dysfunctional uterine bleedingdysfunctional uterine bleeding: abnormal uterine bleeding is a common...
TRANSCRIPT
Dysfunctional uterine bleeding
Abnormal uterine bleeding is a common presenting problem (DUB) is defined as abnormal uterine bleeding in the absence of organic disease Dysfunctional uterine bleeding is the most common cause of abnormal vaginal bleeding during a womans reproductive years Dysfunctional uterine bleeding can have a substantial financial and quality-of-life burden It affects womens health both medically and socially
Terms frequently used to describeabnormal uterine bleeding
A normal menstrual cycle is characterized by an approximate flow of 30 mL per period which lasts for 2 to 7 days and occurs with a mean interval of 21 to 35 daysDUB refers to abnormal bleeding from the uterus and can be characterized clinically by amount duration and periodicity
Menorrhagia - Prolonged (gt7 d) or excessive (gt80 mL daily) uterine bleeding occurring at regular intervalsMetrorrhagia - Uterine bleeding occurring at irregular and more frequent than normal intervalsMenometrorrhagia - Prolonged or excessive uterine bleeding occurring at irregular and more frequent than normal intervalsIntermenstrual bleeding - Uterine bleeding of variable amounts occurring between regular menstrual periodsMidcycle spotting - Spotting occurring just before ovulation typically from declining estrogen levelsPostmenopausal bleeding - Recurrence of bleeding in a menopausal woman at least 6 months to 1 year after cessation of cyclesAmenorrhea - No uterine bleeding for 6 months or longer
Dysfunctional uterine bleeding is a diagnosis of exclusion It is ovulatory or anovulatory bleeding diagnosed after pregnancy medications iatrogenic causes genital tract pathology malignancy and systemic disease have been ruled out by appropriate investigations Approximately 90 of dysfunctional uterine bleeding cases result from an ovulation and 10 of cases occur with ovulatory cycles
-Anovulatory dysfunctional uterine bleeding results from a disturbance of the normal hypothalamic-pituitary-ovarian axis and is particularly common at the extremes of the reproductive years When ovulation does not occur no progesterone is produced to stabilize the endometrium thus proliferative endometrium persists
Bleeding episodes become irregular and amenorrhea metrorrhagia and menometrorrhagia are common Bleeding from anovulatory dysfunctional uterine bleeding is thought to result from changes in prostaglandin concentration increased endometrial responsiveness to vasodilating prostaglandins and changes in endometrial vascular structure
-In ovulatory dysfunctional uterine bleeding bleeding occurs cyclically and menorrhagia is thought to originate from defects in the control mechanisms of menstruation It is thought that in women with ovulatory dysfunctional uterine bleeding there is an increased rate of blood loss resulting from vasodilatation of the vessels supplying the endometrium due to decreased vascular tone and prostaglandins have been strongly implicated Therefore these women lose blood at rates about 3 times faster than women with normal menses4
-MortalityMorbidityMorbidity is related to the amount of blood loss at the time of menstruation which occasionally is severe enough to cause hemorrhagic shock Excessive menstrual bleeding accounts for two thirds of all hysterectomies and most endoscopic endometrial destructive surgery Menorrhagia has several adverse effects including anemia and iron deficiency reduced quality of life and increased healthcare costsRaceDysfunctional uterine bleeding has no predilection for race however black women have a higher incidence of leiomyomas and as a result they are prone to experiencing more episodes of abnormal vaginal bleeding-AgeDysfunctional uterine bleeding is most common at the extreme ages of a womans reproductive years either at the beginning or near the end but it may occur at any time during her reproductive life
Most cases of dysfunctional uterine bleeding in adolescent girls occur during the first 2 years after the onset of menstruation when their immature hypothalamic-pituitary axis may fail to respond to estrogen and progesterone resulting in an ovulationAbnormal uterine bleeding affects up to 50 of perimenopausal women In the perimenopausal period dysfunctional uterine bleeding may be an early manifestation of ovarian failure causing decreased hormone levels or responsiveness to hormones thus also leading to anovulatory cycles In patients who are 40 years or older the number and quality of ovarian follicles diminishes Follicles continue to develop but do not produce enough estrogen in response to FSH to trigger ovulation The estrogen that is produced usually results in late-cycle estrogen breakthrough bleeding
-HistoryPatients often present with complaints of amenorrhea menorrhagia metrorrhagia or menometrorrhagia The amount and frequency of bleeding and the duration of symptoms as well as the relationship to the menstrual cycle should be established Ask patients to compare the number of pads or tampons used per day in a normal menstrual cycle to the number used at the time of presentation The average tampon or pad absorbs 20-30 mL or vaginal effluent Personal habits vary greatly among women therefore the number of pads or tampons used is unreliable
A reproductive history should always be obtained including the following Age of menarche and menstrual history and regularityLast menstrual period (LMP) including flow duration and presence of dysmenorrheaPostcoital bleedingGravida and paraPrevious abortion or recent termination of pregnancyContraceptive use use of barrier protection and sexual activity (including vigorous sexual activity or trauma)
History of sexually transmitted diseases (STDs) or ectopic pregnancy
Questions about medical history should include the following Signs and symptoms of anemia or hypovolemia (including fatigue dizziness and syncope)Diabetes mellitusThyroid diseaseEndocrine problems or pituitary tumorsLiver diseaseRecent illness psychological stress excessive exercise or weight changeMedication usage including exogenous hormones anticoagulants aspirin anticonvulsants and antibiotics
An international expert panel including obstetriciangynecologists and hematologists has issued guidelines to assist physicians to better recognize bleeding disorders such as von Will brand disease as a cause of menorrhagia and postpartum hemorrhage and to provide disease-specific therapy for the bleeding disorder5Historically a lack of awareness of underlying bleeding disorders has led to under diagnosis in women with abnormal reproductive tract bleeding The panel provided expert consensus recommendations on how to identify confirm and manage a bleeding disorder If a bleeding disorder is suspected evaluation for a coagulation problem is required and consultation with a hematologist is suggested An underlying bleeding disorder should be considered when a patient has any of the following
Menorrhagia since menarcheFamily history of bleeding disordersPersonal history of 1 or several of the following
Notable bruising without known injuryBleeding of oral cavity or GI tract without obvious lesionEpistaxis gt10 min duration (possibly necessitating packing or cautery)
-Physical1) Vital signs including postural changes should be assessed Initial evaluation should be directed at assessing the patients volume status and degree of anemia Examine for pallor and absence of conjunctival vessels to gauge anemia2) An abdominal examination should be performed Femoral and inguinal lymph nodes should be examined Stool should be evaluated for the presence of blood3) Patients who are hemodynamically stable require a pelvic speculum bimanual and rectovaginal examination to define the etiology of vaginal bleeding A careful physical examination will exclude vaginal or rectal sources of bleeding The examination should look for the following
The vagina should be inspected for signs of trauma lesions infection and foreign bodiesThe cervix should be visualized and inspected for lesions polyps infection or intrauterine device (IUD)Bleeding from the cervical osA rectovaginal examination should be performed to evaluate the cul-de-sac posterior wall of the uterus and uterosacral ligaments
4) Uterine or ovarian structural abnormalities including leiomyoma or fibroid uterus may be noted on bimanual examination5) Patients with hematologic pathology may also have cutaneous evidence of bleeding diathesis Physical findings include petechiae purpura and mucosal bleeding (eg gums) in addition to vaginal bleeding6) Patients with liver disease that has resulted in a coagulopathy may manifest additional symptomatology because of abnormal hepatic function Evaluate patients for spider angioma palmar erythema splenomegaly ascites jaundice7) Women with polycystic ovary disease present with signs of hyperandrogenism including hirsutism obesity acne palpable enlarged ovaries and acanthosis nigricans (hyper pigmentation typically seen in the folds of the skin in the neck groin or axilla)8) Hyperactive and hypoactive thyroid can cause menstrual irregularities Patients may have varying degrees of characteristic vital sign abnormalities eye findings tremors changes in skin texture and weight change Goiter may be present
Systemic disease including thrombocytopenia hypothyroidism hyperthyroidism Cushing disease liver disease diabetes mellitus and adrenal and other endocrine disorders can present as abnormal uterine bleedingPregnancy and pregnancy-related conditions may be associated with vaginal bleedingTrauma to the cervix vulva or vagina may cause abnormal bleedingCarcinomas of the vagina cervix uterus and ovaries must always be considered in patients with the appropriate history and physical examination findings Endometrial cancer is associated with obesity diabetes mellitus anovulatory cycles nulliparity and age older than 35 yearsOther causes of abnormal uterine bleeding include structural disorders such as functional ovarian cystscervicitis endometritis salpingitis leiomyomas and adenomyosis Cervical dysplasia or other genital tract pathology may present as postcoital or irregular bleeding
-Causes
Polycystic ovary disease results in excess estrogen production and commonly presents as abnormal uterine bleedingPrimary coagulation disorders such as von Will brand disease myeloproliferative disorders and immune thrombocytopenia can present with menorrhagiaExcessive exercise stress and weight loss cause hypothalamic suppression leading to abnormal uterine bleeding due to disruption along the hypothalamus-pituitary-ovarian pathwayBleeding disturbances are common with combination oral contraceptive pills as well as progestin-only methods of birth control However the incidence of bleeding decreases significantly with time Therefore only counseling and reassurance are required during the early months of use Contraceptive intrauterine devices (IUDs) can cause variable vaginal bleeding for the first few cycles after placement and intermittent spotting subsequently The progesterone impregnated IUD (Mirena) is associated with less menometrorrhagia and usually results in secondary amenorrhea
-Causes
AbortionAbruptio PlacentaeAn ovulationAnticoagulantsAntipsychoticMalformationsCervical CancerCervicitisCoagulopathiesCushing SyndromeEndocervical PolypEndometrial CarcinomaEndometrial PolypEndometriosisEstrogen Therapy
-Differential Diagnoses
FibroidsHydatidiform MoleHypothyroidismIntrauterine devicesLiver diseaseMullerian Duct AnomaliesOvarian CystsPelvic Inflammatory DiseasePlacenta PreviaPlatelet Disordersvon Will brand DiseaseVulvovaginitis
When evaluating a woman of reproductive age with vaginal bleeding pregnancy must always be ruled out by urine or serum human chorionic gonadotropinIn a patient with any hemodynamic instability excessive bleeding or clinical evidence of anemia a complete blood count is essentialCoagulation studies should be considered when indicated by the history or physical examination findings and in patients with underlying liver disease or other coagulopathiesIn patients with suspected endocrine disorders other laboratory studies such as thyroid function tests and prolactin levels may be helpful although these results may not be available from the ED (endocrine disorders)
Pelvic ultrasonography is an important imaging modality for non pregnant patients with abnormal vaginal bleeding It may determine the etiology of the bleeding such as a fibroid uterus endometrial thickening or a focal mass
Thickened endometrium may indicate an underlying lesion or excess estrogen and may be suggestive of malignancy
An endometrial stripe measuring less than 4 mm thick is unlikely to have endometrial hyperplasia or cancer and biopsy is often considered unnecessary before treatmentWomen with a normal endometrial stripe (5ndash12 mm) may require biopsy particularly if they have risk factors for endometrial cancerWhen the endometrial stripe is larger than 12 mm a biopsy should be performed6
Imaging Studies
Depending on the urgency to determine the etiology of bleeding and on the reliability of outpatient follow-up ultrasonography may be deferred for outpatient evaluations because for the majority of nonpregnant patients ultrasonographic findings do not immediately affect ED decision-making3
Transvaginal ultrasonography may be particularly helpful in further delineating ovarian cysts and fluid in the cul-de-sacComputed tomography is used primarily for evaluation of other causes of acute abdominal or pelvic painMagnetic resonance imaging is used primarily for cancer staging
ProceduresBefore instituting therapy many consulting gynecologists perform endometrial sampling or biopsy to diagnose intrauterine pathology and to exclude endometrial malignancyEndometrial biopsy is indicated for the following patients with abnormal uterine bleeding6
Women older than 35 yearsObese patientsWomen who have prolonged periods of unopposed estrogen stimulationWomen with chronic an ovulation
Hysteroscopy is the definitive way to detect intrauterine lesions It offers a more complete examination of the surface of the endometrium However it is usually reserved for treating lesions that were detected by other less invasive means
TreatmentEmergency Department CareHemodynamically unstable patients with uncontrolled bleeding and signs of significant blood loss should have aggressive resuscitation with saline and blood as with other types of hemorrhagic shock
Evaluate ABCs and address the prioritiesInitiate 2 large-bore intravenous lines (IVs) oxygen and cardiac monitorIf bleeding is profuse and the patient is unresponsive to initial fluid management consider administration of IV conjugated estrogen (Premarin) 25 mg IV every 4-6 hours until the bleeding stopsIn women with severe persistent uterine bleeding an immediate dilation and curettage (DampC) procedure may be necessary
Treatment contCombination oral contraceptive pills may be used in women who are not pregnant and have no anatomic abnormalities An oral contraceptive with 35 mcg can be taken twice a day until the bleeding stops for up to 7 days at which time the dose is decreased to once a day until the pack is completed They provide the additional benefits of reducing dysmenorrhea and providing contraception Side effects include nausea and vomitingProgesterone alone can be used to stabilize an immature endometrium It is usually successful in the treatment of women with anovulatory dysfunctional uterine bleeding (DUB) because these women have unopposed estrogen stimulation Medroxyprogesterone acetate 10 mg is taken orally once daily for 10 days followed by withdrawal bleeding 3-5 days after completion of the course Currently there is not enough evidence comparing the effect of either progesterone alone or in combination with estrogens for the treatment of dysfunctional uterine bleeding7
Treatment contNo steroidal anti-inflammatory drugs (NSAIDs) are generally effective for the treatment of dysfunctional uterine bleeding and dysmenorrhea NSAIDs inhibiting prostaglandin synthesis and increasing thromboxane A2 levels
This leads to vasoconstriction and increased platelet aggregation These medications may reduce blood loss by 20-50 NSAIDs are most effective if used with the onset of menses or just prior to its onset and continued throughout its durationDanazol creates a hypoestrogenic and hyper androgenic environment which induces endometrial atrophy resulting in reduced menstrual loss Side effects include musculoskeletal pain breast atrophy hirsutism weight gain oily skin and acne Because of the significant androgenic side effects this drug is usually reserved as a second-line treatment for short-term use prior to surgeryGonadotropin-releasing hormone agonists may be helpful for short-term use in inducing amenorrhea and allowing women to rebuild their red blood cell mass They produce a profound hypoestrogenic state similar to menopause Side effects include menopausal symptoms and bone loss with long-term useTranexamic acid is an antifibrinolytic drug that exerts its effects by reversibly inhibiting plasminogen
Treatment contConsultationsSeek an emergency gynecologic consultation for patients requiring hemodynamic stabilization If parenteral therapy does not completely arrest vaginal bleeding in the hemodynamically unstable patient an emergency DampC may be warrantedConsultation with or urgent referral to a gynecologist for surgical treatment may be necessary for patients who do not desire fertility and in whom medical therapy fails Both endometrial ablation and hysterectomy are effective treatments in women with dysfunctional uterine bleeding with comparable patient satisfaction rates
Endometrial ablation is( a medical procedure that is used to remove (ablate) or destroy the endometrial lining of a uterus) may be performed using laser electrocautery or roller ball
Treatment contAmenorrhea is seen in approximately 35 of women treated and decreased flow is seen in another 45 although treatment failures increase with time following the procedure due to endometrial regeneration A substantial number of patients receiving endometrial ablation require reoperation (30 by 48 months)
Hysterectomy is the most effective treatment for bleeding However it is associated with more frequent and severe adverse events compared with either conservative medical or ablation procedures Operating time hospitalization recovery times and costs are also greater Hence hysterectomy is reserved for selected patient populations
MedicationThe goals of pharmacotherapy are to control the bleeding reduce morbidity and prevent complications Steroid hormonesContraceptive pills Medroxyprogesterone acetate (Provera)After acute bleeding episode controlled can be used alone in patients with adequate amounts of endogenous estrogen to cause endometrial growth Progestin therapy in adolescents produces regular cyclic withdrawal bleeding until positive feedback system matures Progestins stop endometrial growth and support and organize endometrium to allow organized sloughing after their withdrawal Bleeding ceases rapidly because of an organized slough to the basalis layer These drugs usually do not stop acute bleeding episodes yet produce a normal bleeding episode following their withdrawal
ComplicationsAnemia (may become severe)Adenocarcinoma of the uterus (if prolonged unopposed estrogen stimulation)PrognosisHormonal contraceptives reduce blood loss by 40-70 when used long termAlthough medical therapy is generally used first over half of women with menorrhagia undergo hysterectomy within 5 years of referral to a gynecologist[2 ]
Patient EducationInstruct patients to continue prescribed medications although bleeding may still be occurring during the early part of the cycle Also patients should be told to expect menses after cessation of the regimenYoung patients with small amounts of irregular bleeding need reassurance and observation only prior to instituting a drug regimen Express to patients that pharmacologic intervention will not be necessary once menstrual cycles become regularDiscuss ways the patient can avoid prolonged emotional stress and maintain a normal body mass indexFor excellent patient education resources visit medicines Womens Health Center
- Dysfunctional uterine bleeding
- Terms frequently used to describeabnormal uterine bleeding
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Treatment
- Treatment cont
- Slide 21
- Slide 22
- Slide 23
- Medication
- Slide 25
- Slide 26
- Slide 27
-
Terms frequently used to describeabnormal uterine bleeding
A normal menstrual cycle is characterized by an approximate flow of 30 mL per period which lasts for 2 to 7 days and occurs with a mean interval of 21 to 35 daysDUB refers to abnormal bleeding from the uterus and can be characterized clinically by amount duration and periodicity
Menorrhagia - Prolonged (gt7 d) or excessive (gt80 mL daily) uterine bleeding occurring at regular intervalsMetrorrhagia - Uterine bleeding occurring at irregular and more frequent than normal intervalsMenometrorrhagia - Prolonged or excessive uterine bleeding occurring at irregular and more frequent than normal intervalsIntermenstrual bleeding - Uterine bleeding of variable amounts occurring between regular menstrual periodsMidcycle spotting - Spotting occurring just before ovulation typically from declining estrogen levelsPostmenopausal bleeding - Recurrence of bleeding in a menopausal woman at least 6 months to 1 year after cessation of cyclesAmenorrhea - No uterine bleeding for 6 months or longer
Dysfunctional uterine bleeding is a diagnosis of exclusion It is ovulatory or anovulatory bleeding diagnosed after pregnancy medications iatrogenic causes genital tract pathology malignancy and systemic disease have been ruled out by appropriate investigations Approximately 90 of dysfunctional uterine bleeding cases result from an ovulation and 10 of cases occur with ovulatory cycles
-Anovulatory dysfunctional uterine bleeding results from a disturbance of the normal hypothalamic-pituitary-ovarian axis and is particularly common at the extremes of the reproductive years When ovulation does not occur no progesterone is produced to stabilize the endometrium thus proliferative endometrium persists
Bleeding episodes become irregular and amenorrhea metrorrhagia and menometrorrhagia are common Bleeding from anovulatory dysfunctional uterine bleeding is thought to result from changes in prostaglandin concentration increased endometrial responsiveness to vasodilating prostaglandins and changes in endometrial vascular structure
-In ovulatory dysfunctional uterine bleeding bleeding occurs cyclically and menorrhagia is thought to originate from defects in the control mechanisms of menstruation It is thought that in women with ovulatory dysfunctional uterine bleeding there is an increased rate of blood loss resulting from vasodilatation of the vessels supplying the endometrium due to decreased vascular tone and prostaglandins have been strongly implicated Therefore these women lose blood at rates about 3 times faster than women with normal menses4
-MortalityMorbidityMorbidity is related to the amount of blood loss at the time of menstruation which occasionally is severe enough to cause hemorrhagic shock Excessive menstrual bleeding accounts for two thirds of all hysterectomies and most endoscopic endometrial destructive surgery Menorrhagia has several adverse effects including anemia and iron deficiency reduced quality of life and increased healthcare costsRaceDysfunctional uterine bleeding has no predilection for race however black women have a higher incidence of leiomyomas and as a result they are prone to experiencing more episodes of abnormal vaginal bleeding-AgeDysfunctional uterine bleeding is most common at the extreme ages of a womans reproductive years either at the beginning or near the end but it may occur at any time during her reproductive life
Most cases of dysfunctional uterine bleeding in adolescent girls occur during the first 2 years after the onset of menstruation when their immature hypothalamic-pituitary axis may fail to respond to estrogen and progesterone resulting in an ovulationAbnormal uterine bleeding affects up to 50 of perimenopausal women In the perimenopausal period dysfunctional uterine bleeding may be an early manifestation of ovarian failure causing decreased hormone levels or responsiveness to hormones thus also leading to anovulatory cycles In patients who are 40 years or older the number and quality of ovarian follicles diminishes Follicles continue to develop but do not produce enough estrogen in response to FSH to trigger ovulation The estrogen that is produced usually results in late-cycle estrogen breakthrough bleeding
-HistoryPatients often present with complaints of amenorrhea menorrhagia metrorrhagia or menometrorrhagia The amount and frequency of bleeding and the duration of symptoms as well as the relationship to the menstrual cycle should be established Ask patients to compare the number of pads or tampons used per day in a normal menstrual cycle to the number used at the time of presentation The average tampon or pad absorbs 20-30 mL or vaginal effluent Personal habits vary greatly among women therefore the number of pads or tampons used is unreliable
A reproductive history should always be obtained including the following Age of menarche and menstrual history and regularityLast menstrual period (LMP) including flow duration and presence of dysmenorrheaPostcoital bleedingGravida and paraPrevious abortion or recent termination of pregnancyContraceptive use use of barrier protection and sexual activity (including vigorous sexual activity or trauma)
History of sexually transmitted diseases (STDs) or ectopic pregnancy
Questions about medical history should include the following Signs and symptoms of anemia or hypovolemia (including fatigue dizziness and syncope)Diabetes mellitusThyroid diseaseEndocrine problems or pituitary tumorsLiver diseaseRecent illness psychological stress excessive exercise or weight changeMedication usage including exogenous hormones anticoagulants aspirin anticonvulsants and antibiotics
An international expert panel including obstetriciangynecologists and hematologists has issued guidelines to assist physicians to better recognize bleeding disorders such as von Will brand disease as a cause of menorrhagia and postpartum hemorrhage and to provide disease-specific therapy for the bleeding disorder5Historically a lack of awareness of underlying bleeding disorders has led to under diagnosis in women with abnormal reproductive tract bleeding The panel provided expert consensus recommendations on how to identify confirm and manage a bleeding disorder If a bleeding disorder is suspected evaluation for a coagulation problem is required and consultation with a hematologist is suggested An underlying bleeding disorder should be considered when a patient has any of the following
Menorrhagia since menarcheFamily history of bleeding disordersPersonal history of 1 or several of the following
Notable bruising without known injuryBleeding of oral cavity or GI tract without obvious lesionEpistaxis gt10 min duration (possibly necessitating packing or cautery)
-Physical1) Vital signs including postural changes should be assessed Initial evaluation should be directed at assessing the patients volume status and degree of anemia Examine for pallor and absence of conjunctival vessels to gauge anemia2) An abdominal examination should be performed Femoral and inguinal lymph nodes should be examined Stool should be evaluated for the presence of blood3) Patients who are hemodynamically stable require a pelvic speculum bimanual and rectovaginal examination to define the etiology of vaginal bleeding A careful physical examination will exclude vaginal or rectal sources of bleeding The examination should look for the following
The vagina should be inspected for signs of trauma lesions infection and foreign bodiesThe cervix should be visualized and inspected for lesions polyps infection or intrauterine device (IUD)Bleeding from the cervical osA rectovaginal examination should be performed to evaluate the cul-de-sac posterior wall of the uterus and uterosacral ligaments
4) Uterine or ovarian structural abnormalities including leiomyoma or fibroid uterus may be noted on bimanual examination5) Patients with hematologic pathology may also have cutaneous evidence of bleeding diathesis Physical findings include petechiae purpura and mucosal bleeding (eg gums) in addition to vaginal bleeding6) Patients with liver disease that has resulted in a coagulopathy may manifest additional symptomatology because of abnormal hepatic function Evaluate patients for spider angioma palmar erythema splenomegaly ascites jaundice7) Women with polycystic ovary disease present with signs of hyperandrogenism including hirsutism obesity acne palpable enlarged ovaries and acanthosis nigricans (hyper pigmentation typically seen in the folds of the skin in the neck groin or axilla)8) Hyperactive and hypoactive thyroid can cause menstrual irregularities Patients may have varying degrees of characteristic vital sign abnormalities eye findings tremors changes in skin texture and weight change Goiter may be present
Systemic disease including thrombocytopenia hypothyroidism hyperthyroidism Cushing disease liver disease diabetes mellitus and adrenal and other endocrine disorders can present as abnormal uterine bleedingPregnancy and pregnancy-related conditions may be associated with vaginal bleedingTrauma to the cervix vulva or vagina may cause abnormal bleedingCarcinomas of the vagina cervix uterus and ovaries must always be considered in patients with the appropriate history and physical examination findings Endometrial cancer is associated with obesity diabetes mellitus anovulatory cycles nulliparity and age older than 35 yearsOther causes of abnormal uterine bleeding include structural disorders such as functional ovarian cystscervicitis endometritis salpingitis leiomyomas and adenomyosis Cervical dysplasia or other genital tract pathology may present as postcoital or irregular bleeding
-Causes
Polycystic ovary disease results in excess estrogen production and commonly presents as abnormal uterine bleedingPrimary coagulation disorders such as von Will brand disease myeloproliferative disorders and immune thrombocytopenia can present with menorrhagiaExcessive exercise stress and weight loss cause hypothalamic suppression leading to abnormal uterine bleeding due to disruption along the hypothalamus-pituitary-ovarian pathwayBleeding disturbances are common with combination oral contraceptive pills as well as progestin-only methods of birth control However the incidence of bleeding decreases significantly with time Therefore only counseling and reassurance are required during the early months of use Contraceptive intrauterine devices (IUDs) can cause variable vaginal bleeding for the first few cycles after placement and intermittent spotting subsequently The progesterone impregnated IUD (Mirena) is associated with less menometrorrhagia and usually results in secondary amenorrhea
-Causes
AbortionAbruptio PlacentaeAn ovulationAnticoagulantsAntipsychoticMalformationsCervical CancerCervicitisCoagulopathiesCushing SyndromeEndocervical PolypEndometrial CarcinomaEndometrial PolypEndometriosisEstrogen Therapy
-Differential Diagnoses
FibroidsHydatidiform MoleHypothyroidismIntrauterine devicesLiver diseaseMullerian Duct AnomaliesOvarian CystsPelvic Inflammatory DiseasePlacenta PreviaPlatelet Disordersvon Will brand DiseaseVulvovaginitis
When evaluating a woman of reproductive age with vaginal bleeding pregnancy must always be ruled out by urine or serum human chorionic gonadotropinIn a patient with any hemodynamic instability excessive bleeding or clinical evidence of anemia a complete blood count is essentialCoagulation studies should be considered when indicated by the history or physical examination findings and in patients with underlying liver disease or other coagulopathiesIn patients with suspected endocrine disorders other laboratory studies such as thyroid function tests and prolactin levels may be helpful although these results may not be available from the ED (endocrine disorders)
Pelvic ultrasonography is an important imaging modality for non pregnant patients with abnormal vaginal bleeding It may determine the etiology of the bleeding such as a fibroid uterus endometrial thickening or a focal mass
Thickened endometrium may indicate an underlying lesion or excess estrogen and may be suggestive of malignancy
