Download DYSFUNCTIONAL UTERINE BLEEDING

DYSFUNCTIONAL UTERINE
BLEEDING
Modified from talk given by Tiffany Meyer, M.D.
Continuity Clinic
Objectives
• Identify the primary cause of
dysfunctional uterine bleeding (DUB).
• Characterize the evaluation of DUB.
• Describe methods for reducing
menstrual blood loss.
• Explain how coagulation disorders can
cause menorrhagia.
• Delineate the most common ovarian
cause of DUB.
Continuity Clinic
Normal Menstrual Bleeding
• Duration of flow: 2-8 days
• Cycle length: 21-40 days (up to 45
days normal in adolescents)
• Blood loss: average blood loss is
20-80 mL
• 10-15 soaked tampons or pads per
cycle
Continuity Clinic
Normal Menstrual Cycle
Continuity Clinic
Definitions
• Hypermenorrhea or menorrhagia =
prolonged/ excessive uterine bleeding
at regular intervals
• Metrorrhagia = bleeding at irregular
intervals
• Menometrorrhagia =
prolonged/excessive bleeding at
irregular intervals
Continuity Clinic
Definitions con’t
• Polymenorrhea = uterine bleeding at
regular intervals of < 21 days
• Oligomenorrhea = bleeding at
prolonged intervals of 41 days to 3
months but of normal flow, duration, and
quantity
Continuity Clinic
Abnormal Menstrual Bleeding
• Menstrual cycles < 20 days apart
• Lasting over 8-10 days
• Blood loss > 80 mL
Continuity Clinic
Abnormal Menstrual
Bleeding con’t
• Abnormal bleeding patterns are
frequent within first 2-3 years after
menarche
• Caused by immaturity of the
hypothalamic-pituitary-ovarian axis
Continuity Clinic
Dysfunctional Uterine
Bleeding (DUB)
• Abnormal uterine bleeding
• No demonstrable organic lesion
• 90% are result of anovulatory
cycles
Continuity Clinic
Etiology of DUB
• Anovulation (corpus luteum fails to form) 
unopposed estrogen secondary to failure of
normal cyclical progesterone secretion 
without progesterone, inadequate
stabilization of thick proliferative endometrium
which eventually outgrows its blood supply
 heavy, irregular bleeding
Continuity Clinic
Evaluation of DUB
• Assess degree of blood loss
• Assess need for fluid or blood
replacement
• Assess need for hospitalization
• Assess need for hormonal
intervention
Continuity Clinic
DUB: History
• Age of menarche?
• Menstrual pattern? (dates of last 3 cycles)
• Number of pads or tampons used and
amount of saturation?
• Presence or absence of pain?
• Sexual activity? STDs? Vaginal d/c?
• Recent stress? Weight change?
• Chronic diseases? Bleeding problems?
• Sports? Medications?
Continuity Clinic
Taking a Menstrual History
Continuity Clinic
DUB: Physical
• General physical exam
– R/O thyroid/liver disease, bleeding dyscrasia
• Breast examination:  for galactorrhea
• Pelvic examination
– Indicated if history of sexual activity or painful
bleeding
– Can be deferred if painless bleeding within 23 years of menarche and no history of sex
Continuity Clinic
DUB: Laboratory Tests
• CBC, differential, platelet count, and reticulocyte
count
• Pregnancy test
• PT, PTT (LFTs if PT elevated)
• von Willebrand factor antigen and ristocetin
cofactor
• TFTs, LH, FSH, testosterone, DHEAS
• Tests for GC and CT from endocervix if
possibility of sexual activity
Continuity Clinic
Therapy for DUB
• Objectives
– Control bleeding if necessary
– Prevent recurrences
– Correct any organic pathology
– Education and reassurance
(especially if bleeding secondary to
anovulatory cycles)
Continuity Clinic
Mild DUB
• Characteristics
– Menses longer than normal (more than
8-10 days) or cycle shortened (less than
20 days apart)
– Hemoglobin > 11 gm/dl
Continuity Clinic
Therapy For Mild DUB
• Acute treatment
– Observation and reassurance
– Keep a menstrual calendar!!
