Dysfunctional Uterine Bleeding

Chanak Trikhatri

Definition

Dysfunctional uterine bleeding is condition where there is abnormal uterine bleeding without any pathological manifestation in genital tract and does not have a known organic cause. Irregular uterine bleeding that occurs in the absence of recognizable pelvic pathology, general medical disease, or pregnancy. It reflects a disruption in the normal cyclic pattern of ovulatory hormonal stimulation to the endometrial lining.

Incidence

• Incidence: 40/1000• It is usually common in adolescents and

women approaching menopause.• 20% of cases occur in adolescent females, and

as many as 50% of women aged 40-50 years experience DUB.

Classification of DUB

• Primary (DUB): There is no detectable disease in the genital tract or else where in the body. It is due to dysfunction in the menstrual or ovarian cycle or uterine-ovarian-pituitary-hypothalamic axis.

• Secondary (DUB): Disorder outside the genital tract cause of uterine bleeding like hypothyroidism, IUCD, hormones for contraception or other use,

Etiology of Primary DUB• Disturbance in eicosanoids fibrinolytic and lysosomal

enzyme system• Ischemia and cell death• Arachidonic acid• PGF2 (Prostaglandin Alfa 2) vasoconstrictor and weak

platelet aggregator• PGE2 (prostaglandin E 2) vasodilator and platelet ant

aggregator• Thromboxane A2 (TXA2) potent vasoconstrictor and

platelet aggregator

Cont

• Anovulation (lack of ovulation)• Pituitary Cancer• Hypothalamic disorder • In case of adolescents, DUB can happen because

they often do not ovulate as their pituitary-ovarian axis matures.

• In case of Premenopausal women, it can happen due to irregular ovulation because of their decreasing ovarian hormone production.

Secondary DUB• Hormones : low dose progesterone

underdevelopment of spiral arterioles degeneration of large venules

• large doses of progesterone produce superficial dilated venules with atrophy of endometrium

• IUCD: ulceration of endometrium and increased vascularity

• Bleeding disorder, thrombocytopenia, factor 2,5,7,10 def

• Hypothyroidism: direct effect of thyroxin

Pathophysiology

Normal menstrual cycle

• Mean cycle length 28 days • At age 40 20-27 days• Duration 2-7 days• Excessive 8days or longer• MBL 40 ml

Clinical Feature

• Breast tenderness• Nausea• Urinary frequency• Fatigue • Excessive vaginal bleeding with severe pain or

cramping • Excessive vaginal bleeding with the passage of

tissue • Weight gain (Polycystic Ovarian Syndrome)

Cont

• Adolescent and teen age : anovulatory immaturity of hypothalamus

• Adults: Ovulatory, rule out PID fibroids complications of pregnancy

• Perimenopausal: Anovulatory ,rule out fibroids ca cervix and endometrium

Cont

• Regular cyclical : ovulatory for short duration ,rule out fibroids and PID

• Irregular or acyclic: anovulatory, rule out ca cervix or endometrium

• Intermenstrual : ovulatory fall in estrogen secretion following ovulation ,rule out cx polyp sub mucous fibroid and cervical carcinoma

Diagnosis

• History : Age, parity, fertility , occupation • Amount duration and pattern of bleeding

associated gynecological problem dysmenorrheal infertility or menopausal symptoms bleeding disorders or thyroid dysfunction contraception future pregnancies possible hysterectomy social and personal background

• Abdominal and pelvic examination• Physical Assessment

Investgation • Hysteroscopy• Human chorionic gonadotropin (HCG) • Complete blood count (CBC) • Papanicolaou test (Pap smear) • Endometrial sampling • Thyroid functions and prolactin • Liver functions • Coagulation studies/factors • Other hormone assays, as indicated

Medical Management• Non Pharmacological management: Hot/cold

application temporary relief for pain • Bed rest • Proper Nutrition • Oral iron therapy• Treatment of secondary disease• Medical therapy : NSAID, antifibrinolytics,

Transxemic acid, Prostaglandin inhibitors, Hormone therapy COC progesterone estrogens androgens and danazol

Surgical Management

• Endometrial ablation • Hysterectomy• Radiotherapy• Transcervical Resection • Uterine curettage

Nursing Diagnosis

• Pain related to DUB• Fear related to abnormal health status• Risk for deficient fluid volume related to fever• Fatigue due to blood loss• Sexual dysfunction related to altered body function

associated with uterine bleeding

Nursing Management • Encourage patient to comply the medication to reduce

discomfort and pain • Explain importance of iron-rich foods to supplement iron.• Explain methods of quantifying blood loss and reporting to

health-care provider.• Assist in and teach patient pain-relieving techniques to

promote self-sufficiency in managing pain.• Assess meaning of dysfunction for patient to explore self-

concept issues.• Encourage patient to express her feelings to increase

understanding of individual coping style.

Recent Research and Advancement

Safety and Effectiveness of Cavaterm TM Thermal Balloon Endometrial Ablation in Women With Dysfunctional Uterine Bleeding Compared to Transcervical Resection of the Endometrium (TCRE)

Reference Behera MA, Price TM. Dysfunctional uterine bleeding. Medscape Drugs & Diseases [serial online].

September 29, 2014;Accessed April 20, 2015. Available at http://emedicine.medscape.com/article/257007-overview

Center watch, (2008), https://www.centerwatch.com/clinical-trials/listings/external-studydetails.aspx?StudyID=NCT00549159&CatID=730

Nazar, N., (2013), Dysfunctional uterine bleeding. Health & medicine. http://www.slideshare.net/naz777ni/dysfunctional-uterine-bleeding-26616203

Smeltzer, Suzanne C, and Bare Brenda G (2000). Medical Surgical Nursing (9th). Philadelphia: Lippincott William & Wilkins.2000.