductive years

Shortening of the menstrual cycle and polymenorrhoea.

Prolonged activity of the corpus luteum, results in
prolonged and excessive menstruation
Anovulatory Dysfunctional uterine bleeding

Failure of ovulation is the most common
abnormality

May result in apparently normal periods e.g.
regular cycles but with excessive loss

Irregular menstruation with periods of amenorrhea
followed by excessive loss
Clinical presentation

There is no specific pattern of bleeding.
May be abnormal in:
1- amount.
2- duration.
3- frequency and its relation to menstruation.
The incidence of pathological disease and prognosis varies
with age. Therefore, it consider under 3 age groups:



under 20 years (adolescent DUB)
20-40 years
over 40 years
Clinical diagnosis

Hx, abdominal, pelvic examination

Hematological

Endocrine: progesterone on the 21st day of the cycle
(will indicate whether ovulation has occurred or if
there is corpus luteum insufficiency).

Others: hysteroscopy, laparoscopy
Management

Exclude organic disease

Individualize treatment according to age, parity,
severity, nature of the underlying defect and
likelihood of organic disease

Explanation of the situation

If in doubt, keep record of loss for about 2-3months
Management

Under 20 years
- Dilatation & curettage only if bleeding persists, hormone therapy,
antifbrinolytic therapy. Never hysterectomy.

20-40years
- Always D&C
- Next line of action after D&C ( hormone therapy, antifbrinolytic
therapy)
- Seldom hysterectomy

Over 40 years
- D&C mandatory
- Hormone therapy and antifbrinolytic therapy only after D&C in the
absence of organic disease
- Hysterectomy first resort if bleeding persists.
Hormone Therapy

Estrogens in cases of severe .

Progestogens: administered orally.
Medical Therapy

Antifibrinolytic agents.

Epsilon Aminocaproic acid

Tranexamic acid.

Prostaglandin synthetase inhibitors.

mefenamic acid.

flufenamic acid.
Surgical Treatment

Surgery

D&C

Hysterectomy

Radiotherapy. For those who are unfit for surgery
and over 40 years. Produces amenorrhea in 99% of
cases.
Gynaecological Nursing
NUR 352
Lecture 7
Mr. Othman Ta’ani
Definition


Pregnant has not occurred after at least 1 year of
engaging in unprotected coitus.
Sterility:
Is a lessened ability to conceive.
About 14% of couples in USA are infertile
TYPES OF INFERTILITY

1- PRIMARY : When there is no previous
conceptions
20%
2- SECONDARY : When there has been a previous
viable pregnancy but the couple is unable to
conceive at present
80%
MALE INFERTILITY FACTORS
1- Disturbance in spermatogenesis
2- Obstruction in the seminiferous tubules, ducts or
vessels preventing movements of spermatozoa.
3- Qualitative or Quantitative changes in the seminal
fluid preventing sperm motility.
4- Problems in ejaculation or deposition preventing
spermatozoa from being placed close enough to
woman's cervix.
Causes are as follows in a general scale

Female factor 30%
 Male factor 30%
 Female and male 30%
 Idiopathic 10%

The causes will vary from this general scale
according to the locality.
In Adequate Sperm Count

The sperm count is the number of sperm in a single
ejaculation or in a milliliter of sperm.

Minimum sperm count considered normal is 20
million per milliliter of seminal fluid or 50 million
per ejaculation.

At least 50% of sperm should be motile and 30% of
sperm should be normal in shape and form
FACTORS AFFECTING SPERM
1- Body Temperature.
2- Congenital Abnormalities e.g (undescended testes).
3- Varicocele ( varicosity of the spermatic vein).
4- Trauma to the testes.
5- Drug use
6- Environmental Factors e.g X-Ray
FEMALE INFERTILITY FACTORS
1- Anovulation: ( absence of ovulation) Most Common cause of
infertility in women.
2- Tubal transport problems
3- Uterine Problems : e.g Tumors , Uterine malformations
4- Cervical Problems:
 Normal Cervical mucus is thin & watery that help sperm to
penetrate the cervix when become this mucus too thick
difficulty to allow sperm to penetrate to cervix.
 Cervix Stenosis.
 D&C several times.
5- Vaginal Problems: Infection
PH of vaginal secretion
become acidotic
destroying the motility of spermatozoa
genetic factors – vaginal obstruction
DIAGNOSIS OF INFERTILITY

Semen analysis

Ovulation Monitoring
1- By Recording Basal Body Temperature for at
least 1 month
every day each morning
before getting out of bed.
2- Assessing the upsurge of LH that occurs before
ovulation by urine sample using kit.

Tubal Patency :
Ultrasound
X-Ray imaging
MANAGEMENT OF INFERTILITY





Correction of underlying problem:
Sperm count & motility.
Presence of infection.
Hormone Therapy.
Surgery: e.g Fibroid Tumor
Myomectomy
MANAGEMENT OF INFERTILITY

Artificial Insemination:
Instillation of sperm into the female reproductive tract to aid
conception
 This technique can be done in case of :
1- In adequate amount of sperm count
2- Woman has vaginal or cervical factors

In Vitro Fertilization ( IVF ): This technique used in
 Blocked or Damaged fallopian tubes.
 Oligospermia or Sperm count
Social and Psychological Implications Related
to Infertility

Psychological reactions
 Guilt
 Isolation
 Depression
 Stress on the relationship

Cultural and religious considerations
Slide 30
NURSING MANAGEMENT

The Major focus of nursing care are:
1- Providing support for couple as they undergo
diagnosis and their chosen treatment.
2- Therapeutic communication skills.