An endometrial stripe measuring less than 4 mm thick is unlikely to have endometrial hyperplasia or cancer and biopsy is often considered unnecessary before treatmentWomen with a normal endometrial stripe (5ndash12 mm) may require biopsy particularly if they have risk factors for endometrial cancerWhen the endometrial stripe is larger than 12 mm a biopsy should be performed6
Imaging Studies
Depending on the urgency to determine the etiology of bleeding and on the reliability of outpatient follow-up ultrasonography may be deferred for outpatient evaluations because for the majority of nonpregnant patients ultrasonographic findings do not immediately affect ED decision-making3
Transvaginal ultrasonography may be particularly helpful in further delineating ovarian cysts and fluid in the cul-de-sacComputed tomography is used primarily for evaluation of other causes of acute abdominal or pelvic painMagnetic resonance imaging is used primarily for cancer staging
ProceduresBefore instituting therapy many consulting gynecologists perform endometrial sampling or biopsy to diagnose intrauterine pathology and to exclude endometrial malignancyEndometrial biopsy is indicated for the following patients with abnormal uterine bleeding6
Women older than 35 yearsObese patientsWomen who have prolonged periods of unopposed estrogen stimulationWomen with chronic an ovulation
Hysteroscopy is the definitive way to detect intrauterine lesions It offers a more complete examination of the surface of the endometrium However it is usually reserved for treating lesions that were detected by other less invasive means
TreatmentEmergency Department CareHemodynamically unstable patients with uncontrolled bleeding and signs of significant blood loss should have aggressive resuscitation with saline and blood as with other types of hemorrhagic shock
Evaluate ABCs and address the prioritiesInitiate 2 large-bore intravenous lines (IVs) oxygen and cardiac monitorIf bleeding is profuse and the patient is unresponsive to initial fluid management consider administration of IV conjugated estrogen (Premarin) 25 mg IV every 4-6 hours until the bleeding stopsIn women with severe persistent uterine bleeding an immediate dilation and curettage (DampC) procedure may be necessary
Treatment contCombination oral contraceptive pills may be used in women who are not pregnant and have no anatomic abnormalities An oral contraceptive with 35 mcg can be taken twice a day until the bleeding stops for up to 7 days at which time the dose is decreased to once a day until the pack is completed They provide the additional benefits of reducing dysmenorrhea and providing contraception Side effects include nausea and vomitingProgesterone alone can be used to stabilize an immature endometrium It is usually successful in the treatment of women with anovulatory dysfunctional uterine bleeding (DUB) because these women have unopposed estrogen stimulation Medroxyprogesterone acetate 10 mg is taken orally once daily for 10 days followed by withdrawal bleeding 3-5 days after completion of the course Currently there is not enough evidence comparing the effect of either progesterone alone or in combination with estrogens for the treatment of dysfunctional uterine bleeding7
Treatment contNo steroidal anti-inflammatory drugs (NSAIDs) are generally effective for the treatment of dysfunctional uterine bleeding and dysmenorrhea NSAIDs inhibiting prostaglandin synthesis and increasing thromboxane A2 levels
This leads to vasoconstriction and increased platelet aggregation These medications may reduce blood loss by 20-50 NSAIDs are most effective if used with the onset of menses or just prior to its onset and continued throughout its durationDanazol creates a hypoestrogenic and hyper androgenic environment which induces endometrial atrophy resulting in reduced menstrual loss Side effects include musculoskeletal pain breast atrophy hirsutism weight gain oily skin and acne Because of the significant androgenic side effects this drug is usually reserved as a second-line treatment for short-term use prior to surgeryGonadotropin-releasing hormone agonists may be helpful for short-term use in inducing amenorrhea and allowing women to rebuild their red blood cell mass They produce a profound hypoestrogenic state similar to menopause Side effects include menopausal symptoms and bone loss with long-term useTranexamic acid is an antifibrinolytic drug that exerts its effects by reversibly inhibiting plasminogen
Treatment contConsultationsSeek an emergency gynecologic consultation for patients requiring hemodynamic stabilization If parenteral therapy does not completely arrest vaginal bleeding in the hemodynamically unstable patient an emergency DampC may be warrantedConsultation with or urgent referral to a gynecologist for surgical treatment may be necessary for patients who do not desire fertility and in whom medical therapy fails Both endometrial ablation and hysterectomy are effective treatments in women with dysfunctional uterine bleeding with comparable patient satisfaction rates
Endometrial ablation is( a medical procedure that is used to remove (ablate) or destroy the endometrial lining of a uterus) may be performed using laser electrocautery or roller ball
Treatment contAmenorrhea is seen in approximately 35 of women treated and decreased flow is seen in another 45 although treatment failures increase with time following the procedure due to endometrial regeneration A substantial number of patients receiving endometrial ablation require reoperation (30 by 48 months)
Hysterectomy is the most effective treatment for bleeding However it is associated with more frequent and severe adverse events compared with either conservative medical or ablation procedures Operating time hospitalization recovery times and costs are also greater Hence hysterectomy is reserved for selected patient populations
MedicationThe goals of pharmacotherapy are to control the bleeding reduce morbidity and prevent complications Steroid hormonesContraceptive pills Medroxyprogesterone acetate (Provera)After acute bleeding episode controlled can be used alone in patients with adequate amounts of endogenous estrogen to cause endometrial growth Progestin therapy in adolescents produces regular cyclic withdrawal bleeding until positive feedback system matures Progestins stop endometrial growth and support and organize endometrium to allow organized sloughing after their withdrawal Bleeding ceases rapidly because of an organized slough to the basalis layer These drugs usually do not stop acute bleeding episodes yet produce a normal bleeding episode following their withdrawal
ComplicationsAnemia (may become severe)Adenocarcinoma of the uterus (if prolonged unopposed estrogen stimulation)PrognosisHormonal contraceptives reduce blood loss by 40-70 when used long termAlthough medical therapy is generally used first over half of women with menorrhagia undergo hysterectomy within 5 years of referral to a gynecologist[2 ]
Patient EducationInstruct patients to continue prescribed medications although bleeding may still be occurring during the early part of the cycle Also patients should be told to expect menses after cessation of the regimenYoung patients with small amounts of irregular bleeding need reassurance and observation only prior to instituting a drug regimen Express to patients that pharmacologic intervention will not be necessary once menstrual cycles become regularDiscuss ways the patient can avoid prolonged emotional stress and maintain a normal body mass indexFor excellent patient education resources visit medicines Womens Health Center
- Dysfunctional uterine bleeding
- Terms frequently used to describeabnormal uterine bleeding
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Treatment
- Treatment cont
- Slide 21
- Slide 22
- Slide 23
- Medication
- Slide 25
- Slide 26
- Slide 27
-
Dysfunctional uterine bleeding is a diagnosis of exclusion It is ovulatory or anovulatory bleeding diagnosed after pregnancy medications iatrogenic causes genital tract pathology malignancy and systemic disease have been ruled out by appropriate investigations Approximately 90 of dysfunctional uterine bleeding cases result from an ovulation and 10 of cases occur with ovulatory cycles
-Anovulatory dysfunctional uterine bleeding results from a disturbance of the normal hypothalamic-pituitary-ovarian axis and is particularly common at the extremes of the reproductive years When ovulation does not occur no progesterone is produced to stabilize the endometrium thus proliferative endometrium persists
Bleeding episodes become irregular and amenorrhea metrorrhagia and menometrorrhagia are common Bleeding from anovulatory dysfunctional uterine bleeding is thought to result from changes in prostaglandin concentration increased endometrial responsiveness to vasodilating prostaglandins and changes in endometrial vascular structure
-In ovulatory dysfunctional uterine bleeding bleeding occurs cyclically and menorrhagia is thought to originate from defects in the control mechanisms of menstruation It is thought that in women with ovulatory dysfunctional uterine bleeding there is an increased rate of blood loss resulting from vasodilatation of the vessels supplying the endometrium due to decreased vascular tone and prostaglandins have been strongly implicated Therefore these women lose blood at rates about 3 times faster than women with normal menses4
-MortalityMorbidityMorbidity is related to the amount of blood loss at the time of menstruation which occasionally is severe enough to cause hemorrhagic shock Excessive menstrual bleeding accounts for two thirds of all hysterectomies and most endoscopic endometrial destructive surgery Menorrhagia has several adverse effects including anemia and iron deficiency reduced quality of life and increased healthcare costsRaceDysfunctional uterine bleeding has no predilection for race however black women have a higher incidence of leiomyomas and as a result they are prone to experiencing more episodes of abnormal vaginal bleeding-AgeDysfunctional uterine bleeding is most common at the extreme ages of a womans reproductive years either at the beginning or near the end but it may occur at any time during her reproductive life
Most cases of dysfunctional uterine bleeding in adolescent girls occur during the first 2 years after the onset of menstruation when their immature hypothalamic-pituitary axis may fail to respond to estrogen and progesterone resulting in an ovulationAbnormal uterine bleeding affects up to 50 of perimenopausal women In the perimenopausal period dysfunctional uterine bleeding may be an early manifestation of ovarian failure causing decreased hormone levels or responsiveness to hormones thus also leading to anovulatory cycles In patients who are 40 years or older the number and quality of ovarian follicles diminishes Follicles continue to develop but do not produce enough estrogen in response to FSH to trigger ovulation The estrogen that is produced usually results in late-cycle estrogen breakthrough bleeding
-HistoryPatients often present with complaints of amenorrhea menorrhagia metrorrhagia or menometrorrhagia The amount and frequency of bleeding and the duration of symptoms as well as the relationship to the menstrual cycle should be established Ask patients to compare the number of pads or tampons used per day in a normal menstrual cycle to the number used at the time of presentation The average tampon or pad absorbs 20-30 mL or vaginal effluent Personal habits vary greatly among women therefore the number of pads or tampons used is unreliable
A reproductive history should always be obtained including the following Age of menarche and menstrual history and regularityLast menstrual period (LMP) including flow duration and presence of dysmenorrheaPostcoital bleedingGravida and paraPrevious abortion or recent termination of pregnancyContraceptive use use of barrier protection and sexual activity (including vigorous sexual activity or trauma)
History of sexually transmitted diseases (STDs) or ectopic pregnancy
Questions about medical history should include the following Signs and symptoms of anemia or hypovolemia (including fatigue dizziness and syncope)Diabetes mellitusThyroid diseaseEndocrine problems or pituitary tumorsLiver diseaseRecent illness psychological stress excessive exercise or weight changeMedication usage including exogenous hormones anticoagulants aspirin anticonvulsants and antibiotics
An international expert panel including obstetriciangynecologists and hematologists has issued guidelines to assist physicians to better recognize bleeding disorders such as von Will brand disease as a cause of menorrhagia and postpartum hemorrhage and to provide disease-specific therapy for the bleeding disorder5Historically a lack of awareness of underlying bleeding disorders has led to under diagnosis in women with abnormal reproductive tract bleeding The panel provided expert consensus recommendations on how to identify confirm and manage a bleeding disorder If a bleeding disorder is suspected evaluation for a coagulation problem is required and consultation with a hematologist is suggested An underlying bleeding disorder should be considered when a patient has any of the following
Menorrhagia since menarcheFamily history of bleeding disordersPersonal history of 1 or several of the following
Notable bruising without known injuryBleeding of oral cavity or GI tract without obvious lesionEpistaxis gt10 min duration (possibly necessitating packing or cautery)
-Physical1) Vital signs including postural changes should be assessed Initial evaluation should be directed at assessing the patients volume status and degree of anemia Examine for pallor and absence of conjunctival vessels to gauge anemia2) An abdominal examination should be performed Femoral and inguinal lymph nodes should be examined Stool should be evaluated for the presence of blood3) Patients who are hemodynamically stable require a pelvic speculum bimanual and rectovaginal examination to define the etiology of vaginal bleeding A careful physical examination will exclude vaginal or rectal sources of bleeding The examination should look for the following
The vagina should be inspected for signs of trauma lesions infection and foreign bodiesThe cervix should be visualized and inspected for lesions polyps infection or intrauterine device (IUD)Bleeding from the cervical osA rectovaginal examination should be performed to evaluate the cul-de-sac posterior wall of the uterus and uterosacral ligaments
4) Uterine or ovarian structural abnormalities including leiomyoma or fibroid uterus may be noted on bimanual examination5) Patients with hematologic pathology may also have cutaneous evidence of bleeding diathesis Physical findings include petechiae purpura and mucosal bleeding (eg gums) in addition to vaginal bleeding6) Patients with liver disease that has resulted in a coagulopathy may manifest additional symptomatology because of abnormal hepatic function Evaluate patients for spider angioma palmar erythema splenomegaly ascites jaundice7) Women with polycystic ovary disease present with signs of hyperandrogenism including hirsutism obesity acne palpable enlarged ovaries and acanthosis nigricans (hyper pigmentation typically seen in the folds of the skin in the neck groin or axilla)8) Hyperactive and hypoactive thyroid can cause menstrual irregularities Patients may have varying degrees of characteristic vital sign abnormalities eye findings tremors changes in skin texture and weight change Goiter may be present
Systemic disease including thrombocytopenia hypothyroidism hyperthyroidism Cushing disease liver disease diabetes mellitus and adrenal and other endocrine disorders can present as abnormal uterine bleedingPregnancy and pregnancy-related conditions may be associated with vaginal bleedingTrauma to the cervix vulva or vagina may cause abnormal bleedingCarcinomas of the vagina cervix uterus and ovaries must always be considered in patients with the appropriate history and physical examination findings Endometrial cancer is associated with obesity diabetes mellitus anovulatory cycles nulliparity and age older than 35 yearsOther causes of abnormal uterine bleeding include structural disorders such as functional ovarian cystscervicitis endometritis salpingitis leiomyomas and adenomyosis Cervical dysplasia or other genital tract pathology may present as postcoital or irregular bleeding
-Causes
Polycystic ovary disease results in excess estrogen production and commonly presents as abnormal uterine bleedingPrimary coagulation disorders such as von Will brand disease myeloproliferative disorders and immune thrombocytopenia can present with menorrhagiaExcessive exercise stress and weight loss cause hypothalamic suppression leading to abnormal uterine bleeding due to disruption along the hypothalamus-pituitary-ovarian pathwayBleeding disturbances are common with combination oral contraceptive pills as well as progestin-only methods of birth control However the incidence of bleeding decreases significantly with time Therefore only counseling and reassurance are required during the early months of use Contraceptive intrauterine devices (IUDs) can cause variable vaginal bleeding for the first few cycles after placement and intermittent spotting subsequently The progesterone impregnated IUD (Mirena) is associated with less menometrorrhagia and usually results in secondary amenorrhea
-Causes
AbortionAbruptio PlacentaeAn ovulationAnticoagulantsAntipsychoticMalformationsCervical CancerCervicitisCoagulopathiesCushing SyndromeEndocervical PolypEndometrial CarcinomaEndometrial PolypEndometriosisEstrogen Therapy
-Differential Diagnoses
FibroidsHydatidiform MoleHypothyroidismIntrauterine devicesLiver diseaseMullerian Duct AnomaliesOvarian CystsPelvic Inflammatory DiseasePlacenta PreviaPlatelet Disordersvon Will brand DiseaseVulvovaginitis
When evaluating a woman of reproductive age with vaginal bleeding pregnancy must always be ruled out by urine or serum human chorionic gonadotropinIn a patient with any hemodynamic instability excessive bleeding or clinical evidence of anemia a complete blood count is essentialCoagulation studies should be considered when indicated by the history or physical examination findings and in patients with underlying liver disease or other coagulopathiesIn patients with suspected endocrine disorders other laboratory studies such as thyroid function tests and prolactin levels may be helpful although these results may not be available from the ED (endocrine disorders)
Pelvic ultrasonography is an important imaging modality for non pregnant patients with abnormal vaginal bleeding It may determine the etiology of the bleeding such as a fibroid uterus endometrial thickening or a focal mass
Thickened endometrium may indicate an underlying lesion or excess estrogen and may be suggestive of malignancy
An endometrial stripe measuring less than 4 mm thick is unlikely to have endometrial hyperplasia or cancer and biopsy is often considered unnecessary before treatmentWomen with a normal endometrial stripe (5ndash12 mm) may require biopsy particularly if they have risk factors for endometrial cancerWhen the endometrial stripe is larger than 12 mm a biopsy should be performed6
Imaging Studies
Depending on the urgency to determine the etiology of bleeding and on the reliability of outpatient follow-up ultrasonography may be deferred for outpatient evaluations because for the majority of nonpregnant patients ultrasonographic findings do not immediately affect ED decision-making3
Transvaginal ultrasonography may be particularly helpful in further delineating ovarian cysts and fluid in the cul-de-sacComputed tomography is used primarily for evaluation of other causes of acute abdominal or pelvic painMagnetic resonance imaging is used primarily for cancer staging
ProceduresBefore instituting therapy many consulting gynecologists perform endometrial sampling or biopsy to diagnose intrauterine pathology and to exclude endometrial malignancyEndometrial biopsy is indicated for the following patients with abnormal uterine bleeding6
Women older than 35 yearsObese patientsWomen who have prolonged periods of unopposed estrogen stimulationWomen with chronic an ovulation
Hysteroscopy is the definitive way to detect intrauterine lesions It offers a more complete examination of the surface of the endometrium However it is usually reserved for treating lesions that were detected by other less invasive means
TreatmentEmergency Department CareHemodynamically unstable patients with uncontrolled bleeding and signs of significant blood loss should have aggressive resuscitation with saline and blood as with other types of hemorrhagic shock
Evaluate ABCs and address the prioritiesInitiate 2 large-bore intravenous lines (IVs) oxygen and cardiac monitorIf bleeding is profuse and the patient is unresponsive to initial fluid management consider administration of IV conjugated estrogen (Premarin) 25 mg IV every 4-6 hours until the bleeding stopsIn women with severe persistent uterine bleeding an immediate dilation and curettage (DampC) procedure may be necessary
Treatment contCombination oral contraceptive pills may be used in women who are not pregnant and have no anatomic abnormalities An oral contraceptive with 35 mcg can be taken twice a day until the bleeding stops for up to 7 days at which time the dose is decreased to once a day until the pack is completed They provide the additional benefits of reducing dysmenorrhea and providing contraception Side effects include nausea and vomitingProgesterone alone can be used to stabilize an immature endometrium It is usually successful in the treatment of women with anovulatory dysfunctional uterine bleeding (DUB) because these women have unopposed estrogen stimulation Medroxyprogesterone acetate 10 mg is taken orally once daily for 10 days followed by withdrawal bleeding 3-5 days after completion of the course Currently there is not enough evidence comparing the effect of either progesterone alone or in combination with estrogens for the treatment of dysfunctional uterine bleeding7
Treatment contNo steroidal anti-inflammatory drugs (NSAIDs) are generally effective for the treatment of dysfunctional uterine bleeding and dysmenorrhea NSAIDs inhibiting prostaglandin synthesis and increasing thromboxane A2 levels
This leads to vasoconstriction and increased platelet aggregation These medications may reduce blood loss by 20-50 NSAIDs are most effective if used with the onset of menses or just prior to its onset and continued throughout its durationDanazol creates a hypoestrogenic and hyper androgenic environment which induces endometrial atrophy resulting in reduced menstrual loss Side effects include musculoskeletal pain breast atrophy hirsutism weight gain oily skin and acne Because of the significant androgenic side effects this drug is usually reserved as a second-line treatment for short-term use prior to surgeryGonadotropin-releasing hormone agonists may be helpful for short-term use in inducing amenorrhea and allowing women to rebuild their red blood cell mass They produce a profound hypoestrogenic state similar to menopause Side effects include menopausal symptoms and bone loss with long-term useTranexamic acid is an antifibrinolytic drug that exerts its effects by reversibly inhibiting plasminogen
Treatment contConsultationsSeek an emergency gynecologic consultation for patients requiring hemodynamic stabilization If parenteral therapy does not completely arrest vaginal bleeding in the hemodynamically unstable patient an emergency DampC may be warrantedConsultation with or urgent referral to a gynecologist for surgical treatment may be necessary for patients who do not desire fertility and in whom medical therapy fails Both endometrial ablation and hysterectomy are effective treatments in women with dysfunctional uterine bleeding with comparable patient satisfaction rates
Endometrial ablation is( a medical procedure that is used to remove (ablate) or destroy the endometrial lining of a uterus) may be performed using laser electrocautery or roller ball
Treatment contAmenorrhea is seen in approximately 35 of women treated and decreased flow is seen in another 45 although treatment failures increase with time following the procedure due to endometrial regeneration A substantial number of patients receiving endometrial ablation require reoperation (30 by 48 months)
Hysterectomy is the most effective treatment for bleeding However it is associated with more frequent and severe adverse events compared with either conservative medical or ablation procedures Operating time hospitalization recovery times and costs are also greater Hence hysterectomy is reserved for selected patient populations
MedicationThe goals of pharmacotherapy are to control the bleeding reduce morbidity and prevent complications Steroid hormonesContraceptive pills Medroxyprogesterone acetate (Provera)After acute bleeding episode controlled can be used alone in patients with adequate amounts of endogenous estrogen to cause endometrial growth Progestin therapy in adolescents produces regular cyclic withdrawal bleeding until positive feedback system matures Progestins stop endometrial growth and support and organize endometrium to allow organized sloughing after their withdrawal Bleeding ceases rapidly because of an organized slough to the basalis layer These drugs usually do not stop acute bleeding episodes yet produce a normal bleeding episode following their withdrawal
ComplicationsAnemia (may become severe)Adenocarcinoma of the uterus (if prolonged unopposed estrogen stimulation)PrognosisHormonal contraceptives reduce blood loss by 40-70 when used long termAlthough medical therapy is generally used first over half of women with menorrhagia undergo hysterectomy within 5 years of referral to a gynecologist[2 ]
Patient EducationInstruct patients to continue prescribed medications although bleeding may still be occurring during the early part of the cycle Also patients should be told to expect menses after cessation of the regimenYoung patients with small amounts of irregular bleeding need reassurance and observation only prior to instituting a drug regimen Express to patients that pharmacologic intervention will not be necessary once menstrual cycles become regularDiscuss ways the patient can avoid prolonged emotional stress and maintain a normal body mass indexFor excellent patient education resources visit medicines Womens Health Center
- Dysfunctional uterine bleeding
- Terms frequently used to describeabnormal uterine bleeding
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Treatment
- Treatment cont
- Slide 21
- Slide 22
- Slide 23
- Medication
- Slide 25
- Slide 26
- Slide 27
-
Bleeding episodes become irregular and amenorrhea metrorrhagia and menometrorrhagia are common Bleeding from anovulatory dysfunctional uterine bleeding is thought to result from changes in prostaglandin concentration increased endometrial responsiveness to vasodilating prostaglandins and changes in endometrial vascular structure
-In ovulatory dysfunctional uterine bleeding bleeding occurs cyclically and menorrhagia is thought to originate from defects in the control mechanisms of menstruation It is thought that in women with ovulatory dysfunctional uterine bleeding there is an increased rate of blood loss resulting from vasodilatation of the vessels supplying the endometrium due to decreased vascular tone and prostaglandins have been strongly implicated Therefore these women lose blood at rates about 3 times faster than women with normal menses4
-MortalityMorbidityMorbidity is related to the amount of blood loss at the time of menstruation which occasionally is severe enough to cause hemorrhagic shock Excessive menstrual bleeding accounts for two thirds of all hysterectomies and most endoscopic endometrial destructive surgery Menorrhagia has several adverse effects including anemia and iron deficiency reduced quality of life and increased healthcare costsRaceDysfunctional uterine bleeding has no predilection for race however black women have a higher incidence of leiomyomas and as a result they are prone to experiencing more episodes of abnormal vaginal bleeding-AgeDysfunctional uterine bleeding is most common at the extreme ages of a womans reproductive years either at the beginning or near the end but it may occur at any time during her reproductive life
Most cases of dysfunctional uterine bleeding in adolescent girls occur during the first 2 years after the onset of menstruation when their immature hypothalamic-pituitary axis may fail to respond to estrogen and progesterone resulting in an ovulationAbnormal uterine bleeding affects up to 50 of perimenopausal women In the perimenopausal period dysfunctional uterine bleeding may be an early manifestation of ovarian failure causing decreased hormone levels or responsiveness to hormones thus also leading to anovulatory cycles In patients who are 40 years or older the number and quality of ovarian follicles diminishes Follicles continue to develop but do not produce enough estrogen in response to FSH to trigger ovulation The estrogen that is produced usually results in late-cycle estrogen breakthrough bleeding
-HistoryPatients often present with complaints of amenorrhea menorrhagia metrorrhagia or menometrorrhagia The amount and frequency of bleeding and the duration of symptoms as well as the relationship to the menstrual cycle should be established Ask patients to compare the number of pads or tampons used per day in a normal menstrual cycle to the number used at the time of presentation The average tampon or pad absorbs 20-30 mL or vaginal effluent Personal habits vary greatly among women therefore the number of pads or tampons used is unreliable
A reproductive history should always be obtained including the following Age of menarche and menstrual history and regularityLast menstrual period (LMP) including flow duration and presence of dysmenorrheaPostcoital bleedingGravida and paraPrevious abortion or recent termination of pregnancyContraceptive use use of barrier protection and sexual activity (including vigorous sexual activity or trauma)
History of sexually transmitted diseases (STDs) or ectopic pregnancy
Questions about medical history should include the following Signs and symptoms of anemia or hypovolemia (including fatigue dizziness and syncope)Diabetes mellitusThyroid diseaseEndocrine problems or pituitary tumorsLiver diseaseRecent illness psychological stress excessive exercise or weight changeMedication usage including exogenous hormones anticoagulants aspirin anticonvulsants and antibiotics
An international expert panel including obstetriciangynecologists and hematologists has issued guidelines to assist physicians to better recognize bleeding disorders such as von Will brand disease as a cause of menorrhagia and postpartum hemorrhage and to provide disease-specific therapy for the bleeding disorder5Historically a lack of awareness of underlying bleeding disorders has led to under diagnosis in women with abnormal reproductive tract bleeding The panel provided expert consensus recommendations on how to identify confirm and manage a bleeding disorder If a bleeding disorder is suspected evaluation for a coagulation problem is required and consultation with a hematologist is suggested An underlying bleeding disorder should be considered when a patient has any of the following
Menorrhagia since menarcheFamily history of bleeding disordersPersonal history of 1 or several of the following
Notable bruising without known injuryBleeding of oral cavity or GI tract without obvious lesionEpistaxis gt10 min duration (possibly necessitating packing or cautery)
-Physical1) Vital signs including postural changes should be assessed Initial evaluation should be directed at assessing the patients volume status and degree of anemia Examine for pallor and absence of conjunctival vessels to gauge anemia2) An abdominal examination should be performed Femoral and inguinal lymph nodes should be examined Stool should be evaluated for the presence of blood3) Patients who are hemodynamically stable require a pelvic speculum bimanual and rectovaginal examination to define the etiology of vaginal bleeding A careful physical examination will exclude vaginal or rectal sources of bleeding The examination should look for the following
