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DYSFUNCTIONAL UTERINE BLEEDING

Modified from talk given by Tiffany Meyer, M.D.

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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.

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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

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Normal Menstrual Cycle

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Definitions

• Hypermenorrhea or menorrhagia = prolonged/ excessive uterine bleeding at regular intervals

• Metrorrhagia = bleeding at irregular intervals

• Menometrorrhagia = prolonged/excessive bleeding at irregular intervals

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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

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Abnormal Menstrual Bleeding

• Menstrual cycles < 20 days apart

• Lasting over 8-10 days

• Blood loss > 80 mL

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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

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Dysfunctional Uterine Bleeding (DUB)

• Abnormal uterine bleeding

• No demonstrable organic lesion

• 90% are result of anovulatory cycles

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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

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Evaluation of DUB

• Assess degree of blood loss

• Assess need for fluid or blood replacement

• Assess need for hospitalization

• Assess need for hormonal intervention

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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?

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Taking a Menstrual History

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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 2-3 years of menarche and no history of sex

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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

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Therapy for DUB

• Objectives– Control bleeding if necessary

– Prevent recurrences

– Correct any organic pathology

– Education and reassurance (especially if bleeding secondary to anovulatory cycles)

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Mild DUB

• Characteristics– Menses longer than normal (more than

8-10 days) or cycle shortened (less than 20 days apart)

– Hemoglobin > 11 gm/dl

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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

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Example ofMenstrual Calendar

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Moderate DUB

• Characteristics– Menses moderately prolonged or cycles

shortened

– Hemoglobin 9-11 gm/dl

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Therapy For Moderate DUB• Acute treatment

– OCPs (Lo-Ovral or Ovral) taken BID x 3-4 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

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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 10-14 days starting on 14th day of menstrual cycle or starting on first day of each month

– Continued for 3-6 months

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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

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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

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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

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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

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Overview of DUB Management

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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%

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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

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Etiology of Acute Adolescent Menorrhagia

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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

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Other Coagulation DisordersCausing Menorrhagia

• Idiopathic thrombocytopenic purpura (ITP)

• Platelet dysfunction secondary to medications (NSAIDs)

• Coagulopathy from systemic illness (liver disease)

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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