– Iron supplements to prevent anemia
– NSAIDs to lessen flow
• Long-term treatment
– Monitor iron status (H and H)
– Follow-up in 2 months
Continuity Clinic
Example of
Menstrual Calendar
Continuity Clinic
Moderate DUB
• Characteristics
– Menses moderately prolonged or cycles
shortened
– Hemoglobin 9-11 gm/dl
Continuity Clinic
Therapy For Moderate DUB
• Acute treatment
– OCPs (Lo-Ovral or Ovral) taken BID x 34 days until bleeding stops then QD to
finish 21-day cycle
– May require anti-emetic
• Long-term treatment
– Cycle for 3 months, but length of use
depends on resolution of anemia/iron
supplementation
– Follow-up within 2-3 weeks and Q 3
months
Continuity Clinic
Therapy For Moderate DUB con’t
• Another option:
– Medroxyprogesterone (Provera) can be
used if
• Patient is not bleeding at time of visit
• Patient or parent does not want OCPs
• Medical contraindication to estrogens
– Provera is given as 10 mg PO QD x 1014 days starting on 14th day of
menstrual cycle or starting on first day
of each month
– Continued for 3-6 months
Continuity Clinic
Severe DUB
• Characteristics
– Prolonged, heavy bleeding
– Hemoglobin < 9 gm/dl or dropping
• Consider admission if
– Initial hemoglobin < 7 gm
– Orthostatic signs or tachycardia
present
– Bleeding is heavy and Hb < 10 gm
Continuity Clinic
Therapy For Severe DUB
• Acute treatment
– Consider transfusion if very low
hematocrit and unstable vital signs
– Obtain clotting studies
– Consider conjugated estrogens 25
mg IV Q 4-6 hours x 24 hours until
bleeding stops
Continuity Clinic
Therapy for Severe DUB con’t
• Acute treatment con’t
– Can also use Lo-Ovral 1 pill Q 4
hours until bleeding slows or stops
then QID x 4 days, TID x 3 days,
and BID x 2 weeks
– Can also use Ovral or Nordette
(monophasic)
– May need anti-emetic
Continuity Clinic
Therapy For Severe DUB con’t
• Long-term treatment
– Iron supplementation to correct
anemia
– Should take OCPs for 3-6 months
– Follow-up within 2-3 weeks and Q 3
months
Continuity Clinic
Overview of DUB Management
Continuity Clinic
When to Expect
Improvement With DUB
• Bleeding usually tapers after the first few
doses of hormones
• After 6-12 months, the patient who does
not want to remain on OCPs can be given
a trial off medication
• DUB persists for 2 years in 60%, 4 years
in 50%, and up to 10 years in 30%
Continuity Clinic
Coagulation Disorders and DUB
• Odds of bleeding disorder increase with
the severity of bleeding (Canadian study)
– 1 in 5 patients who require hospitalization
– 1 in 4 patients with hemoglobin less than 10
– 1 in 3 patients requiring transfusion
– 1 in 2 patients who present with menorrhagia
from her very first menses
Continuity Clinic
Etiology of Acute
Adolescent Menorrhagia
Continuity Clinic
von Willebrand Disease
• Most common inherited bleeding disorder
• Many girls diagnosed during childhood
with easy bruising, frequent or prolonged
nosebleeds, and prolonged bleeding after
surgery, injury, or dental work
• However, often menorrhagia at menarche
can be the presenting symptom
Continuity Clinic
Other Coagulation Disorders
Causing Menorrhagia
• Idiopathic thrombocytopenic purpura (ITP)
• Platelet dysfunction secondary to
medications (NSAIDs)
• Coagulopathy from systemic illness (liver
disease)
Continuity Clinic
Polycystic Ovarian
Syndrome (PCOS)
• 10% of cases of DUB can occur in an
ovulatory cycle
• PCOS is most common form of ovulatory
DUB (but majority with PCOS are
anovulatory)
• About 5-10% of adolescent girls and
women have PCOS
Continuity Clinic