The vagina should be inspected for signs of trauma lesions infection and foreign bodiesThe cervix should be visualized and inspected for lesions polyps infection or intrauterine device (IUD)Bleeding from the cervical osA rectovaginal examination should be performed to evaluate the cul-de-sac posterior wall of the uterus and uterosacral ligaments
4) Uterine or ovarian structural abnormalities including leiomyoma or fibroid uterus may be noted on bimanual examination5) Patients with hematologic pathology may also have cutaneous evidence of bleeding diathesis Physical findings include petechiae purpura and mucosal bleeding (eg gums) in addition to vaginal bleeding6) Patients with liver disease that has resulted in a coagulopathy may manifest additional symptomatology because of abnormal hepatic function Evaluate patients for spider angioma palmar erythema splenomegaly ascites jaundice7) Women with polycystic ovary disease present with signs of hyperandrogenism including hirsutism obesity acne palpable enlarged ovaries and acanthosis nigricans (hyper pigmentation typically seen in the folds of the skin in the neck groin or axilla)8) Hyperactive and hypoactive thyroid can cause menstrual irregularities Patients may have varying degrees of characteristic vital sign abnormalities eye findings tremors changes in skin texture and weight change Goiter may be present
Systemic disease including thrombocytopenia hypothyroidism hyperthyroidism Cushing disease liver disease diabetes mellitus and adrenal and other endocrine disorders can present as abnormal uterine bleedingPregnancy and pregnancy-related conditions may be associated with vaginal bleedingTrauma to the cervix vulva or vagina may cause abnormal bleedingCarcinomas of the vagina cervix uterus and ovaries must always be considered in patients with the appropriate history and physical examination findings Endometrial cancer is associated with obesity diabetes mellitus anovulatory cycles nulliparity and age older than 35 yearsOther causes of abnormal uterine bleeding include structural disorders such as functional ovarian cystscervicitis endometritis salpingitis leiomyomas and adenomyosis Cervical dysplasia or other genital tract pathology may present as postcoital or irregular bleeding
-Causes
Polycystic ovary disease results in excess estrogen production and commonly presents as abnormal uterine bleedingPrimary coagulation disorders such as von Will brand disease myeloproliferative disorders and immune thrombocytopenia can present with menorrhagiaExcessive exercise stress and weight loss cause hypothalamic suppression leading to abnormal uterine bleeding due to disruption along the hypothalamus-pituitary-ovarian pathwayBleeding disturbances are common with combination oral contraceptive pills as well as progestin-only methods of birth control However the incidence of bleeding decreases significantly with time Therefore only counseling and reassurance are required during the early months of use Contraceptive intrauterine devices (IUDs) can cause variable vaginal bleeding for the first few cycles after placement and intermittent spotting subsequently The progesterone impregnated IUD (Mirena) is associated with less menometrorrhagia and usually results in secondary amenorrhea
-Causes
AbortionAbruptio PlacentaeAn ovulationAnticoagulantsAntipsychoticMalformationsCervical CancerCervicitisCoagulopathiesCushing SyndromeEndocervical PolypEndometrial CarcinomaEndometrial PolypEndometriosisEstrogen Therapy
-Differential Diagnoses
FibroidsHydatidiform MoleHypothyroidismIntrauterine devicesLiver diseaseMullerian Duct AnomaliesOvarian CystsPelvic Inflammatory DiseasePlacenta PreviaPlatelet Disordersvon Will brand DiseaseVulvovaginitis
When evaluating a woman of reproductive age with vaginal bleeding pregnancy must always be ruled out by urine or serum human chorionic gonadotropinIn a patient with any hemodynamic instability excessive bleeding or clinical evidence of anemia a complete blood count is essentialCoagulation studies should be considered when indicated by the history or physical examination findings and in patients with underlying liver disease or other coagulopathiesIn patients with suspected endocrine disorders other laboratory studies such as thyroid function tests and prolactin levels may be helpful although these results may not be available from the ED (endocrine disorders)
Pelvic ultrasonography is an important imaging modality for non pregnant patients with abnormal vaginal bleeding It may determine the etiology of the bleeding such as a fibroid uterus endometrial thickening or a focal mass
Thickened endometrium may indicate an underlying lesion or excess estrogen and may be suggestive of malignancy
An endometrial stripe measuring less than 4 mm thick is unlikely to have endometrial hyperplasia or cancer and biopsy is often considered unnecessary before treatmentWomen with a normal endometrial stripe (5ndash12 mm) may require biopsy particularly if they have risk factors for endometrial cancerWhen the endometrial stripe is larger than 12 mm a biopsy should be performed6
Imaging Studies
Depending on the urgency to determine the etiology of bleeding and on the reliability of outpatient follow-up ultrasonography may be deferred for outpatient evaluations because for the majority of nonpregnant patients ultrasonographic findings do not immediately affect ED decision-making3
Transvaginal ultrasonography may be particularly helpful in further delineating ovarian cysts and fluid in the cul-de-sacComputed tomography is used primarily for evaluation of other causes of acute abdominal or pelvic painMagnetic resonance imaging is used primarily for cancer staging
ProceduresBefore instituting therapy many consulting gynecologists perform endometrial sampling or biopsy to diagnose intrauterine pathology and to exclude endometrial malignancyEndometrial biopsy is indicated for the following patients with abnormal uterine bleeding6
Women older than 35 yearsObese patientsWomen who have prolonged periods of unopposed estrogen stimulationWomen with chronic an ovulation
Hysteroscopy is the definitive way to detect intrauterine lesions It offers a more complete examination of the surface of the endometrium However it is usually reserved for treating lesions that were detected by other less invasive means
TreatmentEmergency Department CareHemodynamically unstable patients with uncontrolled bleeding and signs of significant blood loss should have aggressive resuscitation with saline and blood as with other types of hemorrhagic shock
Evaluate ABCs and address the prioritiesInitiate 2 large-bore intravenous lines (IVs) oxygen and cardiac monitorIf bleeding is profuse and the patient is unresponsive to initial fluid management consider administration of IV conjugated estrogen (Premarin) 25 mg IV every 4-6 hours until the bleeding stopsIn women with severe persistent uterine bleeding an immediate dilation and curettage (DampC) procedure may be necessary
Treatment contCombination oral contraceptive pills may be used in women who are not pregnant and have no anatomic abnormalities An oral contraceptive with 35 mcg can be taken twice a day until the bleeding stops for up to 7 days at which time the dose is decreased to once a day until the pack is completed They provide the additional benefits of reducing dysmenorrhea and providing contraception Side effects include nausea and vomitingProgesterone alone can be used to stabilize an immature endometrium It is usually successful in the treatment of women with anovulatory dysfunctional uterine bleeding (DUB) because these women have unopposed estrogen stimulation Medroxyprogesterone acetate 10 mg is taken orally once daily for 10 days followed by withdrawal bleeding 3-5 days after completion of the course Currently there is not enough evidence comparing the effect of either progesterone alone or in combination with estrogens for the treatment of dysfunctional uterine bleeding7
Treatment contNo steroidal anti-inflammatory drugs (NSAIDs) are generally effective for the treatment of dysfunctional uterine bleeding and dysmenorrhea NSAIDs inhibiting prostaglandin synthesis and increasing thromboxane A2 levels
This leads to vasoconstriction and increased platelet aggregation These medications may reduce blood loss by 20-50 NSAIDs are most effective if used with the onset of menses or just prior to its onset and continued throughout its durationDanazol creates a hypoestrogenic and hyper androgenic environment which induces endometrial atrophy resulting in reduced menstrual loss Side effects include musculoskeletal pain breast atrophy hirsutism weight gain oily skin and acne Because of the significant androgenic side effects this drug is usually reserved as a second-line treatment for short-term use prior to surgeryGonadotropin-releasing hormone agonists may be helpful for short-term use in inducing amenorrhea and allowing women to rebuild their red blood cell mass They produce a profound hypoestrogenic state similar to menopause Side effects include menopausal symptoms and bone loss with long-term useTranexamic acid is an antifibrinolytic drug that exerts its effects by reversibly inhibiting plasminogen
Treatment contConsultationsSeek an emergency gynecologic consultation for patients requiring hemodynamic stabilization If parenteral therapy does not completely arrest vaginal bleeding in the hemodynamically unstable patient an emergency DampC may be warrantedConsultation with or urgent referral to a gynecologist for surgical treatment may be necessary for patients who do not desire fertility and in whom medical therapy fails Both endometrial ablation and hysterectomy are effective treatments in women with dysfunctional uterine bleeding with comparable patient satisfaction rates
Endometrial ablation is( a medical procedure that is used to remove (ablate) or destroy the endometrial lining of a uterus) may be performed using laser electrocautery or roller ball
Treatment contAmenorrhea is seen in approximately 35 of women treated and decreased flow is seen in another 45 although treatment failures increase with time following the procedure due to endometrial regeneration A substantial number of patients receiving endometrial ablation require reoperation (30 by 48 months)
Hysterectomy is the most effective treatment for bleeding However it is associated with more frequent and severe adverse events compared with either conservative medical or ablation procedures Operating time hospitalization recovery times and costs are also greater Hence hysterectomy is reserved for selected patient populations
MedicationThe goals of pharmacotherapy are to control the bleeding reduce morbidity and prevent complications Steroid hormonesContraceptive pills Medroxyprogesterone acetate (Provera)After acute bleeding episode controlled can be used alone in patients with adequate amounts of endogenous estrogen to cause endometrial growth Progestin therapy in adolescents produces regular cyclic withdrawal bleeding until positive feedback system matures Progestins stop endometrial growth and support and organize endometrium to allow organized sloughing after their withdrawal Bleeding ceases rapidly because of an organized slough to the basalis layer These drugs usually do not stop acute bleeding episodes yet produce a normal bleeding episode following their withdrawal
ComplicationsAnemia (may become severe)Adenocarcinoma of the uterus (if prolonged unopposed estrogen stimulation)PrognosisHormonal contraceptives reduce blood loss by 40-70 when used long termAlthough medical therapy is generally used first over half of women with menorrhagia undergo hysterectomy within 5 years of referral to a gynecologist[2 ]
Patient EducationInstruct patients to continue prescribed medications although bleeding may still be occurring during the early part of the cycle Also patients should be told to expect menses after cessation of the regimenYoung patients with small amounts of irregular bleeding need reassurance and observation only prior to instituting a drug regimen Express to patients that pharmacologic intervention will not be necessary once menstrual cycles become regularDiscuss ways the patient can avoid prolonged emotional stress and maintain a normal body mass indexFor excellent patient education resources visit medicines Womens Health Center
- Dysfunctional uterine bleeding
- Terms frequently used to describeabnormal uterine bleeding
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Treatment
- Treatment cont
- Slide 21
- Slide 22
- Slide 23
- Medication
- Slide 25
- Slide 26
- Slide 27
-
-MortalityMorbidityMorbidity is related to the amount of blood loss at the time of menstruation which occasionally is severe enough to cause hemorrhagic shock Excessive menstrual bleeding accounts for two thirds of all hysterectomies and most endoscopic endometrial destructive surgery Menorrhagia has several adverse effects including anemia and iron deficiency reduced quality of life and increased healthcare costsRaceDysfunctional uterine bleeding has no predilection for race however black women have a higher incidence of leiomyomas and as a result they are prone to experiencing more episodes of abnormal vaginal bleeding-AgeDysfunctional uterine bleeding is most common at the extreme ages of a womans reproductive years either at the beginning or near the end but it may occur at any time during her reproductive life
Most cases of dysfunctional uterine bleeding in adolescent girls occur during the first 2 years after the onset of menstruation when their immature hypothalamic-pituitary axis may fail to respond to estrogen and progesterone resulting in an ovulationAbnormal uterine bleeding affects up to 50 of perimenopausal women In the perimenopausal period dysfunctional uterine bleeding may be an early manifestation of ovarian failure causing decreased hormone levels or responsiveness to hormones thus also leading to anovulatory cycles In patients who are 40 years or older the number and quality of ovarian follicles diminishes Follicles continue to develop but do not produce enough estrogen in response to FSH to trigger ovulation The estrogen that is produced usually results in late-cycle estrogen breakthrough bleeding
-HistoryPatients often present with complaints of amenorrhea menorrhagia metrorrhagia or menometrorrhagia The amount and frequency of bleeding and the duration of symptoms as well as the relationship to the menstrual cycle should be established Ask patients to compare the number of pads or tampons used per day in a normal menstrual cycle to the number used at the time of presentation The average tampon or pad absorbs 20-30 mL or vaginal effluent Personal habits vary greatly among women therefore the number of pads or tampons used is unreliable
A reproductive history should always be obtained including the following Age of menarche and menstrual history and regularityLast menstrual period (LMP) including flow duration and presence of dysmenorrheaPostcoital bleedingGravida and paraPrevious abortion or recent termination of pregnancyContraceptive use use of barrier protection and sexual activity (including vigorous sexual activity or trauma)
History of sexually transmitted diseases (STDs) or ectopic pregnancy
Questions about medical history should include the following Signs and symptoms of anemia or hypovolemia (including fatigue dizziness and syncope)Diabetes mellitusThyroid diseaseEndocrine problems or pituitary tumorsLiver diseaseRecent illness psychological stress excessive exercise or weight changeMedication usage including exogenous hormones anticoagulants aspirin anticonvulsants and antibiotics
An international expert panel including obstetriciangynecologists and hematologists has issued guidelines to assist physicians to better recognize bleeding disorders such as von Will brand disease as a cause of menorrhagia and postpartum hemorrhage and to provide disease-specific therapy for the bleeding disorder5Historically a lack of awareness of underlying bleeding disorders has led to under diagnosis in women with abnormal reproductive tract bleeding The panel provided expert consensus recommendations on how to identify confirm and manage a bleeding disorder If a bleeding disorder is suspected evaluation for a coagulation problem is required and consultation with a hematologist is suggested An underlying bleeding disorder should be considered when a patient has any of the following
Menorrhagia since menarcheFamily history of bleeding disordersPersonal history of 1 or several of the following
Notable bruising without known injuryBleeding of oral cavity or GI tract without obvious lesionEpistaxis gt10 min duration (possibly necessitating packing or cautery)
-Physical1) Vital signs including postural changes should be assessed Initial evaluation should be directed at assessing the patients volume status and degree of anemia Examine for pallor and absence of conjunctival vessels to gauge anemia2) An abdominal examination should be performed Femoral and inguinal lymph nodes should be examined Stool should be evaluated for the presence of blood3) Patients who are hemodynamically stable require a pelvic speculum bimanual and rectovaginal examination to define the etiology of vaginal bleeding A careful physical examination will exclude vaginal or rectal sources of bleeding The examination should look for the following
The vagina should be inspected for signs of trauma lesions infection and foreign bodiesThe cervix should be visualized and inspected for lesions polyps infection or intrauterine device (IUD)Bleeding from the cervical osA rectovaginal examination should be performed to evaluate the cul-de-sac posterior wall of the uterus and uterosacral ligaments
4) Uterine or ovarian structural abnormalities including leiomyoma or fibroid uterus may be noted on bimanual examination5) Patients with hematologic pathology may also have cutaneous evidence of bleeding diathesis Physical findings include petechiae purpura and mucosal bleeding (eg gums) in addition to vaginal bleeding6) Patients with liver disease that has resulted in a coagulopathy may manifest additional symptomatology because of abnormal hepatic function Evaluate patients for spider angioma palmar erythema splenomegaly ascites jaundice7) Women with polycystic ovary disease present with signs of hyperandrogenism including hirsutism obesity acne palpable enlarged ovaries and acanthosis nigricans (hyper pigmentation typically seen in the folds of the skin in the neck groin or axilla)8) Hyperactive and hypoactive thyroid can cause menstrual irregularities Patients may have varying degrees of characteristic vital sign abnormalities eye findings tremors changes in skin texture and weight change Goiter may be present
Systemic disease including thrombocytopenia hypothyroidism hyperthyroidism Cushing disease liver disease diabetes mellitus and adrenal and other endocrine disorders can present as abnormal uterine bleedingPregnancy and pregnancy-related conditions may be associated with vaginal bleedingTrauma to the cervix vulva or vagina may cause abnormal bleedingCarcinomas of the vagina cervix uterus and ovaries must always be considered in patients with the appropriate history and physical examination findings Endometrial cancer is associated with obesity diabetes mellitus anovulatory cycles nulliparity and age older than 35 yearsOther causes of abnormal uterine bleeding include structural disorders such as functional ovarian cystscervicitis endometritis salpingitis leiomyomas and adenomyosis Cervical dysplasia or other genital tract pathology may present as postcoital or irregular bleeding
-Causes
Polycystic ovary disease results in excess estrogen production and commonly presents as abnormal uterine bleedingPrimary coagulation disorders such as von Will brand disease myeloproliferative disorders and immune thrombocytopenia can present with menorrhagiaExcessive exercise stress and weight loss cause hypothalamic suppression leading to abnormal uterine bleeding due to disruption along the hypothalamus-pituitary-ovarian pathwayBleeding disturbances are common with combination oral contraceptive pills as well as progestin-only methods of birth control However the incidence of bleeding decreases significantly with time Therefore only counseling and reassurance are required during the early months of use Contraceptive intrauterine devices (IUDs) can cause variable vaginal bleeding for the first few cycles after placement and intermittent spotting subsequently The progesterone impregnated IUD (Mirena) is associated with less menometrorrhagia and usually results in secondary amenorrhea
-Causes
AbortionAbruptio PlacentaeAn ovulationAnticoagulantsAntipsychoticMalformationsCervical CancerCervicitisCoagulopathiesCushing SyndromeEndocervical PolypEndometrial CarcinomaEndometrial PolypEndometriosisEstrogen Therapy
-Differential Diagnoses
FibroidsHydatidiform MoleHypothyroidismIntrauterine devicesLiver diseaseMullerian Duct AnomaliesOvarian CystsPelvic Inflammatory DiseasePlacenta PreviaPlatelet Disordersvon Will brand DiseaseVulvovaginitis
When evaluating a woman of reproductive age with vaginal bleeding pregnancy must always be ruled out by urine or serum human chorionic gonadotropinIn a patient with any hemodynamic instability excessive bleeding or clinical evidence of anemia a complete blood count is essentialCoagulation studies should be considered when indicated by the history or physical examination findings and in patients with underlying liver disease or other coagulopathiesIn patients with suspected endocrine disorders other laboratory studies such as thyroid function tests and prolactin levels may be helpful although these results may not be available from the ED (endocrine disorders)
Pelvic ultrasonography is an important imaging modality for non pregnant patients with abnormal vaginal bleeding It may determine the etiology of the bleeding such as a fibroid uterus endometrial thickening or a focal mass
Thickened endometrium may indicate an underlying lesion or excess estrogen and may be suggestive of malignancy
An endometrial stripe measuring less than 4 mm thick is unlikely to have endometrial hyperplasia or cancer and biopsy is often considered unnecessary before treatmentWomen with a normal endometrial stripe (5ndash12 mm) may require biopsy particularly if they have risk factors for endometrial cancerWhen the endometrial stripe is larger than 12 mm a biopsy should be performed6
Imaging Studies
Depending on the urgency to determine the etiology of bleeding and on the reliability of outpatient follow-up ultrasonography may be deferred for outpatient evaluations because for the majority of nonpregnant patients ultrasonographic findings do not immediately affect ED decision-making3
Transvaginal ultrasonography may be particularly helpful in further delineating ovarian cysts and fluid in the cul-de-sacComputed tomography is used primarily for evaluation of other causes of acute abdominal or pelvic painMagnetic resonance imaging is used primarily for cancer staging
ProceduresBefore instituting therapy many consulting gynecologists perform endometrial sampling or biopsy to diagnose intrauterine pathology and to exclude endometrial malignancyEndometrial biopsy is indicated for the following patients with abnormal uterine bleeding6
Women older than 35 yearsObese patientsWomen who have prolonged periods of unopposed estrogen stimulationWomen with chronic an ovulation
Hysteroscopy is the definitive way to detect intrauterine lesions It offers a more complete examination of the surface of the endometrium However it is usually reserved for treating lesions that were detected by other less invasive means
TreatmentEmergency Department CareHemodynamically unstable patients with uncontrolled bleeding and signs of significant blood loss should have aggressive resuscitation with saline and blood as with other types of hemorrhagic shock
Evaluate ABCs and address the prioritiesInitiate 2 large-bore intravenous lines (IVs) oxygen and cardiac monitorIf bleeding is profuse and the patient is unresponsive to initial fluid management consider administration of IV conjugated estrogen (Premarin) 25 mg IV every 4-6 hours until the bleeding stopsIn women with severe persistent uterine bleeding an immediate dilation and curettage (DampC) procedure may be necessary
Treatment contCombination oral contraceptive pills may be used in women who are not pregnant and have no anatomic abnormalities An oral contraceptive with 35 mcg can be taken twice a day until the bleeding stops for up to 7 days at which time the dose is decreased to once a day until the pack is completed They provide the additional benefits of reducing dysmenorrhea and providing contraception Side effects include nausea and vomitingProgesterone alone can be used to stabilize an immature endometrium It is usually successful in the treatment of women with anovulatory dysfunctional uterine bleeding (DUB) because these women have unopposed estrogen stimulation Medroxyprogesterone acetate 10 mg is taken orally once daily for 10 days followed by withdrawal bleeding 3-5 days after completion of the course Currently there is not enough evidence comparing the effect of either progesterone alone or in combination with estrogens for the treatment of dysfunctional uterine bleeding7
Treatment contNo steroidal anti-inflammatory drugs (NSAIDs) are generally effective for the treatment of dysfunctional uterine bleeding and dysmenorrhea NSAIDs inhibiting prostaglandin synthesis and increasing thromboxane A2 levels
This leads to vasoconstriction and increased platelet aggregation These medications may reduce blood loss by 20-50 NSAIDs are most effective if used with the onset of menses or just prior to its onset and continued throughout its durationDanazol creates a hypoestrogenic and hyper androgenic environment which induces endometrial atrophy resulting in reduced menstrual loss Side effects include musculoskeletal pain breast atrophy hirsutism weight gain oily skin and acne Because of the significant androgenic side effects this drug is usually reserved as a second-line treatment for short-term use prior to surgeryGonadotropin-releasing hormone agonists may be helpful for short-term use in inducing amenorrhea and allowing women to rebuild their red blood cell mass They produce a profound hypoestrogenic state similar to menopause Side effects include menopausal symptoms and bone loss with long-term useTranexamic acid is an antifibrinolytic drug that exerts its effects by reversibly inhibiting plasminogen
Treatment contConsultationsSeek an emergency gynecologic consultation for patients requiring hemodynamic stabilization If parenteral therapy does not completely arrest vaginal bleeding in the hemodynamically unstable patient an emergency DampC may be warrantedConsultation with or urgent referral to a gynecologist for surgical treatment may be necessary for patients who do not desire fertility and in whom medical therapy fails Both endometrial ablation and hysterectomy are effective treatments in women with dysfunctional uterine bleeding with comparable patient satisfaction rates
Endometrial ablation is( a medical procedure that is used to remove (ablate) or destroy the endometrial lining of a uterus) may be performed using laser electrocautery or roller ball
Treatment contAmenorrhea is seen in approximately 35 of women treated and decreased flow is seen in another 45 although treatment failures increase with time following the procedure due to endometrial regeneration A substantial number of patients receiving endometrial ablation require reoperation (30 by 48 months)
Hysterectomy is the most effective treatment for bleeding However it is associated with more frequent and severe adverse events compared with either conservative medical or ablation procedures Operating time hospitalization recovery times and costs are also greater Hence hysterectomy is reserved for selected patient populations
MedicationThe goals of pharmacotherapy are to control the bleeding reduce morbidity and prevent complications Steroid hormonesContraceptive pills Medroxyprogesterone acetate (Provera)After acute bleeding episode controlled can be used alone in patients with adequate amounts of endogenous estrogen to cause endometrial growth Progestin therapy in adolescents produces regular cyclic withdrawal bleeding until positive feedback system matures Progestins stop endometrial growth and support and organize endometrium to allow organized sloughing after their withdrawal Bleeding ceases rapidly because of an organized slough to the basalis layer These drugs usually do not stop acute bleeding episodes yet produce a normal bleeding episode following their withdrawal
ComplicationsAnemia (may become severe)Adenocarcinoma of the uterus (if prolonged unopposed estrogen stimulation)PrognosisHormonal contraceptives reduce blood loss by 40-70 when used long termAlthough medical therapy is generally used first over half of women with menorrhagia undergo hysterectomy within 5 years of referral to a gynecologist[2 ]
Patient EducationInstruct patients to continue prescribed medications although bleeding may still be occurring during the early part of the cycle Also patients should be told to expect menses after cessation of the regimenYoung patients with small amounts of irregular bleeding need reassurance and observation only prior to instituting a drug regimen Express to patients that pharmacologic intervention will not be necessary once menstrual cycles become regularDiscuss ways the patient can avoid prolonged emotional stress and maintain a normal body mass indexFor excellent patient education resources visit medicines Womens Health Center
- Dysfunctional uterine bleeding
- Terms frequently used to describeabnormal uterine bleeding
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Treatment
- Treatment cont
- Slide 21
- Slide 22
- Slide 23
- Medication
- Slide 25
- Slide 26
- Slide 27
-
Most cases of dysfunctional uterine bleeding in adolescent girls occur during the first 2 years after the onset of menstruation when their immature hypothalamic-pituitary axis may fail to respond to estrogen and progesterone resulting in an ovulationAbnormal uterine bleeding affects up to 50 of perimenopausal women In the perimenopausal period dysfunctional uterine bleeding may be an early manifestation of ovarian failure causing decreased hormone levels or responsiveness to hormones thus also leading to anovulatory cycles In patients who are 40 years or older the number and quality of ovarian follicles diminishes Follicles continue to develop but do not produce enough estrogen in response to FSH to trigger ovulation The estrogen that is produced usually results in late-cycle estrogen breakthrough bleeding
-HistoryPatients often present with complaints of amenorrhea menorrhagia metrorrhagia or menometrorrhagia The amount and frequency of bleeding and the duration of symptoms as well as the relationship to the menstrual cycle should be established Ask patients to compare the number of pads or tampons used per day in a normal menstrual cycle to the number used at the time of presentation The average tampon or pad absorbs 20-30 mL or vaginal effluent Personal habits vary greatly among women therefore the number of pads or tampons used is unreliable
A reproductive history should always be obtained including the following Age of menarche and menstrual history and regularityLast menstrual period (LMP) including flow duration and presence of dysmenorrheaPostcoital bleedingGravida and paraPrevious abortion or recent termination of pregnancyContraceptive use use of barrier protection and sexual activity (including vigorous sexual activity or trauma)
History of sexually transmitted diseases (STDs) or ectopic pregnancy
Questions about medical history should include the following Signs and symptoms of anemia or hypovolemia (including fatigue dizziness and syncope)Diabetes mellitusThyroid diseaseEndocrine problems or pituitary tumorsLiver diseaseRecent illness psychological stress excessive exercise or weight changeMedication usage including exogenous hormones anticoagulants aspirin anticonvulsants and antibiotics
An international expert panel including obstetriciangynecologists and hematologists has issued guidelines to assist physicians to better recognize bleeding disorders such as von Will brand disease as a cause of menorrhagia and postpartum hemorrhage and to provide disease-specific therapy for the bleeding disorder5Historically a lack of awareness of underlying bleeding disorders has led to under diagnosis in women with abnormal reproductive tract bleeding The panel provided expert consensus recommendations on how to identify confirm and manage a bleeding disorder If a bleeding disorder is suspected evaluation for a coagulation problem is required and consultation with a hematologist is suggested An underlying bleeding disorder should be considered when a patient has any of the following
Menorrhagia since menarcheFamily history of bleeding disordersPersonal history of 1 or several of the following
Notable bruising without known injuryBleeding of oral cavity or GI tract without obvious lesionEpistaxis gt10 min duration (possibly necessitating packing or cautery)
-Physical1) Vital signs including postural changes should be assessed Initial evaluation should be directed at assessing the patients volume status and degree of anemia Examine for pallor and absence of conjunctival vessels to gauge anemia2) An abdominal examination should be performed Femoral and inguinal lymph nodes should be examined Stool should be evaluated for the presence of blood3) Patients who are hemodynamically stable require a pelvic speculum bimanual and rectovaginal examination to define the etiology of vaginal bleeding A careful physical examination will exclude vaginal or rectal sources of bleeding The examination should look for the following
The vagina should be inspected for signs of trauma lesions infection and foreign bodiesThe cervix should be visualized and inspected for lesions polyps infection or intrauterine device (IUD)Bleeding from the cervical osA rectovaginal examination should be performed to evaluate the cul-de-sac posterior wall of the uterus and uterosacral ligaments
4) Uterine or ovarian structural abnormalities including leiomyoma or fibroid uterus may be noted on bimanual examination5) Patients with hematologic pathology may also have cutaneous evidence of bleeding diathesis Physical findings include petechiae purpura and mucosal bleeding (eg gums) in addition to vaginal bleeding6) Patients with liver disease that has resulted in a coagulopathy may manifest additional symptomatology because of abnormal hepatic function Evaluate patients for spider angioma palmar erythema splenomegaly ascites jaundice7) Women with polycystic ovary disease present with signs of hyperandrogenism including hirsutism obesity acne palpable enlarged ovaries and acanthosis nigricans (hyper pigmentation typically seen in the folds of the skin in the neck groin or axilla)8) Hyperactive and hypoactive thyroid can cause menstrual irregularities Patients may have varying degrees of characteristic vital sign abnormalities eye findings tremors changes in skin texture and weight change Goiter may be present
Systemic disease including thrombocytopenia hypothyroidism hyperthyroidism Cushing disease liver disease diabetes mellitus and adrenal and other endocrine disorders can present as abnormal uterine bleedingPregnancy and pregnancy-related conditions may be associated with vaginal bleedingTrauma to the cervix vulva or vagina may cause abnormal bleedingCarcinomas of the vagina cervix uterus and ovaries must always be considered in patients with the appropriate history and physical examination findings Endometrial cancer is associated with obesity diabetes mellitus anovulatory cycles nulliparity and age older than 35 yearsOther causes of abnormal uterine bleeding include structural disorders such as functional ovarian cystscervicitis endometritis salpingitis leiomyomas and adenomyosis Cervical dysplasia or other genital tract pathology may present as postcoital or irregular bleeding
-Causes
Polycystic ovary disease results in excess estrogen production and commonly presents as abnormal uterine bleedingPrimary coagulation disorders such as von Will brand disease myeloproliferative disorders and immune thrombocytopenia can present with menorrhagiaExcessive exercise stress and weight loss cause hypothalamic suppression leading to abnormal uterine bleeding due to disruption along the hypothalamus-pituitary-ovarian pathwayBleeding disturbances are common with combination oral contraceptive pills as well as progestin-only methods of birth control However the incidence of bleeding decreases significantly with time Therefore only counseling and reassurance are required during the early months of use Contraceptive intrauterine devices (IUDs) can cause variable vaginal bleeding for the first few cycles after placement and intermittent spotting subsequently The progesterone impregnated IUD (Mirena) is associated with less menometrorrhagia and usually results in secondary amenorrhea
-Causes
AbortionAbruptio PlacentaeAn ovulationAnticoagulantsAntipsychoticMalformationsCervical CancerCervicitisCoagulopathiesCushing SyndromeEndocervical PolypEndometrial CarcinomaEndometrial PolypEndometriosisEstrogen Therapy
-Differential Diagnoses
FibroidsHydatidiform MoleHypothyroidismIntrauterine devicesLiver diseaseMullerian Duct AnomaliesOvarian CystsPelvic Inflammatory DiseasePlacenta PreviaPlatelet Disordersvon Will brand DiseaseVulvovaginitis
When evaluating a woman of reproductive age with vaginal bleeding pregnancy must always be ruled out by urine or serum human chorionic gonadotropinIn a patient with any hemodynamic instability excessive bleeding or clinical evidence of anemia a complete blood count is essentialCoagulation studies should be considered when indicated by the history or physical examination findings and in patients with underlying liver disease or other coagulopathiesIn patients with suspected endocrine disorders other laboratory studies such as thyroid function tests and prolactin levels may be helpful although these results may not be available from the ED (endocrine disorders)
Pelvic ultrasonography is an important imaging modality for non pregnant patients with abnormal vaginal bleeding It may determine the etiology of the bleeding such as a fibroid uterus endometrial thickening or a focal mass
Thickened endometrium may indicate an underlying lesion or excess estrogen and may be suggestive of malignancy
An endometrial stripe measuring less than 4 mm thick is unlikely to have endometrial hyperplasia or cancer and biopsy is often considered unnecessary before treatmentWomen with a normal endometrial stripe (5ndash12 mm) may require biopsy particularly if they have risk factors for endometrial cancerWhen the endometrial stripe is larger than 12 mm a biopsy should be performed6
Imaging Studies
Depending on the urgency to determine the etiology of bleeding and on the reliability of outpatient follow-up ultrasonography may be deferred for outpatient evaluations because for the majority of nonpregnant patients ultrasonographic findings do not immediately affect ED decision-making3
Transvaginal ultrasonography may be particularly helpful in further delineating ovarian cysts and fluid in the cul-de-sacComputed tomography is used primarily for evaluation of other causes of acute abdominal or pelvic painMagnetic resonance imaging is used primarily for cancer staging
ProceduresBefore instituting therapy many consulting gynecologists perform endometrial sampling or biopsy to diagnose intrauterine pathology and to exclude endometrial malignancyEndometrial biopsy is indicated for the following patients with abnormal uterine bleeding6
Women older than 35 yearsObese patientsWomen who have prolonged periods of unopposed estrogen stimulationWomen with chronic an ovulation
Hysteroscopy is the definitive way to detect intrauterine lesions It offers a more complete examination of the surface of the endometrium However it is usually reserved for treating lesions that were detected by other less invasive means
TreatmentEmergency Department CareHemodynamically unstable patients with uncontrolled bleeding and signs of significant blood loss should have aggressive resuscitation with saline and blood as with other types of hemorrhagic shock
Evaluate ABCs and address the prioritiesInitiate 2 large-bore intravenous lines (IVs) oxygen and cardiac monitorIf bleeding is profuse and the patient is unresponsive to initial fluid management consider administration of IV conjugated estrogen (Premarin) 25 mg IV every 4-6 hours until the bleeding stopsIn women with severe persistent uterine bleeding an immediate dilation and curettage (DampC) procedure may be necessary
Treatment contCombination oral contraceptive pills may be used in women who are not pregnant and have no anatomic abnormalities An oral contraceptive with 35 mcg can be taken twice a day until the bleeding stops for up to 7 days at which time the dose is decreased to once a day until the pack is completed They provide the additional benefits of reducing dysmenorrhea and providing contraception Side effects include nausea and vomitingProgesterone alone can be used to stabilize an immature endometrium It is usually successful in the treatment of women with anovulatory dysfunctional uterine bleeding (DUB) because these women have unopposed estrogen stimulation Medroxyprogesterone acetate 10 mg is taken orally once daily for 10 days followed by withdrawal bleeding 3-5 days after completion of the course Currently there is not enough evidence comparing the effect of either progesterone alone or in combination with estrogens for the treatment of dysfunctional uterine bleeding7
Treatment contNo steroidal anti-inflammatory drugs (NSAIDs) are generally effective for the treatment of dysfunctional uterine bleeding and dysmenorrhea NSAIDs inhibiting prostaglandin synthesis and increasing thromboxane A2 levels
This leads to vasoconstriction and increased platelet aggregation These medications may reduce blood loss by 20-50 NSAIDs are most effective if used with the onset of menses or just prior to its onset and continued throughout its durationDanazol creates a hypoestrogenic and hyper androgenic environment which induces endometrial atrophy resulting in reduced menstrual loss Side effects include musculoskeletal pain breast atrophy hirsutism weight gain oily skin and acne Because of the significant androgenic side effects this drug is usually reserved as a second-line treatment for short-term use prior to surgeryGonadotropin-releasing hormone agonists may be helpful for short-term use in inducing amenorrhea and allowing women to rebuild their red blood cell mass They produce a profound hypoestrogenic state similar to menopause Side effects include menopausal symptoms and bone loss with long-term useTranexamic acid is an antifibrinolytic drug that exerts its effects by reversibly inhibiting plasminogen
Treatment contConsultationsSeek an emergency gynecologic consultation for patients requiring hemodynamic stabilization If parenteral therapy does not completely arrest vaginal bleeding in the hemodynamically unstable patient an emergency DampC may be warrantedConsultation with or urgent referral to a gynecologist for surgical treatment may be necessary for patients who do not desire fertility and in whom medical therapy fails Both endometrial ablation and hysterectomy are effective treatments in women with dysfunctional uterine bleeding with comparable patient satisfaction rates
Endometrial ablation is( a medical procedure that is used to remove (ablate) or destroy the endometrial lining of a uterus) may be performed using laser electrocautery or roller ball
Treatment contAmenorrhea is seen in approximately 35 of women treated and decreased flow is seen in another 45 although treatment failures increase with time following the procedure due to endometrial regeneration A substantial number of patients receiving endometrial ablation require reoperation (30 by 48 months)
Hysterectomy is the most effective treatment for bleeding However it is associated with more frequent and severe adverse events compared with either conservative medical or ablation procedures Operating time hospitalization recovery times and costs are also greater Hence hysterectomy is reserved for selected patient populations
MedicationThe goals of pharmacotherapy are to control the bleeding reduce morbidity and prevent complications Steroid hormonesContraceptive pills Medroxyprogesterone acetate (Provera)After acute bleeding episode controlled can be used alone in patients with adequate amounts of endogenous estrogen to cause endometrial growth Progestin therapy in adolescents produces regular cyclic withdrawal bleeding until positive feedback system matures Progestins stop endometrial growth and support and organize endometrium to allow organized sloughing after their withdrawal Bleeding ceases rapidly because of an organized slough to the basalis layer These drugs usually do not stop acute bleeding episodes yet produce a normal bleeding episode following their withdrawal
ComplicationsAnemia (may become severe)Adenocarcinoma of the uterus (if prolonged unopposed estrogen stimulation)PrognosisHormonal contraceptives reduce blood loss by 40-70 when used long termAlthough medical therapy is generally used first over half of women with menorrhagia undergo hysterectomy within 5 years of referral to a gynecologist[2 ]
Patient EducationInstruct patients to continue prescribed medications although bleeding may still be occurring during the early part of the cycle Also patients should be told to expect menses after cessation of the regimenYoung patients with small amounts of irregular bleeding need reassurance and observation only prior to instituting a drug regimen Express to patients that pharmacologic intervention will not be necessary once menstrual cycles become regularDiscuss ways the patient can avoid prolonged emotional stress and maintain a normal body mass indexFor excellent patient education resources visit medicines Womens Health Center
- Dysfunctional uterine bleeding
- Terms frequently used to describeabnormal uterine bleeding
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Treatment
- Treatment cont
- Slide 21
- Slide 22
- Slide 23
- Medication
- Slide 25
- Slide 26
- Slide 27
-
-HistoryPatients often present with complaints of amenorrhea menorrhagia metrorrhagia or menometrorrhagia The amount and frequency of bleeding and the duration of symptoms as well as the relationship to the menstrual cycle should be established Ask patients to compare the number of pads or tampons used per day in a normal menstrual cycle to the number used at the time of presentation The average tampon or pad absorbs 20-30 mL or vaginal effluent Personal habits vary greatly among women therefore the number of pads or tampons used is unreliable
A reproductive history should always be obtained including the following Age of menarche and menstrual history and regularityLast menstrual period (LMP) including flow duration and presence of dysmenorrheaPostcoital bleedingGravida and paraPrevious abortion or recent termination of pregnancyContraceptive use use of barrier protection and sexual activity (including vigorous sexual activity or trauma)
History of sexually transmitted diseases (STDs) or ectopic pregnancy
Questions about medical history should include the following Signs and symptoms of anemia or hypovolemia (including fatigue dizziness and syncope)Diabetes mellitusThyroid diseaseEndocrine problems or pituitary tumorsLiver diseaseRecent illness psychological stress excessive exercise or weight changeMedication usage including exogenous hormones anticoagulants aspirin anticonvulsants and antibiotics
An international expert panel including obstetriciangynecologists and hematologists has issued guidelines to assist physicians to better recognize bleeding disorders such as von Will brand disease as a cause of menorrhagia and postpartum hemorrhage and to provide disease-specific therapy for the bleeding disorder5Historically a lack of awareness of underlying bleeding disorders has led to under diagnosis in women with abnormal reproductive tract bleeding The panel provided expert consensus recommendations on how to identify confirm and manage a bleeding disorder If a bleeding disorder is suspected evaluation for a coagulation problem is required and consultation with a hematologist is suggested An underlying bleeding disorder should be considered when a patient has any of the following
Menorrhagia since menarcheFamily history of bleeding disordersPersonal history of 1 or several of the following
Notable bruising without known injuryBleeding of oral cavity or GI tract without obvious lesionEpistaxis gt10 min duration (possibly necessitating packing or cautery)
-Physical1) Vital signs including postural changes should be assessed Initial evaluation should be directed at assessing the patients volume status and degree of anemia Examine for pallor and absence of conjunctival vessels to gauge anemia2) An abdominal examination should be performed Femoral and inguinal lymph nodes should be examined Stool should be evaluated for the presence of blood3) Patients who are hemodynamically stable require a pelvic speculum bimanual and rectovaginal examination to define the etiology of vaginal bleeding A careful physical examination will exclude vaginal or rectal sources of bleeding The examination should look for the following
The vagina should be inspected for signs of trauma lesions infection and foreign bodiesThe cervix should be visualized and inspected for lesions polyps infection or intrauterine device (IUD)Bleeding from the cervical osA rectovaginal examination should be performed to evaluate the cul-de-sac posterior wall of the uterus and uterosacral ligaments
4) Uterine or ovarian structural abnormalities including leiomyoma or fibroid uterus may be noted on bimanual examination5) Patients with hematologic pathology may also have cutaneous evidence of bleeding diathesis Physical findings include petechiae purpura and mucosal bleeding (eg gums) in addition to vaginal bleeding6) Patients with liver disease that has resulted in a coagulopathy may manifest additional symptomatology because of abnormal hepatic function Evaluate patients for spider angioma palmar erythema splenomegaly ascites jaundice7) Women with polycystic ovary disease present with signs of hyperandrogenism including hirsutism obesity acne palpable enlarged ovaries and acanthosis nigricans (hyper pigmentation typically seen in the folds of the skin in the neck groin or axilla)8) Hyperactive and hypoactive thyroid can cause menstrual irregularities Patients may have varying degrees of characteristic vital sign abnormalities eye findings tremors changes in skin texture and weight change Goiter may be present
Systemic disease including thrombocytopenia hypothyroidism hyperthyroidism Cushing disease liver disease diabetes mellitus and adrenal and other endocrine disorders can present as abnormal uterine bleedingPregnancy and pregnancy-related conditions may be associated with vaginal bleedingTrauma to the cervix vulva or vagina may cause abnormal bleedingCarcinomas of the vagina cervix uterus and ovaries must always be considered in patients with the appropriate history and physical examination findings Endometrial cancer is associated with obesity diabetes mellitus anovulatory cycles nulliparity and age older than 35 yearsOther causes of abnormal uterine bleeding include structural disorders such as functional ovarian cystscervicitis endometritis salpingitis leiomyomas and adenomyosis Cervical dysplasia or other genital tract pathology may present as postcoital or irregular bleeding
-Causes
Polycystic ovary disease results in excess estrogen production and commonly presents as abnormal uterine bleedingPrimary coagulation disorders such as von Will brand disease myeloproliferative disorders and immune thrombocytopenia can present with menorrhagiaExcessive exercise stress and weight loss cause hypothalamic suppression leading to abnormal uterine bleeding due to disruption along the hypothalamus-pituitary-ovarian pathwayBleeding disturbances are common with combination oral contraceptive pills as well as progestin-only methods of birth control However the incidence of bleeding decreases significantly with time Therefore only counseling and reassurance are required during the early months of use Contraceptive intrauterine devices (IUDs) can cause variable vaginal bleeding for the first few cycles after placement and intermittent spotting subsequently The progesterone impregnated IUD (Mirena) is associated with less menometrorrhagia and usually results in secondary amenorrhea
-Causes
AbortionAbruptio PlacentaeAn ovulationAnticoagulantsAntipsychoticMalformationsCervical CancerCervicitisCoagulopathiesCushing SyndromeEndocervical PolypEndometrial CarcinomaEndometrial PolypEndometriosisEstrogen Therapy
-Differential Diagnoses
FibroidsHydatidiform MoleHypothyroidismIntrauterine devicesLiver diseaseMullerian Duct AnomaliesOvarian CystsPelvic Inflammatory DiseasePlacenta PreviaPlatelet Disordersvon Will brand DiseaseVulvovaginitis
When evaluating a woman of reproductive age with vaginal bleeding pregnancy must always be ruled out by urine or serum human chorionic gonadotropinIn a patient with any hemodynamic instability excessive bleeding or clinical evidence of anemia a complete blood count is essentialCoagulation studies should be considered when indicated by the history or physical examination findings and in patients with underlying liver disease or other coagulopathiesIn patients with suspected endocrine disorders other laboratory studies such as thyroid function tests and prolactin levels may be helpful although these results may not be available from the ED (endocrine disorders)
Pelvic ultrasonography is an important imaging modality for non pregnant patients with abnormal vaginal bleeding It may determine the etiology of the bleeding such as a fibroid uterus endometrial thickening or a focal mass
Thickened endometrium may indicate an underlying lesion or excess estrogen and may be suggestive of malignancy
An endometrial stripe measuring less than 4 mm thick is unlikely to have endometrial hyperplasia or cancer and biopsy is often considered unnecessary before treatmentWomen with a normal endometrial stripe (5ndash12 mm) may require biopsy particularly if they have risk factors for endometrial cancerWhen the endometrial stripe is larger than 12 mm a biopsy should be performed6
Imaging Studies
Depending on the urgency to determine the etiology of bleeding and on the reliability of outpatient follow-up ultrasonography may be deferred for outpatient evaluations because for the majority of nonpregnant patients ultrasonographic findings do not immediately affect ED decision-making3
Transvaginal ultrasonography may be particularly helpful in further delineating ovarian cysts and fluid in the cul-de-sacComputed tomography is used primarily for evaluation of other causes of acute abdominal or pelvic painMagnetic resonance imaging is used primarily for cancer staging
ProceduresBefore instituting therapy many consulting gynecologists perform endometrial sampling or biopsy to diagnose intrauterine pathology and to exclude endometrial malignancyEndometrial biopsy is indicated for the following patients with abnormal uterine bleeding6
Women older than 35 yearsObese patientsWomen who have prolonged periods of unopposed estrogen stimulationWomen with chronic an ovulation
Hysteroscopy is the definitive way to detect intrauterine lesions It offers a more complete examination of the surface of the endometrium However it is usually reserved for treating lesions that were detected by other less invasive means
TreatmentEmergency Department CareHemodynamically unstable patients with uncontrolled bleeding and signs of significant blood loss should have aggressive resuscitation with saline and blood as with other types of hemorrhagic shock
Evaluate ABCs and address the prioritiesInitiate 2 large-bore intravenous lines (IVs) oxygen and cardiac monitorIf bleeding is profuse and the patient is unresponsive to initial fluid management consider administration of IV conjugated estrogen (Premarin) 25 mg IV every 4-6 hours until the bleeding stopsIn women with severe persistent uterine bleeding an immediate dilation and curettage (DampC) procedure may be necessary
Treatment contCombination oral contraceptive pills may be used in women who are not pregnant and have no anatomic abnormalities An oral contraceptive with 35 mcg can be taken twice a day until the bleeding stops for up to 7 days at which time the dose is decreased to once a day until the pack is completed They provide the additional benefits of reducing dysmenorrhea and providing contraception Side effects include nausea and vomitingProgesterone alone can be used to stabilize an immature endometrium It is usually successful in the treatment of women with anovulatory dysfunctional uterine bleeding (DUB) because these women have unopposed estrogen stimulation Medroxyprogesterone acetate 10 mg is taken orally once daily for 10 days followed by withdrawal bleeding 3-5 days after completion of the course Currently there is not enough evidence comparing the effect of either progesterone alone or in combination with estrogens for the treatment of dysfunctional uterine bleeding7
Treatment contNo steroidal anti-inflammatory drugs (NSAIDs) are generally effective for the treatment of dysfunctional uterine bleeding and dysmenorrhea NSAIDs inhibiting prostaglandin synthesis and increasing thromboxane A2 levels
This leads to vasoconstriction and increased platelet aggregation These medications may reduce blood loss by 20-50 NSAIDs are most effective if used with the onset of menses or just prior to its onset and continued throughout its durationDanazol creates a hypoestrogenic and hyper androgenic environment which induces endometrial atrophy resulting in reduced menstrual loss Side effects include musculoskeletal pain breast atrophy hirsutism weight gain oily skin and acne Because of the significant androgenic side effects this drug is usually reserved as a second-line treatment for short-term use prior to surgeryGonadotropin-releasing hormone agonists may be helpful for short-term use in inducing amenorrhea and allowing women to rebuild their red blood cell mass They produce a profound hypoestrogenic state similar to menopause Side effects include menopausal symptoms and bone loss with long-term useTranexamic acid is an antifibrinolytic drug that exerts its effects by reversibly inhibiting plasminogen
Treatment contConsultationsSeek an emergency gynecologic consultation for patients requiring hemodynamic stabilization If parenteral therapy does not completely arrest vaginal bleeding in the hemodynamically unstable patient an emergency DampC may be warrantedConsultation with or urgent referral to a gynecologist for surgical treatment may be necessary for patients who do not desire fertility and in whom medical therapy fails Both endometrial ablation and hysterectomy are effective treatments in women with dysfunctional uterine bleeding with comparable patient satisfaction rates
Endometrial ablation is( a medical procedure that is used to remove (ablate) or destroy the endometrial lining of a uterus) may be performed using laser electrocautery or roller ball
Treatment contAmenorrhea is seen in approximately 35 of women treated and decreased flow is seen in another 45 although treatment failures increase with time following the procedure due to endometrial regeneration A substantial number of patients receiving endometrial ablation require reoperation (30 by 48 months)
Hysterectomy is the most effective treatment for bleeding However it is associated with more frequent and severe adverse events compared with either conservative medical or ablation procedures Operating time hospitalization recovery times and costs are also greater Hence hysterectomy is reserved for selected patient populations
MedicationThe goals of pharmacotherapy are to control the bleeding reduce morbidity and prevent complications Steroid hormonesContraceptive pills Medroxyprogesterone acetate (Provera)After acute bleeding episode controlled can be used alone in patients with adequate amounts of endogenous estrogen to cause endometrial growth Progestin therapy in adolescents produces regular cyclic withdrawal bleeding until positive feedback system matures Progestins stop endometrial growth and support and organize endometrium to allow organized sloughing after their withdrawal Bleeding ceases rapidly because of an organized slough to the basalis layer These drugs usually do not stop acute bleeding episodes yet produce a normal bleeding episode following their withdrawal
ComplicationsAnemia (may become severe)Adenocarcinoma of the uterus (if prolonged unopposed estrogen stimulation)PrognosisHormonal contraceptives reduce blood loss by 40-70 when used long termAlthough medical therapy is generally used first over half of women with menorrhagia undergo hysterectomy within 5 years of referral to a gynecologist[2 ]
Patient EducationInstruct patients to continue prescribed medications although bleeding may still be occurring during the early part of the cycle Also patients should be told to expect menses after cessation of the regimenYoung patients with small amounts of irregular bleeding need reassurance and observation only prior to instituting a drug regimen Express to patients that pharmacologic intervention will not be necessary once menstrual cycles become regularDiscuss ways the patient can avoid prolonged emotional stress and maintain a normal body mass indexFor excellent patient education resources visit medicines Womens Health Center
- Dysfunctional uterine bleeding
- Terms frequently used to describeabnormal uterine bleeding
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Treatment
- Treatment cont
- Slide 21
- Slide 22
- Slide 23
- Medication
- Slide 25
- Slide 26
- Slide 27
-
A reproductive history should always be obtained including the following Age of menarche and menstrual history and regularityLast menstrual period (LMP) including flow duration and presence of dysmenorrheaPostcoital bleedingGravida and paraPrevious abortion or recent termination of pregnancyContraceptive use use of barrier protection and sexual activity (including vigorous sexual activity or trauma)
History of sexually transmitted diseases (STDs) or ectopic pregnancy
Questions about medical history should include the following Signs and symptoms of anemia or hypovolemia (including fatigue dizziness and syncope)Diabetes mellitusThyroid diseaseEndocrine problems or pituitary tumorsLiver diseaseRecent illness psychological stress excessive exercise or weight changeMedication usage including exogenous hormones anticoagulants aspirin anticonvulsants and antibiotics
An international expert panel including obstetriciangynecologists and hematologists has issued guidelines to assist physicians to better recognize bleeding disorders such as von Will brand disease as a cause of menorrhagia and postpartum hemorrhage and to provide disease-specific therapy for the bleeding disorder5Historically a lack of awareness of underlying bleeding disorders has led to under diagnosis in women with abnormal reproductive tract bleeding The panel provided expert consensus recommendations on how to identify confirm and manage a bleeding disorder If a bleeding disorder is suspected evaluation for a coagulation problem is required and consultation with a hematologist is suggested An underlying bleeding disorder should be considered when a patient has any of the following
Menorrhagia since menarcheFamily history of bleeding disordersPersonal history of 1 or several of the following
Notable bruising without known injuryBleeding of oral cavity or GI tract without obvious lesionEpistaxis gt10 min duration (possibly necessitating packing or cautery)
-Physical1) Vital signs including postural changes should be assessed Initial evaluation should be directed at assessing the patients volume status and degree of anemia Examine for pallor and absence of conjunctival vessels to gauge anemia2) An abdominal examination should be performed Femoral and inguinal lymph nodes should be examined Stool should be evaluated for the presence of blood3) Patients who are hemodynamically stable require a pelvic speculum bimanual and rectovaginal examination to define the etiology of vaginal bleeding A careful physical examination will exclude vaginal or rectal sources of bleeding The examination should look for the following
The vagina should be inspected for signs of trauma lesions infection and foreign bodiesThe cervix should be visualized and inspected for lesions polyps infection or intrauterine device (IUD)Bleeding from the cervical osA rectovaginal examination should be performed to evaluate the cul-de-sac posterior wall of the uterus and uterosacral ligaments
4) Uterine or ovarian structural abnormalities including leiomyoma or fibroid uterus may be noted on bimanual examination5) Patients with hematologic pathology may also have cutaneous evidence of bleeding diathesis Physical findings include petechiae purpura and mucosal bleeding (eg gums) in addition to vaginal bleeding6) Patients with liver disease that has resulted in a coagulopathy may manifest additional symptomatology because of abnormal hepatic function Evaluate patients for spider angioma palmar erythema splenomegaly ascites jaundice7) Women with polycystic ovary disease present with signs of hyperandrogenism including hirsutism obesity acne palpable enlarged ovaries and acanthosis nigricans (hyper pigmentation typically seen in the folds of the skin in the neck groin or axilla)8) Hyperactive and hypoactive thyroid can cause menstrual irregularities Patients may have varying degrees of characteristic vital sign abnormalities eye findings tremors changes in skin texture and weight change Goiter may be present
Systemic disease including thrombocytopenia hypothyroidism hyperthyroidism Cushing disease liver disease diabetes mellitus and adrenal and other endocrine disorders can present as abnormal uterine bleedingPregnancy and pregnancy-related conditions may be associated with vaginal bleedingTrauma to the cervix vulva or vagina may cause abnormal bleedingCarcinomas of the vagina cervix uterus and ovaries must always be considered in patients with the appropriate history and physical examination findings Endometrial cancer is associated with obesity diabetes mellitus anovulatory cycles nulliparity and age older than 35 yearsOther causes of abnormal uterine bleeding include structural disorders such as functional ovarian cystscervicitis endometritis salpingitis leiomyomas and adenomyosis Cervical dysplasia or other genital tract pathology may present as postcoital or irregular bleeding
-Causes
Polycystic ovary disease results in excess estrogen production and commonly presents as abnormal uterine bleedingPrimary coagulation disorders such as von Will brand disease myeloproliferative disorders and immune thrombocytopenia can present with menorrhagiaExcessive exercise stress and weight loss cause hypothalamic suppression leading to abnormal uterine bleeding due to disruption along the hypothalamus-pituitary-ovarian pathwayBleeding disturbances are common with combination oral contraceptive pills as well as progestin-only methods of birth control However the incidence of bleeding decreases significantly with time Therefore only counseling and reassurance are required during the early months of use Contraceptive intrauterine devices (IUDs) can cause variable vaginal bleeding for the first few cycles after placement and intermittent spotting subsequently The progesterone impregnated IUD (Mirena) is associated with less menometrorrhagia and usually results in secondary amenorrhea
-Causes
AbortionAbruptio PlacentaeAn ovulationAnticoagulantsAntipsychoticMalformationsCervical CancerCervicitisCoagulopathiesCushing SyndromeEndocervical PolypEndometrial CarcinomaEndometrial PolypEndometriosisEstrogen Therapy
-Differential Diagnoses
FibroidsHydatidiform MoleHypothyroidismIntrauterine devicesLiver diseaseMullerian Duct AnomaliesOvarian CystsPelvic Inflammatory DiseasePlacenta PreviaPlatelet Disordersvon Will brand DiseaseVulvovaginitis
When evaluating a woman of reproductive age with vaginal bleeding pregnancy must always be ruled out by urine or serum human chorionic gonadotropinIn a patient with any hemodynamic instability excessive bleeding or clinical evidence of anemia a complete blood count is essentialCoagulation studies should be considered when indicated by the history or physical examination findings and in patients with underlying liver disease or other coagulopathiesIn patients with suspected endocrine disorders other laboratory studies such as thyroid function tests and prolactin levels may be helpful although these results may not be available from the ED (endocrine disorders)
Pelvic ultrasonography is an important imaging modality for non pregnant patients with abnormal vaginal bleeding It may determine the etiology of the bleeding such as a fibroid uterus endometrial thickening or a focal mass
Thickened endometrium may indicate an underlying lesion or excess estrogen and may be suggestive of malignancy
An endometrial stripe measuring less than 4 mm thick is unlikely to have endometrial hyperplasia or cancer and biopsy is often considered unnecessary before treatmentWomen with a normal endometrial stripe (5ndash12 mm) may require biopsy particularly if they have risk factors for endometrial cancerWhen the endometrial stripe is larger than 12 mm a biopsy should be performed6
Imaging Studies
Depending on the urgency to determine the etiology of bleeding and on the reliability of outpatient follow-up ultrasonography may be deferred for outpatient evaluations because for the majority of nonpregnant patients ultrasonographic findings do not immediately affect ED decision-making3
Transvaginal ultrasonography may be particularly helpful in further delineating ovarian cysts and fluid in the cul-de-sacComputed tomography is used primarily for evaluation of other causes of acute abdominal or pelvic painMagnetic resonance imaging is used primarily for cancer staging
ProceduresBefore instituting therapy many consulting gynecologists perform endometrial sampling or biopsy to diagnose intrauterine pathology and to exclude endometrial malignancyEndometrial biopsy is indicated for the following patients with abnormal uterine bleeding6
Women older than 35 yearsObese patientsWomen who have prolonged periods of unopposed estrogen stimulationWomen with chronic an ovulation
Hysteroscopy is the definitive way to detect intrauterine lesions It offers a more complete examination of the surface of the endometrium However it is usually reserved for treating lesions that were detected by other less invasive means
TreatmentEmergency Department CareHemodynamically unstable patients with uncontrolled bleeding and signs of significant blood loss should have aggressive resuscitation with saline and blood as with other types of hemorrhagic shock
Evaluate ABCs and address the prioritiesInitiate 2 large-bore intravenous lines (IVs) oxygen and cardiac monitorIf bleeding is profuse and the patient is unresponsive to initial fluid management consider administration of IV conjugated estrogen (Premarin) 25 mg IV every 4-6 hours until the bleeding stopsIn women with severe persistent uterine bleeding an immediate dilation and curettage (DampC) procedure may be necessary
Treatment contCombination oral contraceptive pills may be used in women who are not pregnant and have no anatomic abnormalities An oral contraceptive with 35 mcg can be taken twice a day until the bleeding stops for up to 7 days at which time the dose is decreased to once a day until the pack is completed They provide the additional benefits of reducing dysmenorrhea and providing contraception Side effects include nausea and vomitingProgesterone alone can be used to stabilize an immature endometrium It is usually successful in the treatment of women with anovulatory dysfunctional uterine bleeding (DUB) because these women have unopposed estrogen stimulation Medroxyprogesterone acetate 10 mg is taken orally once daily for 10 days followed by withdrawal bleeding 3-5 days after completion of the course Currently there is not enough evidence comparing the effect of either progesterone alone or in combination with estrogens for the treatment of dysfunctional uterine bleeding7
Treatment contNo steroidal anti-inflammatory drugs (NSAIDs) are generally effective for the treatment of dysfunctional uterine bleeding and dysmenorrhea NSAIDs inhibiting prostaglandin synthesis and increasing thromboxane A2 levels
This leads to vasoconstriction and increased platelet aggregation These medications may reduce blood loss by 20-50 NSAIDs are most effective if used with the onset of menses or just prior to its onset and continued throughout its durationDanazol creates a hypoestrogenic and hyper androgenic environment which induces endometrial atrophy resulting in reduced menstrual loss Side effects include musculoskeletal pain breast atrophy hirsutism weight gain oily skin and acne Because of the significant androgenic side effects this drug is usually reserved as a second-line treatment for short-term use prior to surgeryGonadotropin-releasing hormone agonists may be helpful for short-term use in inducing amenorrhea and allowing women to rebuild their red blood cell mass They produce a profound hypoestrogenic state similar to menopause Side effects include menopausal symptoms and bone loss with long-term useTranexamic acid is an antifibrinolytic drug that exerts its effects by reversibly inhibiting plasminogen
Treatment contConsultationsSeek an emergency gynecologic consultation for patients requiring hemodynamic stabilization If parenteral therapy does not completely arrest vaginal bleeding in the hemodynamically unstable patient an emergency DampC may be warrantedConsultation with or urgent referral to a gynecologist for surgical treatment may be necessary for patients who do not desire fertility and in whom medical therapy fails Both endometrial ablation and hysterectomy are effective treatments in women with dysfunctional uterine bleeding with comparable patient satisfaction rates
Endometrial ablation is( a medical procedure that is used to remove (ablate) or destroy the endometrial lining of a uterus) may be performed using laser electrocautery or roller ball
Treatment contAmenorrhea is seen in approximately 35 of women treated and decreased flow is seen in another 45 although treatment failures increase with time following the procedure due to endometrial regeneration A substantial number of patients receiving endometrial ablation require reoperation (30 by 48 months)
Hysterectomy is the most effective treatment for bleeding However it is associated with more frequent and severe adverse events compared with either conservative medical or ablation procedures Operating time hospitalization recovery times and costs are also greater Hence hysterectomy is reserved for selected patient populations
MedicationThe goals of pharmacotherapy are to control the bleeding reduce morbidity and prevent complications Steroid hormonesContraceptive pills Medroxyprogesterone acetate (Provera)After acute bleeding episode controlled can be used alone in patients with adequate amounts of endogenous estrogen to cause endometrial growth Progestin therapy in adolescents produces regular cyclic withdrawal bleeding until positive feedback system matures Progestins stop endometrial growth and support and organize endometrium to allow organized sloughing after their withdrawal Bleeding ceases rapidly because of an organized slough to the basalis layer These drugs usually do not stop acute bleeding episodes yet produce a normal bleeding episode following their withdrawal
ComplicationsAnemia (may become severe)Adenocarcinoma of the uterus (if prolonged unopposed estrogen stimulation)PrognosisHormonal contraceptives reduce blood loss by 40-70 when used long termAlthough medical therapy is generally used first over half of women with menorrhagia undergo hysterectomy within 5 years of referral to a gynecologist[2 ]
Patient EducationInstruct patients to continue prescribed medications although bleeding may still be occurring during the early part of the cycle Also patients should be told to expect menses after cessation of the regimenYoung patients with small amounts of irregular bleeding need reassurance and observation only prior to instituting a drug regimen Express to patients that pharmacologic intervention will not be necessary once menstrual cycles become regularDiscuss ways the patient can avoid prolonged emotional stress and maintain a normal body mass indexFor excellent patient education resources visit medicines Womens Health Center
- Dysfunctional uterine bleeding
- Terms frequently used to describeabnormal uterine bleeding
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Treatment
- Treatment cont
- Slide 21
- Slide 22
- Slide 23
- Medication
- Slide 25
- Slide 26
- Slide 27
-
An international expert panel including obstetriciangynecologists and hematologists has issued guidelines to assist physicians to better recognize bleeding disorders such as von Will brand disease as a cause of menorrhagia and postpartum hemorrhage and to provide disease-specific therapy for the bleeding disorder5Historically a lack of awareness of underlying bleeding disorders has led to under diagnosis in women with abnormal reproductive tract bleeding The panel provided expert consensus recommendations on how to identify confirm and manage a bleeding disorder If a bleeding disorder is suspected evaluation for a coagulation problem is required and consultation with a hematologist is suggested An underlying bleeding disorder should be considered when a patient has any of the following
Menorrhagia since menarcheFamily history of bleeding disordersPersonal history of 1 or several of the following
Notable bruising without known injuryBleeding of oral cavity or GI tract without obvious lesionEpistaxis gt10 min duration (possibly necessitating packing or cautery)
-Physical1) Vital signs including postural changes should be assessed Initial evaluation should be directed at assessing the patients volume status and degree of anemia Examine for pallor and absence of conjunctival vessels to gauge anemia2) An abdominal examination should be performed Femoral and inguinal lymph nodes should be examined Stool should be evaluated for the presence of blood3) Patients who are hemodynamically stable require a pelvic speculum bimanual and rectovaginal examination to define the etiology of vaginal bleeding A careful physical examination will exclude vaginal or rectal sources of bleeding The examination should look for the following
The vagina should be inspected for signs of trauma lesions infection and foreign bodiesThe cervix should be visualized and inspected for lesions polyps infection or intrauterine device (IUD)Bleeding from the cervical osA rectovaginal examination should be performed to evaluate the cul-de-sac posterior wall of the uterus and uterosacral ligaments
4) Uterine or ovarian structural abnormalities including leiomyoma or fibroid uterus may be noted on bimanual examination5) Patients with hematologic pathology may also have cutaneous evidence of bleeding diathesis Physical findings include petechiae purpura and mucosal bleeding (eg gums) in addition to vaginal bleeding6) Patients with liver disease that has resulted in a coagulopathy may manifest additional symptomatology because of abnormal hepatic function Evaluate patients for spider angioma palmar erythema splenomegaly ascites jaundice7) Women with polycystic ovary disease present with signs of hyperandrogenism including hirsutism obesity acne palpable enlarged ovaries and acanthosis nigricans (hyper pigmentation typically seen in the folds of the skin in the neck groin or axilla)8) Hyperactive and hypoactive thyroid can cause menstrual irregularities Patients may have varying degrees of characteristic vital sign abnormalities eye findings tremors changes in skin texture and weight change Goiter may be present
Systemic disease including thrombocytopenia hypothyroidism hyperthyroidism Cushing disease liver disease diabetes mellitus and adrenal and other endocrine disorders can present as abnormal uterine bleedingPregnancy and pregnancy-related conditions may be associated with vaginal bleedingTrauma to the cervix vulva or vagina may cause abnormal bleedingCarcinomas of the vagina cervix uterus and ovaries must always be considered in patients with the appropriate history and physical examination findings Endometrial cancer is associated with obesity diabetes mellitus anovulatory cycles nulliparity and age older than 35 yearsOther causes of abnormal uterine bleeding include structural disorders such as functional ovarian cystscervicitis endometritis salpingitis leiomyomas and adenomyosis Cervical dysplasia or other genital tract pathology may present as postcoital or irregular bleeding
-Causes
Polycystic ovary disease results in excess estrogen production and commonly presents as abnormal uterine bleedingPrimary coagulation disorders such as von Will brand disease myeloproliferative disorders and immune thrombocytopenia can present with menorrhagiaExcessive exercise stress and weight loss cause hypothalamic suppression leading to abnormal uterine bleeding due to disruption along the hypothalamus-pituitary-ovarian pathwayBleeding disturbances are common with combination oral contraceptive pills as well as progestin-only methods of birth control However the incidence of bleeding decreases significantly with time Therefore only counseling and reassurance are required during the early months of use Contraceptive intrauterine devices (IUDs) can cause variable vaginal bleeding for the first few cycles after placement and intermittent spotting subsequently The progesterone impregnated IUD (Mirena) is associated with less menometrorrhagia and usually results in secondary amenorrhea
-Causes
AbortionAbruptio PlacentaeAn ovulationAnticoagulantsAntipsychoticMalformationsCervical CancerCervicitisCoagulopathiesCushing SyndromeEndocervical PolypEndometrial CarcinomaEndometrial PolypEndometriosisEstrogen Therapy
-Differential Diagnoses
FibroidsHydatidiform MoleHypothyroidismIntrauterine devicesLiver diseaseMullerian Duct AnomaliesOvarian CystsPelvic Inflammatory DiseasePlacenta PreviaPlatelet Disordersvon Will brand DiseaseVulvovaginitis
When evaluating a woman of reproductive age with vaginal bleeding pregnancy must always be ruled out by urine or serum human chorionic gonadotropinIn a patient with any hemodynamic instability excessive bleeding or clinical evidence of anemia a complete blood count is essentialCoagulation studies should be considered when indicated by the history or physical examination findings and in patients with underlying liver disease or other coagulopathiesIn patients with suspected endocrine disorders other laboratory studies such as thyroid function tests and prolactin levels may be helpful although these results may not be available from the ED (endocrine disorders)
Pelvic ultrasonography is an important imaging modality for non pregnant patients with abnormal vaginal bleeding It may determine the etiology of the bleeding such as a fibroid uterus endometrial thickening or a focal mass
Thickened endometrium may indicate an underlying lesion or excess estrogen and may be suggestive of malignancy
An endometrial stripe measuring less than 4 mm thick is unlikely to have endometrial hyperplasia or cancer and biopsy is often considered unnecessary before treatmentWomen with a normal endometrial stripe (5ndash12 mm) may require biopsy particularly if they have risk factors for endometrial cancerWhen the endometrial stripe is larger than 12 mm a biopsy should be performed6
Imaging Studies
Depending on the urgency to determine the etiology of bleeding and on the reliability of outpatient follow-up ultrasonography may be deferred for outpatient evaluations because for the majority of nonpregnant patients ultrasonographic findings do not immediately affect ED decision-making3
Transvaginal ultrasonography may be particularly helpful in further delineating ovarian cysts and fluid in the cul-de-sacComputed tomography is used primarily for evaluation of other causes of acute abdominal or pelvic painMagnetic resonance imaging is used primarily for cancer staging
ProceduresBefore instituting therapy many consulting gynecologists perform endometrial sampling or biopsy to diagnose intrauterine pathology and to exclude endometrial malignancyEndometrial biopsy is indicated for the following patients with abnormal uterine bleeding6
Women older than 35 yearsObese patientsWomen who have prolonged periods of unopposed estrogen stimulationWomen with chronic an ovulation
Hysteroscopy is the definitive way to detect intrauterine lesions It offers a more complete examination of the surface of the endometrium However it is usually reserved for treating lesions that were detected by other less invasive means
TreatmentEmergency Department CareHemodynamically unstable patients with uncontrolled bleeding and signs of significant blood loss should have aggressive resuscitation with saline and blood as with other types of hemorrhagic shock
Evaluate ABCs and address the prioritiesInitiate 2 large-bore intravenous lines (IVs) oxygen and cardiac monitorIf bleeding is profuse and the patient is unresponsive to initial fluid management consider administration of IV conjugated estrogen (Premarin) 25 mg IV every 4-6 hours until the bleeding stopsIn women with severe persistent uterine bleeding an immediate dilation and curettage (DampC) procedure may be necessary
Treatment contCombination oral contraceptive pills may be used in women who are not pregnant and have no anatomic abnormalities An oral contraceptive with 35 mcg can be taken twice a day until the bleeding stops for up to 7 days at which time the dose is decreased to once a day until the pack is completed They provide the additional benefits of reducing dysmenorrhea and providing contraception Side effects include nausea and vomitingProgesterone alone can be used to stabilize an immature endometrium It is usually successful in the treatment of women with anovulatory dysfunctional uterine bleeding (DUB) because these women have unopposed estrogen stimulation Medroxyprogesterone acetate 10 mg is taken orally once daily for 10 days followed by withdrawal bleeding 3-5 days after completion of the course Currently there is not enough evidence comparing the effect of either progesterone alone or in combination with estrogens for the treatment of dysfunctional uterine bleeding7
Treatment contNo steroidal anti-inflammatory drugs (NSAIDs) are generally effective for the treatment of dysfunctional uterine bleeding and dysmenorrhea NSAIDs inhibiting prostaglandin synthesis and increasing thromboxane A2 levels
This leads to vasoconstriction and increased platelet aggregation These medications may reduce blood loss by 20-50 NSAIDs are most effective if used with the onset of menses or just prior to its onset and continued throughout its durationDanazol creates a hypoestrogenic and hyper androgenic environment which induces endometrial atrophy resulting in reduced menstrual loss Side effects include musculoskeletal pain breast atrophy hirsutism weight gain oily skin and acne Because of the significant androgenic side effects this drug is usually reserved as a second-line treatment for short-term use prior to surgeryGonadotropin-releasing hormone agonists may be helpful for short-term use in inducing amenorrhea and allowing women to rebuild their red blood cell mass They produce a profound hypoestrogenic state similar to menopause Side effects include menopausal symptoms and bone loss with long-term useTranexamic acid is an antifibrinolytic drug that exerts its effects by reversibly inhibiting plasminogen
Treatment contConsultationsSeek an emergency gynecologic consultation for patients requiring hemodynamic stabilization If parenteral therapy does not completely arrest vaginal bleeding in the hemodynamically unstable patient an emergency DampC may be warrantedConsultation with or urgent referral to a gynecologist for surgical treatment may be necessary for patients who do not desire fertility and in whom medical therapy fails Both endometrial ablation and hysterectomy are effective treatments in women with dysfunctional uterine bleeding with comparable patient satisfaction rates
Endometrial ablation is( a medical procedure that is used to remove (ablate) or destroy the endometrial lining of a uterus) may be performed using laser electrocautery or roller ball
Treatment contAmenorrhea is seen in approximately 35 of women treated and decreased flow is seen in another 45 although treatment failures increase with time following the procedure due to endometrial regeneration A substantial number of patients receiving endometrial ablation require reoperation (30 by 48 months)
Hysterectomy is the most effective treatment for bleeding However it is associated with more frequent and severe adverse events compared with either conservative medical or ablation procedures Operating time hospitalization recovery times and costs are also greater Hence hysterectomy is reserved for selected patient populations
MedicationThe goals of pharmacotherapy are to control the bleeding reduce morbidity and prevent complications Steroid hormonesContraceptive pills Medroxyprogesterone acetate (Provera)After acute bleeding episode controlled can be used alone in patients with adequate amounts of endogenous estrogen to cause endometrial growth Progestin therapy in adolescents produces regular cyclic withdrawal bleeding until positive feedback system matures Progestins stop endometrial growth and support and organize endometrium to allow organized sloughing after their withdrawal Bleeding ceases rapidly because of an organized slough to the basalis layer These drugs usually do not stop acute bleeding episodes yet produce a normal bleeding episode following their withdrawal
ComplicationsAnemia (may become severe)Adenocarcinoma of the uterus (if prolonged unopposed estrogen stimulation)PrognosisHormonal contraceptives reduce blood loss by 40-70 when used long termAlthough medical therapy is generally used first over half of women with menorrhagia undergo hysterectomy within 5 years of referral to a gynecologist[2 ]
Patient EducationInstruct patients to continue prescribed medications although bleeding may still be occurring during the early part of the cycle Also patients should be told to expect menses after cessation of the regimenYoung patients with small amounts of irregular bleeding need reassurance and observation only prior to instituting a drug regimen Express to patients that pharmacologic intervention will not be necessary once menstrual cycles become regularDiscuss ways the patient can avoid prolonged emotional stress and maintain a normal body mass indexFor excellent patient education resources visit medicines Womens Health Center
- Dysfunctional uterine bleeding
- Terms frequently used to describeabnormal uterine bleeding
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Treatment
- Treatment cont
- Slide 21
- Slide 22
- Slide 23
- Medication
- Slide 25
- Slide 26
- Slide 27
-
-Physical1) Vital signs including postural changes should be assessed Initial evaluation should be directed at assessing the patients volume status and degree of anemia Examine for pallor and absence of conjunctival vessels to gauge anemia2) An abdominal examination should be performed Femoral and inguinal lymph nodes should be examined Stool should be evaluated for the presence of blood3) Patients who are hemodynamically stable require a pelvic speculum bimanual and rectovaginal examination to define the etiology of vaginal bleeding A careful physical examination will exclude vaginal or rectal sources of bleeding The examination should look for the following
The vagina should be inspected for signs of trauma lesions infection and foreign bodiesThe cervix should be visualized and inspected for lesions polyps infection or intrauterine device (IUD)Bleeding from the cervical osA rectovaginal examination should be performed to evaluate the cul-de-sac posterior wall of the uterus and uterosacral ligaments
4) Uterine or ovarian structural abnormalities including leiomyoma or fibroid uterus may be noted on bimanual examination5) Patients with hematologic pathology may also have cutaneous evidence of bleeding diathesis Physical findings include petechiae purpura and mucosal bleeding (eg gums) in addition to vaginal bleeding6) Patients with liver disease that has resulted in a coagulopathy may manifest additional symptomatology because of abnormal hepatic function Evaluate patients for spider angioma palmar erythema splenomegaly ascites jaundice7) Women with polycystic ovary disease present with signs of hyperandrogenism including hirsutism obesity acne palpable enlarged ovaries and acanthosis nigricans (hyper pigmentation typically seen in the folds of the skin in the neck groin or axilla)8) Hyperactive and hypoactive thyroid can cause menstrual irregularities Patients may have varying degrees of characteristic vital sign abnormalities eye findings tremors changes in skin texture and weight change Goiter may be present
Systemic disease including thrombocytopenia hypothyroidism hyperthyroidism Cushing disease liver disease diabetes mellitus and adrenal and other endocrine disorders can present as abnormal uterine bleedingPregnancy and pregnancy-related conditions may be associated with vaginal bleedingTrauma to the cervix vulva or vagina may cause abnormal bleedingCarcinomas of the vagina cervix uterus and ovaries must always be considered in patients with the appropriate history and physical examination findings Endometrial cancer is associated with obesity diabetes mellitus anovulatory cycles nulliparity and age older than 35 yearsOther causes of abnormal uterine bleeding include structural disorders such as functional ovarian cystscervicitis endometritis salpingitis leiomyomas and adenomyosis Cervical dysplasia or other genital tract pathology may present as postcoital or irregular bleeding
-Causes
Polycystic ovary disease results in excess estrogen production and commonly presents as abnormal uterine bleedingPrimary coagulation disorders such as von Will brand disease myeloproliferative disorders and immune thrombocytopenia can present with menorrhagiaExcessive exercise stress and weight loss cause hypothalamic suppression leading to abnormal uterine bleeding due to disruption along the hypothalamus-pituitary-ovarian pathwayBleeding disturbances are common with combination oral contraceptive pills as well as progestin-only methods of birth control However the incidence of bleeding decreases significantly with time Therefore only counseling and reassurance are required during the early months of use Contraceptive intrauterine devices (IUDs) can cause variable vaginal bleeding for the first few cycles after placement and intermittent spotting subsequently The progesterone impregnated IUD (Mirena) is associated with less menometrorrhagia and usually results in secondary amenorrhea
-Causes
AbortionAbruptio PlacentaeAn ovulationAnticoagulantsAntipsychoticMalformationsCervical CancerCervicitisCoagulopathiesCushing SyndromeEndocervical PolypEndometrial CarcinomaEndometrial PolypEndometriosisEstrogen Therapy
-Differential Diagnoses
FibroidsHydatidiform MoleHypothyroidismIntrauterine devicesLiver diseaseMullerian Duct AnomaliesOvarian CystsPelvic Inflammatory DiseasePlacenta PreviaPlatelet Disordersvon Will brand DiseaseVulvovaginitis
When evaluating a woman of reproductive age with vaginal bleeding pregnancy must always be ruled out by urine or serum human chorionic gonadotropinIn a patient with any hemodynamic instability excessive bleeding or clinical evidence of anemia a complete blood count is essentialCoagulation studies should be considered when indicated by the history or physical examination findings and in patients with underlying liver disease or other coagulopathiesIn patients with suspected endocrine disorders other laboratory studies such as thyroid function tests and prolactin levels may be helpful although these results may not be available from the ED (endocrine disorders)
Pelvic ultrasonography is an important imaging modality for non pregnant patients with abnormal vaginal bleeding It may determine the etiology of the bleeding such as a fibroid uterus endometrial thickening or a focal mass
Thickened endometrium may indicate an underlying lesion or excess estrogen and may be suggestive of malignancy
An endometrial stripe measuring less than 4 mm thick is unlikely to have endometrial hyperplasia or cancer and biopsy is often considered unnecessary before treatmentWomen with a normal endometrial stripe (5ndash12 mm) may require biopsy particularly if they have risk factors for endometrial cancerWhen the endometrial stripe is larger than 12 mm a biopsy should be performed6
Imaging Studies
Depending on the urgency to determine the etiology of bleeding and on the reliability of outpatient follow-up ultrasonography may be deferred for outpatient evaluations because for the majority of nonpregnant patients ultrasonographic findings do not immediately affect ED decision-making3
Transvaginal ultrasonography may be particularly helpful in further delineating ovarian cysts and fluid in the cul-de-sacComputed tomography is used primarily for evaluation of other causes of acute abdominal or pelvic painMagnetic resonance imaging is used primarily for cancer staging
ProceduresBefore instituting therapy many consulting gynecologists perform endometrial sampling or biopsy to diagnose intrauterine pathology and to exclude endometrial malignancyEndometrial biopsy is indicated for the following patients with abnormal uterine bleeding6
Women older than 35 yearsObese patientsWomen who have prolonged periods of unopposed estrogen stimulationWomen with chronic an ovulation
Hysteroscopy is the definitive way to detect intrauterine lesions It offers a more complete examination of the surface of the endometrium However it is usually reserved for treating lesions that were detected by other less invasive means
TreatmentEmergency Department CareHemodynamically unstable patients with uncontrolled bleeding and signs of significant blood loss should have aggressive resuscitation with saline and blood as with other types of hemorrhagic shock
Evaluate ABCs and address the prioritiesInitiate 2 large-bore intravenous lines (IVs) oxygen and cardiac monitorIf bleeding is profuse and the patient is unresponsive to initial fluid management consider administration of IV conjugated estrogen (Premarin) 25 mg IV every 4-6 hours until the bleeding stopsIn women with severe persistent uterine bleeding an immediate dilation and curettage (DampC) procedure may be necessary
Treatment contCombination oral contraceptive pills may be used in women who are not pregnant and have no anatomic abnormalities An oral contraceptive with 35 mcg can be taken twice a day until the bleeding stops for up to 7 days at which time the dose is decreased to once a day until the pack is completed They provide the additional benefits of reducing dysmenorrhea and providing contraception Side effects include nausea and vomitingProgesterone alone can be used to stabilize an immature endometrium It is usually successful in the treatment of women with anovulatory dysfunctional uterine bleeding (DUB) because these women have unopposed estrogen stimulation Medroxyprogesterone acetate 10 mg is taken orally once daily for 10 days followed by withdrawal bleeding 3-5 days after completion of the course Currently there is not enough evidence comparing the effect of either progesterone alone or in combination with estrogens for the treatment of dysfunctional uterine bleeding7
Treatment contNo steroidal anti-inflammatory drugs (NSAIDs) are generally effective for the treatment of dysfunctional uterine bleeding and dysmenorrhea NSAIDs inhibiting prostaglandin synthesis and increasing thromboxane A2 levels
This leads to vasoconstriction and increased platelet aggregation These medications may reduce blood loss by 20-50 NSAIDs are most effective if used with the onset of menses or just prior to its onset and continued throughout its durationDanazol creates a hypoestrogenic and hyper androgenic environment which induces endometrial atrophy resulting in reduced menstrual loss Side effects include musculoskeletal pain breast atrophy hirsutism weight gain oily skin and acne Because of the significant androgenic side effects this drug is usually reserved as a second-line treatment for short-term use prior to surgeryGonadotropin-releasing hormone agonists may be helpful for short-term use in inducing amenorrhea and allowing women to rebuild their red blood cell mass They produce a profound hypoestrogenic state similar to menopause Side effects include menopausal symptoms and bone loss with long-term useTranexamic acid is an antifibrinolytic drug that exerts its effects by reversibly inhibiting plasminogen
Treatment contConsultationsSeek an emergency gynecologic consultation for patients requiring hemodynamic stabilization If parenteral therapy does not completely arrest vaginal bleeding in the hemodynamically unstable patient an emergency DampC may be warrantedConsultation with or urgent referral to a gynecologist for surgical treatment may be necessary for patients who do not desire fertility and in whom medical therapy fails Both endometrial ablation and hysterectomy are effective treatments in women with dysfunctional uterine bleeding with comparable patient satisfaction rates
Endometrial ablation is( a medical procedure that is used to remove (ablate) or destroy the endometrial lining of a uterus) may be performed using laser electrocautery or roller ball
Treatment contAmenorrhea is seen in approximately 35 of women treated and decreased flow is seen in another 45 although treatment failures increase with time following the procedure due to endometrial regeneration A substantial number of patients receiving endometrial ablation require reoperation (30 by 48 months)
Hysterectomy is the most effective treatment for bleeding However it is associated with more frequent and severe adverse events compared with either conservative medical or ablation procedures Operating time hospitalization recovery times and costs are also greater Hence hysterectomy is reserved for selected patient populations
MedicationThe goals of pharmacotherapy are to control the bleeding reduce morbidity and prevent complications Steroid hormonesContraceptive pills Medroxyprogesterone acetate (Provera)After acute bleeding episode controlled can be used alone in patients with adequate amounts of endogenous estrogen to cause endometrial growth Progestin therapy in adolescents produces regular cyclic withdrawal bleeding until positive feedback system matures Progestins stop endometrial growth and support and organize endometrium to allow organized sloughing after their withdrawal Bleeding ceases rapidly because of an organized slough to the basalis layer These drugs usually do not stop acute bleeding episodes yet produce a normal bleeding episode following their withdrawal
ComplicationsAnemia (may become severe)Adenocarcinoma of the uterus (if prolonged unopposed estrogen stimulation)PrognosisHormonal contraceptives reduce blood loss by 40-70 when used long termAlthough medical therapy is generally used first over half of women with menorrhagia undergo hysterectomy within 5 years of referral to a gynecologist[2 ]
Patient EducationInstruct patients to continue prescribed medications although bleeding may still be occurring during the early part of the cycle Also patients should be told to expect menses after cessation of the regimenYoung patients with small amounts of irregular bleeding need reassurance and observation only prior to instituting a drug regimen Express to patients that pharmacologic intervention will not be necessary once menstrual cycles become regularDiscuss ways the patient can avoid prolonged emotional stress and maintain a normal body mass indexFor excellent patient education resources visit medicines Womens Health Center
- Dysfunctional uterine bleeding
- Terms frequently used to describeabnormal uterine bleeding
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Treatment
- Treatment cont
- Slide 21
- Slide 22
- Slide 23
- Medication
- Slide 25
- Slide 26
- Slide 27
-
4) Uterine or ovarian structural abnormalities including leiomyoma or fibroid uterus may be noted on bimanual examination5) Patients with hematologic pathology may also have cutaneous evidence of bleeding diathesis Physical findings include petechiae purpura and mucosal bleeding (eg gums) in addition to vaginal bleeding6) Patients with liver disease that has resulted in a coagulopathy may manifest additional symptomatology because of abnormal hepatic function Evaluate patients for spider angioma palmar erythema splenomegaly ascites jaundice7) Women with polycystic ovary disease present with signs of hyperandrogenism including hirsutism obesity acne palpable enlarged ovaries and acanthosis nigricans (hyper pigmentation typically seen in the folds of the skin in the neck groin or axilla)8) Hyperactive and hypoactive thyroid can cause menstrual irregularities Patients may have varying degrees of characteristic vital sign abnormalities eye findings tremors changes in skin texture and weight change Goiter may be present
Systemic disease including thrombocytopenia hypothyroidism hyperthyroidism Cushing disease liver disease diabetes mellitus and adrenal and other endocrine disorders can present as abnormal uterine bleedingPregnancy and pregnancy-related conditions may be associated with vaginal bleedingTrauma to the cervix vulva or vagina may cause abnormal bleedingCarcinomas of the vagina cervix uterus and ovaries must always be considered in patients with the appropriate history and physical examination findings Endometrial cancer is associated with obesity diabetes mellitus anovulatory cycles nulliparity and age older than 35 yearsOther causes of abnormal uterine bleeding include structural disorders such as functional ovarian cystscervicitis endometritis salpingitis leiomyomas and adenomyosis Cervical dysplasia or other genital tract pathology may present as postcoital or irregular bleeding
-Causes
Polycystic ovary disease results in excess estrogen production and commonly presents as abnormal uterine bleedingPrimary coagulation disorders such as von Will brand disease myeloproliferative disorders and immune thrombocytopenia can present with menorrhagiaExcessive exercise stress and weight loss cause hypothalamic suppression leading to abnormal uterine bleeding due to disruption along the hypothalamus-pituitary-ovarian pathwayBleeding disturbances are common with combination oral contraceptive pills as well as progestin-only methods of birth control However the incidence of bleeding decreases significantly with time Therefore only counseling and reassurance are required during the early months of use Contraceptive intrauterine devices (IUDs) can cause variable vaginal bleeding for the first few cycles after placement and intermittent spotting subsequently The progesterone impregnated IUD (Mirena) is associated with less menometrorrhagia and usually results in secondary amenorrhea
-Causes
AbortionAbruptio PlacentaeAn ovulationAnticoagulantsAntipsychoticMalformationsCervical CancerCervicitisCoagulopathiesCushing SyndromeEndocervical PolypEndometrial CarcinomaEndometrial PolypEndometriosisEstrogen Therapy
-Differential Diagnoses
FibroidsHydatidiform MoleHypothyroidismIntrauterine devicesLiver diseaseMullerian Duct AnomaliesOvarian CystsPelvic Inflammatory DiseasePlacenta PreviaPlatelet Disordersvon Will brand DiseaseVulvovaginitis
When evaluating a woman of reproductive age with vaginal bleeding pregnancy must always be ruled out by urine or serum human chorionic gonadotropinIn a patient with any hemodynamic instability excessive bleeding or clinical evidence of anemia a complete blood count is essentialCoagulation studies should be considered when indicated by the history or physical examination findings and in patients with underlying liver disease or other coagulopathiesIn patients with suspected endocrine disorders other laboratory studies such as thyroid function tests and prolactin levels may be helpful although these results may not be available from the ED (endocrine disorders)
Pelvic ultrasonography is an important imaging modality for non pregnant patients with abnormal vaginal bleeding It may determine the etiology of the bleeding such as a fibroid uterus endometrial thickening or a focal mass
Thickened endometrium may indicate an underlying lesion or excess estrogen and may be suggestive of malignancy
An endometrial stripe measuring less than 4 mm thick is unlikely to have endometrial hyperplasia or cancer and biopsy is often considered unnecessary before treatmentWomen with a normal endometrial stripe (5ndash12 mm) may require biopsy particularly if they have risk factors for endometrial cancerWhen the endometrial stripe is larger than 12 mm a biopsy should be performed6
Imaging Studies
Depending on the urgency to determine the etiology of bleeding and on the reliability of outpatient follow-up ultrasonography may be deferred for outpatient evaluations because for the majority of nonpregnant patients ultrasonographic findings do not immediately affect ED decision-making3
Transvaginal ultrasonography may be particularly helpful in further delineating ovarian cysts and fluid in the cul-de-sacComputed tomography is used primarily for evaluation of other causes of acute abdominal or pelvic painMagnetic resonance imaging is used primarily for cancer staging
ProceduresBefore instituting therapy many consulting gynecologists perform endometrial sampling or biopsy to diagnose intrauterine pathology and to exclude endometrial malignancyEndometrial biopsy is indicated for the following patients with abnormal uterine bleeding6
Women older than 35 yearsObese patientsWomen who have prolonged periods of unopposed estrogen stimulationWomen with chronic an ovulation
Hysteroscopy is the definitive way to detect intrauterine lesions It offers a more complete examination of the surface of the endometrium However it is usually reserved for treating lesions that were detected by other less invasive means
TreatmentEmergency Department CareHemodynamically unstable patients with uncontrolled bleeding and signs of significant blood loss should have aggressive resuscitation with saline and blood as with other types of hemorrhagic shock
Evaluate ABCs and address the prioritiesInitiate 2 large-bore intravenous lines (IVs) oxygen and cardiac monitorIf bleeding is profuse and the patient is unresponsive to initial fluid management consider administration of IV conjugated estrogen (Premarin) 25 mg IV every 4-6 hours until the bleeding stopsIn women with severe persistent uterine bleeding an immediate dilation and curettage (DampC) procedure may be necessary
Treatment contCombination oral contraceptive pills may be used in women who are not pregnant and have no anatomic abnormalities An oral contraceptive with 35 mcg can be taken twice a day until the bleeding stops for up to 7 days at which time the dose is decreased to once a day until the pack is completed They provide the additional benefits of reducing dysmenorrhea and providing contraception Side effects include nausea and vomitingProgesterone alone can be used to stabilize an immature endometrium It is usually successful in the treatment of women with anovulatory dysfunctional uterine bleeding (DUB) because these women have unopposed estrogen stimulation Medroxyprogesterone acetate 10 mg is taken orally once daily for 10 days followed by withdrawal bleeding 3-5 days after completion of the course Currently there is not enough evidence comparing the effect of either progesterone alone or in combination with estrogens for the treatment of dysfunctional uterine bleeding7
Treatment contNo steroidal anti-inflammatory drugs (NSAIDs) are generally effective for the treatment of dysfunctional uterine bleeding and dysmenorrhea NSAIDs inhibiting prostaglandin synthesis and increasing thromboxane A2 levels
This leads to vasoconstriction and increased platelet aggregation These medications may reduce blood loss by 20-50 NSAIDs are most effective if used with the onset of menses or just prior to its onset and continued throughout its durationDanazol creates a hypoestrogenic and hyper androgenic environment which induces endometrial atrophy resulting in reduced menstrual loss Side effects include musculoskeletal pain breast atrophy hirsutism weight gain oily skin and acne Because of the significant androgenic side effects this drug is usually reserved as a second-line treatment for short-term use prior to surgeryGonadotropin-releasing hormone agonists may be helpful for short-term use in inducing amenorrhea and allowing women to rebuild their red blood cell mass They produce a profound hypoestrogenic state similar to menopause Side effects include menopausal symptoms and bone loss with long-term useTranexamic acid is an antifibrinolytic drug that exerts its effects by reversibly inhibiting plasminogen
Treatment contConsultationsSeek an emergency gynecologic consultation for patients requiring hemodynamic stabilization If parenteral therapy does not completely arrest vaginal bleeding in the hemodynamically unstable patient an emergency DampC may be warrantedConsultation with or urgent referral to a gynecologist for surgical treatment may be necessary for patients who do not desire fertility and in whom medical therapy fails Both endometrial ablation and hysterectomy are effective treatments in women with dysfunctional uterine bleeding with comparable patient satisfaction rates
Endometrial ablation is( a medical procedure that is used to remove (ablate) or destroy the endometrial lining of a uterus) may be performed using laser electrocautery or roller ball
Treatment contAmenorrhea is seen in approximately 35 of women treated and decreased flow is seen in another 45 although treatment failures increase with time following the procedure due to endometrial regeneration A substantial number of patients receiving endometrial ablation require reoperation (30 by 48 months)
Hysterectomy is the most effective treatment for bleeding However it is associated with more frequent and severe adverse events compared with either conservative medical or ablation procedures Operating time hospitalization recovery times and costs are also greater Hence hysterectomy is reserved for selected patient populations
MedicationThe goals of pharmacotherapy are to control the bleeding reduce morbidity and prevent complications Steroid hormonesContraceptive pills Medroxyprogesterone acetate (Provera)After acute bleeding episode controlled can be used alone in patients with adequate amounts of endogenous estrogen to cause endometrial growth Progestin therapy in adolescents produces regular cyclic withdrawal bleeding until positive feedback system matures Progestins stop endometrial growth and support and organize endometrium to allow organized sloughing after their withdrawal Bleeding ceases rapidly because of an organized slough to the basalis layer These drugs usually do not stop acute bleeding episodes yet produce a normal bleeding episode following their withdrawal
ComplicationsAnemia (may become severe)Adenocarcinoma of the uterus (if prolonged unopposed estrogen stimulation)PrognosisHormonal contraceptives reduce blood loss by 40-70 when used long termAlthough medical therapy is generally used first over half of women with menorrhagia undergo hysterectomy within 5 years of referral to a gynecologist[2 ]
Patient EducationInstruct patients to continue prescribed medications although bleeding may still be occurring during the early part of the cycle Also patients should be told to expect menses after cessation of the regimenYoung patients with small amounts of irregular bleeding need reassurance and observation only prior to instituting a drug regimen Express to patients that pharmacologic intervention will not be necessary once menstrual cycles become regularDiscuss ways the patient can avoid prolonged emotional stress and maintain a normal body mass indexFor excellent patient education resources visit medicines Womens Health Center
- Dysfunctional uterine bleeding
- Terms frequently used to describeabnormal uterine bleeding
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Treatment
- Treatment cont
- Slide 21
- Slide 22
- Slide 23
- Medication
- Slide 25
- Slide 26
- Slide 27
-
Systemic disease including thrombocytopenia hypothyroidism hyperthyroidism Cushing disease liver disease diabetes mellitus and adrenal and other endocrine disorders can present as abnormal uterine bleedingPregnancy and pregnancy-related conditions may be associated with vaginal bleedingTrauma to the cervix vulva or vagina may cause abnormal bleedingCarcinomas of the vagina cervix uterus and ovaries must always be considered in patients with the appropriate history and physical examination findings Endometrial cancer is associated with obesity diabetes mellitus anovulatory cycles nulliparity and age older than 35 yearsOther causes of abnormal uterine bleeding include structural disorders such as functional ovarian cystscervicitis endometritis salpingitis leiomyomas and adenomyosis Cervical dysplasia or other genital tract pathology may present as postcoital or irregular bleeding
-Causes
Polycystic ovary disease results in excess estrogen production and commonly presents as abnormal uterine bleedingPrimary coagulation disorders such as von Will brand disease myeloproliferative disorders and immune thrombocytopenia can present with menorrhagiaExcessive exercise stress and weight loss cause hypothalamic suppression leading to abnormal uterine bleeding due to disruption along the hypothalamus-pituitary-ovarian pathwayBleeding disturbances are common with combination oral contraceptive pills as well as progestin-only methods of birth control However the incidence of bleeding decreases significantly with time Therefore only counseling and reassurance are required during the early months of use Contraceptive intrauterine devices (IUDs) can cause variable vaginal bleeding for the first few cycles after placement and intermittent spotting subsequently The progesterone impregnated IUD (Mirena) is associated with less menometrorrhagia and usually results in secondary amenorrhea
-Causes
AbortionAbruptio PlacentaeAn ovulationAnticoagulantsAntipsychoticMalformationsCervical CancerCervicitisCoagulopathiesCushing SyndromeEndocervical PolypEndometrial CarcinomaEndometrial PolypEndometriosisEstrogen Therapy
-Differential Diagnoses
FibroidsHydatidiform MoleHypothyroidismIntrauterine devicesLiver diseaseMullerian Duct AnomaliesOvarian CystsPelvic Inflammatory DiseasePlacenta PreviaPlatelet Disordersvon Will brand DiseaseVulvovaginitis
When evaluating a woman of reproductive age with vaginal bleeding pregnancy must always be ruled out by urine or serum human chorionic gonadotropinIn a patient with any hemodynamic instability excessive bleeding or clinical evidence of anemia a complete blood count is essentialCoagulation studies should be considered when indicated by the history or physical examination findings and in patients with underlying liver disease or other coagulopathiesIn patients with suspected endocrine disorders other laboratory studies such as thyroid function tests and prolactin levels may be helpful although these results may not be available from the ED (endocrine disorders)
Pelvic ultrasonography is an important imaging modality for non pregnant patients with abnormal vaginal bleeding It may determine the etiology of the bleeding such as a fibroid uterus endometrial thickening or a focal mass
Thickened endometrium may indicate an underlying lesion or excess estrogen and may be suggestive of malignancy
An endometrial stripe measuring less than 4 mm thick is unlikely to have endometrial hyperplasia or cancer and biopsy is often considered unnecessary before treatmentWomen with a normal endometrial stripe (5ndash12 mm) may require biopsy particularly if they have risk factors for endometrial cancerWhen the endometrial stripe is larger than 12 mm a biopsy should be performed6
Imaging Studies
Depending on the urgency to determine the etiology of bleeding and on the reliability of outpatient follow-up ultrasonography may be deferred for outpatient evaluations because for the majority of nonpregnant patients ultrasonographic findings do not immediately affect ED decision-making3
Transvaginal ultrasonography may be particularly helpful in further delineating ovarian cysts and fluid in the cul-de-sacComputed tomography is used primarily for evaluation of other causes of acute abdominal or pelvic painMagnetic resonance imaging is used primarily for cancer staging
ProceduresBefore instituting therapy many consulting gynecologists perform endometrial sampling or biopsy to diagnose intrauterine pathology and to exclude endometrial malignancyEndometrial biopsy is indicated for the following patients with abnormal uterine bleeding6
Women older than 35 yearsObese patientsWomen who have prolonged periods of unopposed estrogen stimulationWomen with chronic an ovulation
Hysteroscopy is the definitive way to detect intrauterine lesions It offers a more complete examination of the surface of the endometrium However it is usually reserved for treating lesions that were detected by other less invasive means
TreatmentEmergency Department CareHemodynamically unstable patients with uncontrolled bleeding and signs of significant blood loss should have aggressive resuscitation with saline and blood as with other types of hemorrhagic shock
Evaluate ABCs and address the prioritiesInitiate 2 large-bore intravenous lines (IVs) oxygen and cardiac monitorIf bleeding is profuse and the patient is unresponsive to initial fluid management consider administration of IV conjugated estrogen (Premarin) 25 mg IV every 4-6 hours until the bleeding stopsIn women with severe persistent uterine bleeding an immediate dilation and curettage (DampC) procedure may be necessary
Treatment contCombination oral contraceptive pills may be used in women who are not pregnant and have no anatomic abnormalities An oral contraceptive with 35 mcg can be taken twice a day until the bleeding stops for up to 7 days at which time the dose is decreased to once a day until the pack is completed They provide the additional benefits of reducing dysmenorrhea and providing contraception Side effects include nausea and vomitingProgesterone alone can be used to stabilize an immature endometrium It is usually successful in the treatment of women with anovulatory dysfunctional uterine bleeding (DUB) because these women have unopposed estrogen stimulation Medroxyprogesterone acetate 10 mg is taken orally once daily for 10 days followed by withdrawal bleeding 3-5 days after completion of the course Currently there is not enough evidence comparing the effect of either progesterone alone or in combination with estrogens for the treatment of dysfunctional uterine bleeding7
Treatment contNo steroidal anti-inflammatory drugs (NSAIDs) are generally effective for the treatment of dysfunctional uterine bleeding and dysmenorrhea NSAIDs inhibiting prostaglandin synthesis and increasing thromboxane A2 levels
This leads to vasoconstriction and increased platelet aggregation These medications may reduce blood loss by 20-50 NSAIDs are most effective if used with the onset of menses or just prior to its onset and continued throughout its durationDanazol creates a hypoestrogenic and hyper androgenic environment which induces endometrial atrophy resulting in reduced menstrual loss Side effects include musculoskeletal pain breast atrophy hirsutism weight gain oily skin and acne Because of the significant androgenic side effects this drug is usually reserved as a second-line treatment for short-term use prior to surgeryGonadotropin-releasing hormone agonists may be helpful for short-term use in inducing amenorrhea and allowing women to rebuild their red blood cell mass They produce a profound hypoestrogenic state similar to menopause Side effects include menopausal symptoms and bone loss with long-term useTranexamic acid is an antifibrinolytic drug that exerts its effects by reversibly inhibiting plasminogen
Treatment contConsultationsSeek an emergency gynecologic consultation for patients requiring hemodynamic stabilization If parenteral therapy does not completely arrest vaginal bleeding in the hemodynamically unstable patient an emergency DampC may be warrantedConsultation with or urgent referral to a gynecologist for surgical treatment may be necessary for patients who do not desire fertility and in whom medical therapy fails Both endometrial ablation and hysterectomy are effective treatments in women with dysfunctional uterine bleeding with comparable patient satisfaction rates
Endometrial ablation is( a medical procedure that is used to remove (ablate) or destroy the endometrial lining of a uterus) may be performed using laser electrocautery or roller ball
Treatment contAmenorrhea is seen in approximately 35 of women treated and decreased flow is seen in another 45 although treatment failures increase with time following the procedure due to endometrial regeneration A substantial number of patients receiving endometrial ablation require reoperation (30 by 48 months)
Hysterectomy is the most effective treatment for bleeding However it is associated with more frequent and severe adverse events compared with either conservative medical or ablation procedures Operating time hospitalization recovery times and costs are also greater Hence hysterectomy is reserved for selected patient populations
MedicationThe goals of pharmacotherapy are to control the bleeding reduce morbidity and prevent complications Steroid hormonesContraceptive pills Medroxyprogesterone acetate (Provera)After acute bleeding episode controlled can be used alone in patients with adequate amounts of endogenous estrogen to cause endometrial growth Progestin therapy in adolescents produces regular cyclic withdrawal bleeding until positive feedback system matures Progestins stop endometrial growth and support and organize endometrium to allow organized sloughing after their withdrawal Bleeding ceases rapidly because of an organized slough to the basalis layer These drugs usually do not stop acute bleeding episodes yet produce a normal bleeding episode following their withdrawal
ComplicationsAnemia (may become severe)Adenocarcinoma of the uterus (if prolonged unopposed estrogen stimulation)PrognosisHormonal contraceptives reduce blood loss by 40-70 when used long termAlthough medical therapy is generally used first over half of women with menorrhagia undergo hysterectomy within 5 years of referral to a gynecologist[2 ]
Patient EducationInstruct patients to continue prescribed medications although bleeding may still be occurring during the early part of the cycle Also patients should be told to expect menses after cessation of the regimenYoung patients with small amounts of irregular bleeding need reassurance and observation only prior to instituting a drug regimen Express to patients that pharmacologic intervention will not be necessary once menstrual cycles become regularDiscuss ways the patient can avoid prolonged emotional stress and maintain a normal body mass indexFor excellent patient education resources visit medicines Womens Health Center
- Dysfunctional uterine bleeding
- Terms frequently used to describeabnormal uterine bleeding
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Treatment
- Treatment cont
- Slide 21
- Slide 22
- Slide 23
- Medication
- Slide 25
- Slide 26
- Slide 27
-
Polycystic ovary disease results in excess estrogen production and commonly presents as abnormal uterine bleedingPrimary coagulation disorders such as von Will brand disease myeloproliferative disorders and immune thrombocytopenia can present with menorrhagiaExcessive exercise stress and weight loss cause hypothalamic suppression leading to abnormal uterine bleeding due to disruption along the hypothalamus-pituitary-ovarian pathwayBleeding disturbances are common with combination oral contraceptive pills as well as progestin-only methods of birth control However the incidence of bleeding decreases significantly with time Therefore only counseling and reassurance are required during the early months of use Contraceptive intrauterine devices (IUDs) can cause variable vaginal bleeding for the first few cycles after placement and intermittent spotting subsequently The progesterone impregnated IUD (Mirena) is associated with less menometrorrhagia and usually results in secondary amenorrhea
-Causes
AbortionAbruptio PlacentaeAn ovulationAnticoagulantsAntipsychoticMalformationsCervical CancerCervicitisCoagulopathiesCushing SyndromeEndocervical PolypEndometrial CarcinomaEndometrial PolypEndometriosisEstrogen Therapy
-Differential Diagnoses
FibroidsHydatidiform MoleHypothyroidismIntrauterine devicesLiver diseaseMullerian Duct AnomaliesOvarian CystsPelvic Inflammatory DiseasePlacenta PreviaPlatelet Disordersvon Will brand DiseaseVulvovaginitis
When evaluating a woman of reproductive age with vaginal bleeding pregnancy must always be ruled out by urine or serum human chorionic gonadotropinIn a patient with any hemodynamic instability excessive bleeding or clinical evidence of anemia a complete blood count is essentialCoagulation studies should be considered when indicated by the history or physical examination findings and in patients with underlying liver disease or other coagulopathiesIn patients with suspected endocrine disorders other laboratory studies such as thyroid function tests and prolactin levels may be helpful although these results may not be available from the ED (endocrine disorders)
Pelvic ultrasonography is an important imaging modality for non pregnant patients with abnormal vaginal bleeding It may determine the etiology of the bleeding such as a fibroid uterus endometrial thickening or a focal mass
Thickened endometrium may indicate an underlying lesion or excess estrogen and may be suggestive of malignancy
An endometrial stripe measuring less than 4 mm thick is unlikely to have endometrial hyperplasia or cancer and biopsy is often considered unnecessary before treatmentWomen with a normal endometrial stripe (5ndash12 mm) may require biopsy particularly if they have risk factors for endometrial cancerWhen the endometrial stripe is larger than 12 mm a biopsy should be performed6
Imaging Studies
Depending on the urgency to determine the etiology of bleeding and on the reliability of outpatient follow-up ultrasonography may be deferred for outpatient evaluations because for the majority of nonpregnant patients ultrasonographic findings do not immediately affect ED decision-making3
Transvaginal ultrasonography may be particularly helpful in further delineating ovarian cysts and fluid in the cul-de-sacComputed tomography is used primarily for evaluation of other causes of acute abdominal or pelvic painMagnetic resonance imaging is used primarily for cancer staging
ProceduresBefore instituting therapy many consulting gynecologists perform endometrial sampling or biopsy to diagnose intrauterine pathology and to exclude endometrial malignancyEndometrial biopsy is indicated for the following patients with abnormal uterine bleeding6
Women older than 35 yearsObese patientsWomen who have prolonged periods of unopposed estrogen stimulationWomen with chronic an ovulation
Hysteroscopy is the definitive way to detect intrauterine lesions It offers a more complete examination of the surface of the endometrium However it is usually reserved for treating lesions that were detected by other less invasive means
TreatmentEmergency Department CareHemodynamically unstable patients with uncontrolled bleeding and signs of significant blood loss should have aggressive resuscitation with saline and blood as with other types of hemorrhagic shock
Evaluate ABCs and address the prioritiesInitiate 2 large-bore intravenous lines (IVs) oxygen and cardiac monitorIf bleeding is profuse and the patient is unresponsive to initial fluid management consider administration of IV conjugated estrogen (Premarin) 25 mg IV every 4-6 hours until the bleeding stopsIn women with severe persistent uterine bleeding an immediate dilation and curettage (DampC) procedure may be necessary
Treatment contCombination oral contraceptive pills may be used in women who are not pregnant and have no anatomic abnormalities An oral contraceptive with 35 mcg can be taken twice a day until the bleeding stops for up to 7 days at which time the dose is decreased to once a day until the pack is completed They provide the additional benefits of reducing dysmenorrhea and providing contraception Side effects include nausea and vomitingProgesterone alone can be used to stabilize an immature endometrium It is usually successful in the treatment of women with anovulatory dysfunctional uterine bleeding (DUB) because these women have unopposed estrogen stimulation Medroxyprogesterone acetate 10 mg is taken orally once daily for 10 days followed by withdrawal bleeding 3-5 days after completion of the course Currently there is not enough evidence comparing the effect of either progesterone alone or in combination with estrogens for the treatment of dysfunctional uterine bleeding7
Treatment contNo steroidal anti-inflammatory drugs (NSAIDs) are generally effective for the treatment of dysfunctional uterine bleeding and dysmenorrhea NSAIDs inhibiting prostaglandin synthesis and increasing thromboxane A2 levels
This leads to vasoconstriction and increased platelet aggregation These medications may reduce blood loss by 20-50 NSAIDs are most effective if used with the onset of menses or just prior to its onset and continued throughout its durationDanazol creates a hypoestrogenic and hyper androgenic environment which induces endometrial atrophy resulting in reduced menstrual loss Side effects include musculoskeletal pain breast atrophy hirsutism weight gain oily skin and acne Because of the significant androgenic side effects this drug is usually reserved as a second-line treatment for short-term use prior to surgeryGonadotropin-releasing hormone agonists may be helpful for short-term use in inducing amenorrhea and allowing women to rebuild their red blood cell mass They produce a profound hypoestrogenic state similar to menopause Side effects include menopausal symptoms and bone loss with long-term useTranexamic acid is an antifibrinolytic drug that exerts its effects by reversibly inhibiting plasminogen
Treatment contConsultationsSeek an emergency gynecologic consultation for patients requiring hemodynamic stabilization If parenteral therapy does not completely arrest vaginal bleeding in the hemodynamically unstable patient an emergency DampC may be warrantedConsultation with or urgent referral to a gynecologist for surgical treatment may be necessary for patients who do not desire fertility and in whom medical therapy fails Both endometrial ablation and hysterectomy are effective treatments in women with dysfunctional uterine bleeding with comparable patient satisfaction rates
Endometrial ablation is( a medical procedure that is used to remove (ablate) or destroy the endometrial lining of a uterus) may be performed using laser electrocautery or roller ball
Treatment contAmenorrhea is seen in approximately 35 of women treated and decreased flow is seen in another 45 although treatment failures increase with time following the procedure due to endometrial regeneration A substantial number of patients receiving endometrial ablation require reoperation (30 by 48 months)
Hysterectomy is the most effective treatment for bleeding However it is associated with more frequent and severe adverse events compared with either conservative medical or ablation procedures Operating time hospitalization recovery times and costs are also greater Hence hysterectomy is reserved for selected patient populations
MedicationThe goals of pharmacotherapy are to control the bleeding reduce morbidity and prevent complications Steroid hormonesContraceptive pills Medroxyprogesterone acetate (Provera)After acute bleeding episode controlled can be used alone in patients with adequate amounts of endogenous estrogen to cause endometrial growth Progestin therapy in adolescents produces regular cyclic withdrawal bleeding until positive feedback system matures Progestins stop endometrial growth and support and organize endometrium to allow organized sloughing after their withdrawal Bleeding ceases rapidly because of an organized slough to the basalis layer These drugs usually do not stop acute bleeding episodes yet produce a normal bleeding episode following their withdrawal
ComplicationsAnemia (may become severe)Adenocarcinoma of the uterus (if prolonged unopposed estrogen stimulation)PrognosisHormonal contraceptives reduce blood loss by 40-70 when used long termAlthough medical therapy is generally used first over half of women with menorrhagia undergo hysterectomy within 5 years of referral to a gynecologist[2 ]
Patient EducationInstruct patients to continue prescribed medications although bleeding may still be occurring during the early part of the cycle Also patients should be told to expect menses after cessation of the regimenYoung patients with small amounts of irregular bleeding need reassurance and observation only prior to instituting a drug regimen Express to patients that pharmacologic intervention will not be necessary once menstrual cycles become regularDiscuss ways the patient can avoid prolonged emotional stress and maintain a normal body mass indexFor excellent patient education resources visit medicines Womens Health Center
- Dysfunctional uterine bleeding
- Terms frequently used to describeabnormal uterine bleeding
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Treatment
- Treatment cont
- Slide 21
- Slide 22
- Slide 23
- Medication
- Slide 25
- Slide 26
- Slide 27
-
AbortionAbruptio PlacentaeAn ovulationAnticoagulantsAntipsychoticMalformationsCervical CancerCervicitisCoagulopathiesCushing SyndromeEndocervical PolypEndometrial CarcinomaEndometrial PolypEndometriosisEstrogen Therapy
-Differential Diagnoses
FibroidsHydatidiform MoleHypothyroidismIntrauterine devicesLiver diseaseMullerian Duct AnomaliesOvarian CystsPelvic Inflammatory DiseasePlacenta PreviaPlatelet Disordersvon Will brand DiseaseVulvovaginitis
When evaluating a woman of reproductive age with vaginal bleeding pregnancy must always be ruled out by urine or serum human chorionic gonadotropinIn a patient with any hemodynamic instability excessive bleeding or clinical evidence of anemia a complete blood count is essentialCoagulation studies should be considered when indicated by the history or physical examination findings and in patients with underlying liver disease or other coagulopathiesIn patients with suspected endocrine disorders other laboratory studies such as thyroid function tests and prolactin levels may be helpful although these results may not be available from the ED (endocrine disorders)
Pelvic ultrasonography is an important imaging modality for non pregnant patients with abnormal vaginal bleeding It may determine the etiology of the bleeding such as a fibroid uterus endometrial thickening or a focal mass
Thickened endometrium may indicate an underlying lesion or excess estrogen and may be suggestive of malignancy
An endometrial stripe measuring less than 4 mm thick is unlikely to have endometrial hyperplasia or cancer and biopsy is often considered unnecessary before treatmentWomen with a normal endometrial stripe (5ndash12 mm) may require biopsy particularly if they have risk factors for endometrial cancerWhen the endometrial stripe is larger than 12 mm a biopsy should be performed6
Imaging Studies
Depending on the urgency to determine the etiology of bleeding and on the reliability of outpatient follow-up ultrasonography may be deferred for outpatient evaluations because for the majority of nonpregnant patients ultrasonographic findings do not immediately affect ED decision-making3
Transvaginal ultrasonography may be particularly helpful in further delineating ovarian cysts and fluid in the cul-de-sacComputed tomography is used primarily for evaluation of other causes of acute abdominal or pelvic painMagnetic resonance imaging is used primarily for cancer staging
ProceduresBefore instituting therapy many consulting gynecologists perform endometrial sampling or biopsy to diagnose intrauterine pathology and to exclude endometrial malignancyEndometrial biopsy is indicated for the following patients with abnormal uterine bleeding6
Women older than 35 yearsObese patientsWomen who have prolonged periods of unopposed estrogen stimulationWomen with chronic an ovulation
Hysteroscopy is the definitive way to detect intrauterine lesions It offers a more complete examination of the surface of the endometrium However it is usually reserved for treating lesions that were detected by other less invasive means
TreatmentEmergency Department CareHemodynamically unstable patients with uncontrolled bleeding and signs of significant blood loss should have aggressive resuscitation with saline and blood as with other types of hemorrhagic shock
Evaluate ABCs and address the prioritiesInitiate 2 large-bore intravenous lines (IVs) oxygen and cardiac monitorIf bleeding is profuse and the patient is unresponsive to initial fluid management consider administration of IV conjugated estrogen (Premarin) 25 mg IV every 4-6 hours until the bleeding stopsIn women with severe persistent uterine bleeding an immediate dilation and curettage (DampC) procedure may be necessary
Treatment contCombination oral contraceptive pills may be used in women who are not pregnant and have no anatomic abnormalities An oral contraceptive with 35 mcg can be taken twice a day until the bleeding stops for up to 7 days at which time the dose is decreased to once a day until the pack is completed They provide the additional benefits of reducing dysmenorrhea and providing contraception Side effects include nausea and vomitingProgesterone alone can be used to stabilize an immature endometrium It is usually successful in the treatment of women with anovulatory dysfunctional uterine bleeding (DUB) because these women have unopposed estrogen stimulation Medroxyprogesterone acetate 10 mg is taken orally once daily for 10 days followed by withdrawal bleeding 3-5 days after completion of the course Currently there is not enough evidence comparing the effect of either progesterone alone or in combination with estrogens for the treatment of dysfunctional uterine bleeding7
Treatment contNo steroidal anti-inflammatory drugs (NSAIDs) are generally effective for the treatment of dysfunctional uterine bleeding and dysmenorrhea NSAIDs inhibiting prostaglandin synthesis and increasing thromboxane A2 levels
This leads to vasoconstriction and increased platelet aggregation These medications may reduce blood loss by 20-50 NSAIDs are most effective if used with the onset of menses or just prior to its onset and continued throughout its durationDanazol creates a hypoestrogenic and hyper androgenic environment which induces endometrial atrophy resulting in reduced menstrual loss Side effects include musculoskeletal pain breast atrophy hirsutism weight gain oily skin and acne Because of the significant androgenic side effects this drug is usually reserved as a second-line treatment for short-term use prior to surgeryGonadotropin-releasing hormone agonists may be helpful for short-term use in inducing amenorrhea and allowing women to rebuild their red blood cell mass They produce a profound hypoestrogenic state similar to menopause Side effects include menopausal symptoms and bone loss with long-term useTranexamic acid is an antifibrinolytic drug that exerts its effects by reversibly inhibiting plasminogen
Treatment contConsultationsSeek an emergency gynecologic consultation for patients requiring hemodynamic stabilization If parenteral therapy does not completely arrest vaginal bleeding in the hemodynamically unstable patient an emergency DampC may be warrantedConsultation with or urgent referral to a gynecologist for surgical treatment may be necessary for patients who do not desire fertility and in whom medical therapy fails Both endometrial ablation and hysterectomy are effective treatments in women with dysfunctional uterine bleeding with comparable patient satisfaction rates
Endometrial ablation is( a medical procedure that is used to remove (ablate) or destroy the endometrial lining of a uterus) may be performed using laser electrocautery or roller ball
Treatment contAmenorrhea is seen in approximately 35 of women treated and decreased flow is seen in another 45 although treatment failures increase with time following the procedure due to endometrial regeneration A substantial number of patients receiving endometrial ablation require reoperation (30 by 48 months)
Hysterectomy is the most effective treatment for bleeding However it is associated with more frequent and severe adverse events compared with either conservative medical or ablation procedures Operating time hospitalization recovery times and costs are also greater Hence hysterectomy is reserved for selected patient populations
MedicationThe goals of pharmacotherapy are to control the bleeding reduce morbidity and prevent complications Steroid hormonesContraceptive pills Medroxyprogesterone acetate (Provera)After acute bleeding episode controlled can be used alone in patients with adequate amounts of endogenous estrogen to cause endometrial growth Progestin therapy in adolescents produces regular cyclic withdrawal bleeding until positive feedback system matures Progestins stop endometrial growth and support and organize endometrium to allow organized sloughing after their withdrawal Bleeding ceases rapidly because of an organized slough to the basalis layer These drugs usually do not stop acute bleeding episodes yet produce a normal bleeding episode following their withdrawal
ComplicationsAnemia (may become severe)Adenocarcinoma of the uterus (if prolonged unopposed estrogen stimulation)PrognosisHormonal contraceptives reduce blood loss by 40-70 when used long termAlthough medical therapy is generally used first over half of women with menorrhagia undergo hysterectomy within 5 years of referral to a gynecologist[2 ]
Patient EducationInstruct patients to continue prescribed medications although bleeding may still be occurring during the early part of the cycle Also patients should be told to expect menses after cessation of the regimenYoung patients with small amounts of irregular bleeding need reassurance and observation only prior to instituting a drug regimen Express to patients that pharmacologic intervention will not be necessary once menstrual cycles become regularDiscuss ways the patient can avoid prolonged emotional stress and maintain a normal body mass indexFor excellent patient education resources visit medicines Womens Health Center
- Dysfunctional uterine bleeding
- Terms frequently used to describeabnormal uterine bleeding
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Treatment
- Treatment cont
- Slide 21
- Slide 22
- Slide 23
- Medication
- Slide 25
- Slide 26
- Slide 27
-
When evaluating a woman of reproductive age with vaginal bleeding pregnancy must always be ruled out by urine or serum human chorionic gonadotropinIn a patient with any hemodynamic instability excessive bleeding or clinical evidence of anemia a complete blood count is essentialCoagulation studies should be considered when indicated by the history or physical examination findings and in patients with underlying liver disease or other coagulopathiesIn patients with suspected endocrine disorders other laboratory studies such as thyroid function tests and prolactin levels may be helpful although these results may not be available from the ED (endocrine disorders)
Pelvic ultrasonography is an important imaging modality for non pregnant patients with abnormal vaginal bleeding It may determine the etiology of the bleeding such as a fibroid uterus endometrial thickening or a focal mass
Thickened endometrium may indicate an underlying lesion or excess estrogen and may be suggestive of malignancy
An endometrial stripe measuring less than 4 mm thick is unlikely to have endometrial hyperplasia or cancer and biopsy is often considered unnecessary before treatmentWomen with a normal endometrial stripe (5ndash12 mm) may require biopsy particularly if they have risk factors for endometrial cancerWhen the endometrial stripe is larger than 12 mm a biopsy should be performed6
Imaging Studies
Depending on the urgency to determine the etiology of bleeding and on the reliability of outpatient follow-up ultrasonography may be deferred for outpatient evaluations because for the majority of nonpregnant patients ultrasonographic findings do not immediately affect ED decision-making3
Transvaginal ultrasonography may be particularly helpful in further delineating ovarian cysts and fluid in the cul-de-sacComputed tomography is used primarily for evaluation of other causes of acute abdominal or pelvic painMagnetic resonance imaging is used primarily for cancer staging
ProceduresBefore instituting therapy many consulting gynecologists perform endometrial sampling or biopsy to diagnose intrauterine pathology and to exclude endometrial malignancyEndometrial biopsy is indicated for the following patients with abnormal uterine bleeding6
Women older than 35 yearsObese patientsWomen who have prolonged periods of unopposed estrogen stimulationWomen with chronic an ovulation
Hysteroscopy is the definitive way to detect intrauterine lesions It offers a more complete examination of the surface of the endometrium However it is usually reserved for treating lesions that were detected by other less invasive means
TreatmentEmergency Department CareHemodynamically unstable patients with uncontrolled bleeding and signs of significant blood loss should have aggressive resuscitation with saline and blood as with other types of hemorrhagic shock
Evaluate ABCs and address the prioritiesInitiate 2 large-bore intravenous lines (IVs) oxygen and cardiac monitorIf bleeding is profuse and the patient is unresponsive to initial fluid management consider administration of IV conjugated estrogen (Premarin) 25 mg IV every 4-6 hours until the bleeding stopsIn women with severe persistent uterine bleeding an immediate dilation and curettage (DampC) procedure may be necessary
Treatment contCombination oral contraceptive pills may be used in women who are not pregnant and have no anatomic abnormalities An oral contraceptive with 35 mcg can be taken twice a day until the bleeding stops for up to 7 days at which time the dose is decreased to once a day until the pack is completed They provide the additional benefits of reducing dysmenorrhea and providing contraception Side effects include nausea and vomitingProgesterone alone can be used to stabilize an immature endometrium It is usually successful in the treatment of women with anovulatory dysfunctional uterine bleeding (DUB) because these women have unopposed estrogen stimulation Medroxyprogesterone acetate 10 mg is taken orally once daily for 10 days followed by withdrawal bleeding 3-5 days after completion of the course Currently there is not enough evidence comparing the effect of either progesterone alone or in combination with estrogens for the treatment of dysfunctional uterine bleeding7
Treatment contNo steroidal anti-inflammatory drugs (NSAIDs) are generally effective for the treatment of dysfunctional uterine bleeding and dysmenorrhea NSAIDs inhibiting prostaglandin synthesis and increasing thromboxane A2 levels
This leads to vasoconstriction and increased platelet aggregation These medications may reduce blood loss by 20-50 NSAIDs are most effective if used with the onset of menses or just prior to its onset and continued throughout its durationDanazol creates a hypoestrogenic and hyper androgenic environment which induces endometrial atrophy resulting in reduced menstrual loss Side effects include musculoskeletal pain breast atrophy hirsutism weight gain oily skin and acne Because of the significant androgenic side effects this drug is usually reserved as a second-line treatment for short-term use prior to surgeryGonadotropin-releasing hormone agonists may be helpful for short-term use in inducing amenorrhea and allowing women to rebuild their red blood cell mass They produce a profound hypoestrogenic state similar to menopause Side effects include menopausal symptoms and bone loss with long-term useTranexamic acid is an antifibrinolytic drug that exerts its effects by reversibly inhibiting plasminogen
Treatment contConsultationsSeek an emergency gynecologic consultation for patients requiring hemodynamic stabilization If parenteral therapy does not completely arrest vaginal bleeding in the hemodynamically unstable patient an emergency DampC may be warrantedConsultation with or urgent referral to a gynecologist for surgical treatment may be necessary for patients who do not desire fertility and in whom medical therapy fails Both endometrial ablation and hysterectomy are effective treatments in women with dysfunctional uterine bleeding with comparable patient satisfaction rates
Endometrial ablation is( a medical procedure that is used to remove (ablate) or destroy the endometrial lining of a uterus) may be performed using laser electrocautery or roller ball
Treatment contAmenorrhea is seen in approximately 35 of women treated and decreased flow is seen in another 45 although treatment failures increase with time following the procedure due to endometrial regeneration A substantial number of patients receiving endometrial ablation require reoperation (30 by 48 months)
Hysterectomy is the most effective treatment for bleeding However it is associated with more frequent and severe adverse events compared with either conservative medical or ablation procedures Operating time hospitalization recovery times and costs are also greater Hence hysterectomy is reserved for selected patient populations
MedicationThe goals of pharmacotherapy are to control the bleeding reduce morbidity and prevent complications Steroid hormonesContraceptive pills Medroxyprogesterone acetate (Provera)After acute bleeding episode controlled can be used alone in patients with adequate amounts of endogenous estrogen to cause endometrial growth Progestin therapy in adolescents produces regular cyclic withdrawal bleeding until positive feedback system matures Progestins stop endometrial growth and support and organize endometrium to allow organized sloughing after their withdrawal Bleeding ceases rapidly because of an organized slough to the basalis layer These drugs usually do not stop acute bleeding episodes yet produce a normal bleeding episode following their withdrawal
ComplicationsAnemia (may become severe)Adenocarcinoma of the uterus (if prolonged unopposed estrogen stimulation)PrognosisHormonal contraceptives reduce blood loss by 40-70 when used long termAlthough medical therapy is generally used first over half of women with menorrhagia undergo hysterectomy within 5 years of referral to a gynecologist[2 ]
Patient EducationInstruct patients to continue prescribed medications although bleeding may still be occurring during the early part of the cycle Also patients should be told to expect menses after cessation of the regimenYoung patients with small amounts of irregular bleeding need reassurance and observation only prior to instituting a drug regimen Express to patients that pharmacologic intervention will not be necessary once menstrual cycles become regularDiscuss ways the patient can avoid prolonged emotional stress and maintain a normal body mass indexFor excellent patient education resources visit medicines Womens Health Center
- Dysfunctional uterine bleeding
- Terms frequently used to describeabnormal uterine bleeding
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Treatment
- Treatment cont
- Slide 21
- Slide 22
- Slide 23
- Medication
- Slide 25
- Slide 26
- Slide 27
-
Pelvic ultrasonography is an important imaging modality for non pregnant patients with abnormal vaginal bleeding It may determine the etiology of the bleeding such as a fibroid uterus endometrial thickening or a focal mass
Thickened endometrium may indicate an underlying lesion or excess estrogen and may be suggestive of malignancy
An endometrial stripe measuring less than 4 mm thick is unlikely to have endometrial hyperplasia or cancer and biopsy is often considered unnecessary before treatmentWomen with a normal endometrial stripe (5ndash12 mm) may require biopsy particularly if they have risk factors for endometrial cancerWhen the endometrial stripe is larger than 12 mm a biopsy should be performed6
Imaging Studies
Depending on the urgency to determine the etiology of bleeding and on the reliability of outpatient follow-up ultrasonography may be deferred for outpatient evaluations because for the majority of nonpregnant patients ultrasonographic findings do not immediately affect ED decision-making3
Transvaginal ultrasonography may be particularly helpful in further delineating ovarian cysts and fluid in the cul-de-sacComputed tomography is used primarily for evaluation of other causes of acute abdominal or pelvic painMagnetic resonance imaging is used primarily for cancer staging
ProceduresBefore instituting therapy many consulting gynecologists perform endometrial sampling or biopsy to diagnose intrauterine pathology and to exclude endometrial malignancyEndometrial biopsy is indicated for the following patients with abnormal uterine bleeding6
Women older than 35 yearsObese patientsWomen who have prolonged periods of unopposed estrogen stimulationWomen with chronic an ovulation
Hysteroscopy is the definitive way to detect intrauterine lesions It offers a more complete examination of the surface of the endometrium However it is usually reserved for treating lesions that were detected by other less invasive means
TreatmentEmergency Department CareHemodynamically unstable patients with uncontrolled bleeding and signs of significant blood loss should have aggressive resuscitation with saline and blood as with other types of hemorrhagic shock
Evaluate ABCs and address the prioritiesInitiate 2 large-bore intravenous lines (IVs) oxygen and cardiac monitorIf bleeding is profuse and the patient is unresponsive to initial fluid management consider administration of IV conjugated estrogen (Premarin) 25 mg IV every 4-6 hours until the bleeding stopsIn women with severe persistent uterine bleeding an immediate dilation and curettage (DampC) procedure may be necessary
Treatment contCombination oral contraceptive pills may be used in women who are not pregnant and have no anatomic abnormalities An oral contraceptive with 35 mcg can be taken twice a day until the bleeding stops for up to 7 days at which time the dose is decreased to once a day until the pack is completed They provide the additional benefits of reducing dysmenorrhea and providing contraception Side effects include nausea and vomitingProgesterone alone can be used to stabilize an immature endometrium It is usually successful in the treatment of women with anovulatory dysfunctional uterine bleeding (DUB) because these women have unopposed estrogen stimulation Medroxyprogesterone acetate 10 mg is taken orally once daily for 10 days followed by withdrawal bleeding 3-5 days after completion of the course Currently there is not enough evidence comparing the effect of either progesterone alone or in combination with estrogens for the treatment of dysfunctional uterine bleeding7
Treatment contNo steroidal anti-inflammatory drugs (NSAIDs) are generally effective for the treatment of dysfunctional uterine bleeding and dysmenorrhea NSAIDs inhibiting prostaglandin synthesis and increasing thromboxane A2 levels
This leads to vasoconstriction and increased platelet aggregation These medications may reduce blood loss by 20-50 NSAIDs are most effective if used with the onset of menses or just prior to its onset and continued throughout its durationDanazol creates a hypoestrogenic and hyper androgenic environment which induces endometrial atrophy resulting in reduced menstrual loss Side effects include musculoskeletal pain breast atrophy hirsutism weight gain oily skin and acne Because of the significant androgenic side effects this drug is usually reserved as a second-line treatment for short-term use prior to surgeryGonadotropin-releasing hormone agonists may be helpful for short-term use in inducing amenorrhea and allowing women to rebuild their red blood cell mass They produce a profound hypoestrogenic state similar to menopause Side effects include menopausal symptoms and bone loss with long-term useTranexamic acid is an antifibrinolytic drug that exerts its effects by reversibly inhibiting plasminogen
Treatment contConsultationsSeek an emergency gynecologic consultation for patients requiring hemodynamic stabilization If parenteral therapy does not completely arrest vaginal bleeding in the hemodynamically unstable patient an emergency DampC may be warrantedConsultation with or urgent referral to a gynecologist for surgical treatment may be necessary for patients who do not desire fertility and in whom medical therapy fails Both endometrial ablation and hysterectomy are effective treatments in women with dysfunctional uterine bleeding with comparable patient satisfaction rates
Endometrial ablation is( a medical procedure that is used to remove (ablate) or destroy the endometrial lining of a uterus) may be performed using laser electrocautery or roller ball
Treatment contAmenorrhea is seen in approximately 35 of women treated and decreased flow is seen in another 45 although treatment failures increase with time following the procedure due to endometrial regeneration A substantial number of patients receiving endometrial ablation require reoperation (30 by 48 months)
Hysterectomy is the most effective treatment for bleeding However it is associated with more frequent and severe adverse events compared with either conservative medical or ablation procedures Operating time hospitalization recovery times and costs are also greater Hence hysterectomy is reserved for selected patient populations
MedicationThe goals of pharmacotherapy are to control the bleeding reduce morbidity and prevent complications Steroid hormonesContraceptive pills Medroxyprogesterone acetate (Provera)After acute bleeding episode controlled can be used alone in patients with adequate amounts of endogenous estrogen to cause endometrial growth Progestin therapy in adolescents produces regular cyclic withdrawal bleeding until positive feedback system matures Progestins stop endometrial growth and support and organize endometrium to allow organized sloughing after their withdrawal Bleeding ceases rapidly because of an organized slough to the basalis layer These drugs usually do not stop acute bleeding episodes yet produce a normal bleeding episode following their withdrawal
ComplicationsAnemia (may become severe)Adenocarcinoma of the uterus (if prolonged unopposed estrogen stimulation)PrognosisHormonal contraceptives reduce blood loss by 40-70 when used long termAlthough medical therapy is generally used first over half of women with menorrhagia undergo hysterectomy within 5 years of referral to a gynecologist[2 ]
Patient EducationInstruct patients to continue prescribed medications although bleeding may still be occurring during the early part of the cycle Also patients should be told to expect menses after cessation of the regimenYoung patients with small amounts of irregular bleeding need reassurance and observation only prior to instituting a drug regimen Express to patients that pharmacologic intervention will not be necessary once menstrual cycles become regularDiscuss ways the patient can avoid prolonged emotional stress and maintain a normal body mass indexFor excellent patient education resources visit medicines Womens Health Center
- Dysfunctional uterine bleeding
- Terms frequently used to describeabnormal uterine bleeding
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Treatment
- Treatment cont
- Slide 21
- Slide 22
- Slide 23
- Medication
- Slide 25
- Slide 26
- Slide 27
-
Depending on the urgency to determine the etiology of bleeding and on the reliability of outpatient follow-up ultrasonography may be deferred for outpatient evaluations because for the majority of nonpregnant patients ultrasonographic findings do not immediately affect ED decision-making3
Transvaginal ultrasonography may be particularly helpful in further delineating ovarian cysts and fluid in the cul-de-sacComputed tomography is used primarily for evaluation of other causes of acute abdominal or pelvic painMagnetic resonance imaging is used primarily for cancer staging
ProceduresBefore instituting therapy many consulting gynecologists perform endometrial sampling or biopsy to diagnose intrauterine pathology and to exclude endometrial malignancyEndometrial biopsy is indicated for the following patients with abnormal uterine bleeding6
Women older than 35 yearsObese patientsWomen who have prolonged periods of unopposed estrogen stimulationWomen with chronic an ovulation
Hysteroscopy is the definitive way to detect intrauterine lesions It offers a more complete examination of the surface of the endometrium However it is usually reserved for treating lesions that were detected by other less invasive means
TreatmentEmergency Department CareHemodynamically unstable patients with uncontrolled bleeding and signs of significant blood loss should have aggressive resuscitation with saline and blood as with other types of hemorrhagic shock
Evaluate ABCs and address the prioritiesInitiate 2 large-bore intravenous lines (IVs) oxygen and cardiac monitorIf bleeding is profuse and the patient is unresponsive to initial fluid management consider administration of IV conjugated estrogen (Premarin) 25 mg IV every 4-6 hours until the bleeding stopsIn women with severe persistent uterine bleeding an immediate dilation and curettage (DampC) procedure may be necessary
Treatment contCombination oral contraceptive pills may be used in women who are not pregnant and have no anatomic abnormalities An oral contraceptive with 35 mcg can be taken twice a day until the bleeding stops for up to 7 days at which time the dose is decreased to once a day until the pack is completed They provide the additional benefits of reducing dysmenorrhea and providing contraception Side effects include nausea and vomitingProgesterone alone can be used to stabilize an immature endometrium It is usually successful in the treatment of women with anovulatory dysfunctional uterine bleeding (DUB) because these women have unopposed estrogen stimulation Medroxyprogesterone acetate 10 mg is taken orally once daily for 10 days followed by withdrawal bleeding 3-5 days after completion of the course Currently there is not enough evidence comparing the effect of either progesterone alone or in combination with estrogens for the treatment of dysfunctional uterine bleeding7
Treatment contNo steroidal anti-inflammatory drugs (NSAIDs) are generally effective for the treatment of dysfunctional uterine bleeding and dysmenorrhea NSAIDs inhibiting prostaglandin synthesis and increasing thromboxane A2 levels
This leads to vasoconstriction and increased platelet aggregation These medications may reduce blood loss by 20-50 NSAIDs are most effective if used with the onset of menses or just prior to its onset and continued throughout its durationDanazol creates a hypoestrogenic and hyper androgenic environment which induces endometrial atrophy resulting in reduced menstrual loss Side effects include musculoskeletal pain breast atrophy hirsutism weight gain oily skin and acne Because of the significant androgenic side effects this drug is usually reserved as a second-line treatment for short-term use prior to surgeryGonadotropin-releasing hormone agonists may be helpful for short-term use in inducing amenorrhea and allowing women to rebuild their red blood cell mass They produce a profound hypoestrogenic state similar to menopause Side effects include menopausal symptoms and bone loss with long-term useTranexamic acid is an antifibrinolytic drug that exerts its effects by reversibly inhibiting plasminogen
Treatment contConsultationsSeek an emergency gynecologic consultation for patients requiring hemodynamic stabilization If parenteral therapy does not completely arrest vaginal bleeding in the hemodynamically unstable patient an emergency DampC may be warrantedConsultation with or urgent referral to a gynecologist for surgical treatment may be necessary for patients who do not desire fertility and in whom medical therapy fails Both endometrial ablation and hysterectomy are effective treatments in women with dysfunctional uterine bleeding with comparable patient satisfaction rates
Endometrial ablation is( a medical procedure that is used to remove (ablate) or destroy the endometrial lining of a uterus) may be performed using laser electrocautery or roller ball
Treatment contAmenorrhea is seen in approximately 35 of women treated and decreased flow is seen in another 45 although treatment failures increase with time following the procedure due to endometrial regeneration A substantial number of patients receiving endometrial ablation require reoperation (30 by 48 months)
Hysterectomy is the most effective treatment for bleeding However it is associated with more frequent and severe adverse events compared with either conservative medical or ablation procedures Operating time hospitalization recovery times and costs are also greater Hence hysterectomy is reserved for selected patient populations
MedicationThe goals of pharmacotherapy are to control the bleeding reduce morbidity and prevent complications Steroid hormonesContraceptive pills Medroxyprogesterone acetate (Provera)After acute bleeding episode controlled can be used alone in patients with adequate amounts of endogenous estrogen to cause endometrial growth Progestin therapy in adolescents produces regular cyclic withdrawal bleeding until positive feedback system matures Progestins stop endometrial growth and support and organize endometrium to allow organized sloughing after their withdrawal Bleeding ceases rapidly because of an organized slough to the basalis layer These drugs usually do not stop acute bleeding episodes yet produce a normal bleeding episode following their withdrawal
ComplicationsAnemia (may become severe)Adenocarcinoma of the uterus (if prolonged unopposed estrogen stimulation)PrognosisHormonal contraceptives reduce blood loss by 40-70 when used long termAlthough medical therapy is generally used first over half of women with menorrhagia undergo hysterectomy within 5 years of referral to a gynecologist[2 ]
Patient EducationInstruct patients to continue prescribed medications although bleeding may still be occurring during the early part of the cycle Also patients should be told to expect menses after cessation of the regimenYoung patients with small amounts of irregular bleeding need reassurance and observation only prior to instituting a drug regimen Express to patients that pharmacologic intervention will not be necessary once menstrual cycles become regularDiscuss ways the patient can avoid prolonged emotional stress and maintain a normal body mass indexFor excellent patient education resources visit medicines Womens Health Center
- Dysfunctional uterine bleeding
- Terms frequently used to describeabnormal uterine bleeding
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Treatment
- Treatment cont
- Slide 21
- Slide 22
- Slide 23
- Medication
- Slide 25
- Slide 26
- Slide 27
-
ProceduresBefore instituting therapy many consulting gynecologists perform endometrial sampling or biopsy to diagnose intrauterine pathology and to exclude endometrial malignancyEndometrial biopsy is indicated for the following patients with abnormal uterine bleeding6
Women older than 35 yearsObese patientsWomen who have prolonged periods of unopposed estrogen stimulationWomen with chronic an ovulation
Hysteroscopy is the definitive way to detect intrauterine lesions It offers a more complete examination of the surface of the endometrium However it is usually reserved for treating lesions that were detected by other less invasive means
TreatmentEmergency Department CareHemodynamically unstable patients with uncontrolled bleeding and signs of significant blood loss should have aggressive resuscitation with saline and blood as with other types of hemorrhagic shock
Evaluate ABCs and address the prioritiesInitiate 2 large-bore intravenous lines (IVs) oxygen and cardiac monitorIf bleeding is profuse and the patient is unresponsive to initial fluid management consider administration of IV conjugated estrogen (Premarin) 25 mg IV every 4-6 hours until the bleeding stopsIn women with severe persistent uterine bleeding an immediate dilation and curettage (DampC) procedure may be necessary
Treatment contCombination oral contraceptive pills may be used in women who are not pregnant and have no anatomic abnormalities An oral contraceptive with 35 mcg can be taken twice a day until the bleeding stops for up to 7 days at which time the dose is decreased to once a day until the pack is completed They provide the additional benefits of reducing dysmenorrhea and providing contraception Side effects include nausea and vomitingProgesterone alone can be used to stabilize an immature endometrium It is usually successful in the treatment of women with anovulatory dysfunctional uterine bleeding (DUB) because these women have unopposed estrogen stimulation Medroxyprogesterone acetate 10 mg is taken orally once daily for 10 days followed by withdrawal bleeding 3-5 days after completion of the course Currently there is not enough evidence comparing the effect of either progesterone alone or in combination with estrogens for the treatment of dysfunctional uterine bleeding7
Treatment contNo steroidal anti-inflammatory drugs (NSAIDs) are generally effective for the treatment of dysfunctional uterine bleeding and dysmenorrhea NSAIDs inhibiting prostaglandin synthesis and increasing thromboxane A2 levels
This leads to vasoconstriction and increased platelet aggregation These medications may reduce blood loss by 20-50 NSAIDs are most effective if used with the onset of menses or just prior to its onset and continued throughout its durationDanazol creates a hypoestrogenic and hyper androgenic environment which induces endometrial atrophy resulting in reduced menstrual loss Side effects include musculoskeletal pain breast atrophy hirsutism weight gain oily skin and acne Because of the significant androgenic side effects this drug is usually reserved as a second-line treatment for short-term use prior to surgeryGonadotropin-releasing hormone agonists may be helpful for short-term use in inducing amenorrhea and allowing women to rebuild their red blood cell mass They produce a profound hypoestrogenic state similar to menopause Side effects include menopausal symptoms and bone loss with long-term useTranexamic acid is an antifibrinolytic drug that exerts its effects by reversibly inhibiting plasminogen
Treatment contConsultationsSeek an emergency gynecologic consultation for patients requiring hemodynamic stabilization If parenteral therapy does not completely arrest vaginal bleeding in the hemodynamically unstable patient an emergency DampC may be warrantedConsultation with or urgent referral to a gynecologist for surgical treatment may be necessary for patients who do not desire fertility and in whom medical therapy fails Both endometrial ablation and hysterectomy are effective treatments in women with dysfunctional uterine bleeding with comparable patient satisfaction rates
Endometrial ablation is( a medical procedure that is used to remove (ablate) or destroy the endometrial lining of a uterus) may be performed using laser electrocautery or roller ball
Treatment contAmenorrhea is seen in approximately 35 of women treated and decreased flow is seen in another 45 although treatment failures increase with time following the procedure due to endometrial regeneration A substantial number of patients receiving endometrial ablation require reoperation (30 by 48 months)
Hysterectomy is the most effective treatment for bleeding However it is associated with more frequent and severe adverse events compared with either conservative medical or ablation procedures Operating time hospitalization recovery times and costs are also greater Hence hysterectomy is reserved for selected patient populations
MedicationThe goals of pharmacotherapy are to control the bleeding reduce morbidity and prevent complications Steroid hormonesContraceptive pills Medroxyprogesterone acetate (Provera)After acute bleeding episode controlled can be used alone in patients with adequate amounts of endogenous estrogen to cause endometrial growth Progestin therapy in adolescents produces regular cyclic withdrawal bleeding until positive feedback system matures Progestins stop endometrial growth and support and organize endometrium to allow organized sloughing after their withdrawal Bleeding ceases rapidly because of an organized slough to the basalis layer These drugs usually do not stop acute bleeding episodes yet produce a normal bleeding episode following their withdrawal
ComplicationsAnemia (may become severe)Adenocarcinoma of the uterus (if prolonged unopposed estrogen stimulation)PrognosisHormonal contraceptives reduce blood loss by 40-70 when used long termAlthough medical therapy is generally used first over half of women with menorrhagia undergo hysterectomy within 5 years of referral to a gynecologist[2 ]
Patient EducationInstruct patients to continue prescribed medications although bleeding may still be occurring during the early part of the cycle Also patients should be told to expect menses after cessation of the regimenYoung patients with small amounts of irregular bleeding need reassurance and observation only prior to instituting a drug regimen Express to patients that pharmacologic intervention will not be necessary once menstrual cycles become regularDiscuss ways the patient can avoid prolonged emotional stress and maintain a normal body mass indexFor excellent patient education resources visit medicines Womens Health Center
- Dysfunctional uterine bleeding
- Terms frequently used to describeabnormal uterine bleeding
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Treatment
- Treatment cont
- Slide 21
- Slide 22
- Slide 23
- Medication
- Slide 25
- Slide 26
- Slide 27
-
TreatmentEmergency Department CareHemodynamically unstable patients with uncontrolled bleeding and signs of significant blood loss should have aggressive resuscitation with saline and blood as with other types of hemorrhagic shock
Evaluate ABCs and address the prioritiesInitiate 2 large-bore intravenous lines (IVs) oxygen and cardiac monitorIf bleeding is profuse and the patient is unresponsive to initial fluid management consider administration of IV conjugated estrogen (Premarin) 25 mg IV every 4-6 hours until the bleeding stopsIn women with severe persistent uterine bleeding an immediate dilation and curettage (DampC) procedure may be necessary
Treatment contCombination oral contraceptive pills may be used in women who are not pregnant and have no anatomic abnormalities An oral contraceptive with 35 mcg can be taken twice a day until the bleeding stops for up to 7 days at which time the dose is decreased to once a day until the pack is completed They provide the additional benefits of reducing dysmenorrhea and providing contraception Side effects include nausea and vomitingProgesterone alone can be used to stabilize an immature endometrium It is usually successful in the treatment of women with anovulatory dysfunctional uterine bleeding (DUB) because these women have unopposed estrogen stimulation Medroxyprogesterone acetate 10 mg is taken orally once daily for 10 days followed by withdrawal bleeding 3-5 days after completion of the course Currently there is not enough evidence comparing the effect of either progesterone alone or in combination with estrogens for the treatment of dysfunctional uterine bleeding7
Treatment contNo steroidal anti-inflammatory drugs (NSAIDs) are generally effective for the treatment of dysfunctional uterine bleeding and dysmenorrhea NSAIDs inhibiting prostaglandin synthesis and increasing thromboxane A2 levels
This leads to vasoconstriction and increased platelet aggregation These medications may reduce blood loss by 20-50 NSAIDs are most effective if used with the onset of menses or just prior to its onset and continued throughout its durationDanazol creates a hypoestrogenic and hyper androgenic environment which induces endometrial atrophy resulting in reduced menstrual loss Side effects include musculoskeletal pain breast atrophy hirsutism weight gain oily skin and acne Because of the significant androgenic side effects this drug is usually reserved as a second-line treatment for short-term use prior to surgeryGonadotropin-releasing hormone agonists may be helpful for short-term use in inducing amenorrhea and allowing women to rebuild their red blood cell mass They produce a profound hypoestrogenic state similar to menopause Side effects include menopausal symptoms and bone loss with long-term useTranexamic acid is an antifibrinolytic drug that exerts its effects by reversibly inhibiting plasminogen
Treatment contConsultationsSeek an emergency gynecologic consultation for patients requiring hemodynamic stabilization If parenteral therapy does not completely arrest vaginal bleeding in the hemodynamically unstable patient an emergency DampC may be warrantedConsultation with or urgent referral to a gynecologist for surgical treatment may be necessary for patients who do not desire fertility and in whom medical therapy fails Both endometrial ablation and hysterectomy are effective treatments in women with dysfunctional uterine bleeding with comparable patient satisfaction rates
Endometrial ablation is( a medical procedure that is used to remove (ablate) or destroy the endometrial lining of a uterus) may be performed using laser electrocautery or roller ball
Treatment contAmenorrhea is seen in approximately 35 of women treated and decreased flow is seen in another 45 although treatment failures increase with time following the procedure due to endometrial regeneration A substantial number of patients receiving endometrial ablation require reoperation (30 by 48 months)
Hysterectomy is the most effective treatment for bleeding However it is associated with more frequent and severe adverse events compared with either conservative medical or ablation procedures Operating time hospitalization recovery times and costs are also greater Hence hysterectomy is reserved for selected patient populations
MedicationThe goals of pharmacotherapy are to control the bleeding reduce morbidity and prevent complications Steroid hormonesContraceptive pills Medroxyprogesterone acetate (Provera)After acute bleeding episode controlled can be used alone in patients with adequate amounts of endogenous estrogen to cause endometrial growth Progestin therapy in adolescents produces regular cyclic withdrawal bleeding until positive feedback system matures Progestins stop endometrial growth and support and organize endometrium to allow organized sloughing after their withdrawal Bleeding ceases rapidly because of an organized slough to the basalis layer These drugs usually do not stop acute bleeding episodes yet produce a normal bleeding episode following their withdrawal
ComplicationsAnemia (may become severe)Adenocarcinoma of the uterus (if prolonged unopposed estrogen stimulation)PrognosisHormonal contraceptives reduce blood loss by 40-70 when used long termAlthough medical therapy is generally used first over half of women with menorrhagia undergo hysterectomy within 5 years of referral to a gynecologist[2 ]
Patient EducationInstruct patients to continue prescribed medications although bleeding may still be occurring during the early part of the cycle Also patients should be told to expect menses after cessation of the regimenYoung patients with small amounts of irregular bleeding need reassurance and observation only prior to instituting a drug regimen Express to patients that pharmacologic intervention will not be necessary once menstrual cycles become regularDiscuss ways the patient can avoid prolonged emotional stress and maintain a normal body mass indexFor excellent patient education resources visit medicines Womens Health Center
- Dysfunctional uterine bleeding
- Terms frequently used to describeabnormal uterine bleeding
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Treatment
- Treatment cont
- Slide 21
- Slide 22
- Slide 23
- Medication
- Slide 25
- Slide 26
- Slide 27
-
Treatment contCombination oral contraceptive pills may be used in women who are not pregnant and have no anatomic abnormalities An oral contraceptive with 35 mcg can be taken twice a day until the bleeding stops for up to 7 days at which time the dose is decreased to once a day until the pack is completed They provide the additional benefits of reducing dysmenorrhea and providing contraception Side effects include nausea and vomitingProgesterone alone can be used to stabilize an immature endometrium It is usually successful in the treatment of women with anovulatory dysfunctional uterine bleeding (DUB) because these women have unopposed estrogen stimulation Medroxyprogesterone acetate 10 mg is taken orally once daily for 10 days followed by withdrawal bleeding 3-5 days after completion of the course Currently there is not enough evidence comparing the effect of either progesterone alone or in combination with estrogens for the treatment of dysfunctional uterine bleeding7
Treatment contNo steroidal anti-inflammatory drugs (NSAIDs) are generally effective for the treatment of dysfunctional uterine bleeding and dysmenorrhea NSAIDs inhibiting prostaglandin synthesis and increasing thromboxane A2 levels
This leads to vasoconstriction and increased platelet aggregation These medications may reduce blood loss by 20-50 NSAIDs are most effective if used with the onset of menses or just prior to its onset and continued throughout its durationDanazol creates a hypoestrogenic and hyper androgenic environment which induces endometrial atrophy resulting in reduced menstrual loss Side effects include musculoskeletal pain breast atrophy hirsutism weight gain oily skin and acne Because of the significant androgenic side effects this drug is usually reserved as a second-line treatment for short-term use prior to surgeryGonadotropin-releasing hormone agonists may be helpful for short-term use in inducing amenorrhea and allowing women to rebuild their red blood cell mass They produce a profound hypoestrogenic state similar to menopause Side effects include menopausal symptoms and bone loss with long-term useTranexamic acid is an antifibrinolytic drug that exerts its effects by reversibly inhibiting plasminogen
Treatment contConsultationsSeek an emergency gynecologic consultation for patients requiring hemodynamic stabilization If parenteral therapy does not completely arrest vaginal bleeding in the hemodynamically unstable patient an emergency DampC may be warrantedConsultation with or urgent referral to a gynecologist for surgical treatment may be necessary for patients who do not desire fertility and in whom medical therapy fails Both endometrial ablation and hysterectomy are effective treatments in women with dysfunctional uterine bleeding with comparable patient satisfaction rates
Endometrial ablation is( a medical procedure that is used to remove (ablate) or destroy the endometrial lining of a uterus) may be performed using laser electrocautery or roller ball
Treatment contAmenorrhea is seen in approximately 35 of women treated and decreased flow is seen in another 45 although treatment failures increase with time following the procedure due to endometrial regeneration A substantial number of patients receiving endometrial ablation require reoperation (30 by 48 months)
Hysterectomy is the most effective treatment for bleeding However it is associated with more frequent and severe adverse events compared with either conservative medical or ablation procedures Operating time hospitalization recovery times and costs are also greater Hence hysterectomy is reserved for selected patient populations
MedicationThe goals of pharmacotherapy are to control the bleeding reduce morbidity and prevent complications Steroid hormonesContraceptive pills Medroxyprogesterone acetate (Provera)After acute bleeding episode controlled can be used alone in patients with adequate amounts of endogenous estrogen to cause endometrial growth Progestin therapy in adolescents produces regular cyclic withdrawal bleeding until positive feedback system matures Progestins stop endometrial growth and support and organize endometrium to allow organized sloughing after their withdrawal Bleeding ceases rapidly because of an organized slough to the basalis layer These drugs usually do not stop acute bleeding episodes yet produce a normal bleeding episode following their withdrawal
ComplicationsAnemia (may become severe)Adenocarcinoma of the uterus (if prolonged unopposed estrogen stimulation)PrognosisHormonal contraceptives reduce blood loss by 40-70 when used long termAlthough medical therapy is generally used first over half of women with menorrhagia undergo hysterectomy within 5 years of referral to a gynecologist[2 ]
Patient EducationInstruct patients to continue prescribed medications although bleeding may still be occurring during the early part of the cycle Also patients should be told to expect menses after cessation of the regimenYoung patients with small amounts of irregular bleeding need reassurance and observation only prior to instituting a drug regimen Express to patients that pharmacologic intervention will not be necessary once menstrual cycles become regularDiscuss ways the patient can avoid prolonged emotional stress and maintain a normal body mass indexFor excellent patient education resources visit medicines Womens Health Center
- Dysfunctional uterine bleeding
- Terms frequently used to describeabnormal uterine bleeding
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Treatment
- Treatment cont
- Slide 21
- Slide 22
- Slide 23
- Medication
- Slide 25
- Slide 26
- Slide 27
-
Treatment contNo steroidal anti-inflammatory drugs (NSAIDs) are generally effective for the treatment of dysfunctional uterine bleeding and dysmenorrhea NSAIDs inhibiting prostaglandin synthesis and increasing thromboxane A2 levels
This leads to vasoconstriction and increased platelet aggregation These medications may reduce blood loss by 20-50 NSAIDs are most effective if used with the onset of menses or just prior to its onset and continued throughout its durationDanazol creates a hypoestrogenic and hyper androgenic environment which induces endometrial atrophy resulting in reduced menstrual loss Side effects include musculoskeletal pain breast atrophy hirsutism weight gain oily skin and acne Because of the significant androgenic side effects this drug is usually reserved as a second-line treatment for short-term use prior to surgeryGonadotropin-releasing hormone agonists may be helpful for short-term use in inducing amenorrhea and allowing women to rebuild their red blood cell mass They produce a profound hypoestrogenic state similar to menopause Side effects include menopausal symptoms and bone loss with long-term useTranexamic acid is an antifibrinolytic drug that exerts its effects by reversibly inhibiting plasminogen
Treatment contConsultationsSeek an emergency gynecologic consultation for patients requiring hemodynamic stabilization If parenteral therapy does not completely arrest vaginal bleeding in the hemodynamically unstable patient an emergency DampC may be warrantedConsultation with or urgent referral to a gynecologist for surgical treatment may be necessary for patients who do not desire fertility and in whom medical therapy fails Both endometrial ablation and hysterectomy are effective treatments in women with dysfunctional uterine bleeding with comparable patient satisfaction rates
Endometrial ablation is( a medical procedure that is used to remove (ablate) or destroy the endometrial lining of a uterus) may be performed using laser electrocautery or roller ball
Treatment contAmenorrhea is seen in approximately 35 of women treated and decreased flow is seen in another 45 although treatment failures increase with time following the procedure due to endometrial regeneration A substantial number of patients receiving endometrial ablation require reoperation (30 by 48 months)
Hysterectomy is the most effective treatment for bleeding However it is associated with more frequent and severe adverse events compared with either conservative medical or ablation procedures Operating time hospitalization recovery times and costs are also greater Hence hysterectomy is reserved for selected patient populations
MedicationThe goals of pharmacotherapy are to control the bleeding reduce morbidity and prevent complications Steroid hormonesContraceptive pills Medroxyprogesterone acetate (Provera)After acute bleeding episode controlled can be used alone in patients with adequate amounts of endogenous estrogen to cause endometrial growth Progestin therapy in adolescents produces regular cyclic withdrawal bleeding until positive feedback system matures Progestins stop endometrial growth and support and organize endometrium to allow organized sloughing after their withdrawal Bleeding ceases rapidly because of an organized slough to the basalis layer These drugs usually do not stop acute bleeding episodes yet produce a normal bleeding episode following their withdrawal
ComplicationsAnemia (may become severe)Adenocarcinoma of the uterus (if prolonged unopposed estrogen stimulation)PrognosisHormonal contraceptives reduce blood loss by 40-70 when used long termAlthough medical therapy is generally used first over half of women with menorrhagia undergo hysterectomy within 5 years of referral to a gynecologist[2 ]
Patient EducationInstruct patients to continue prescribed medications although bleeding may still be occurring during the early part of the cycle Also patients should be told to expect menses after cessation of the regimenYoung patients with small amounts of irregular bleeding need reassurance and observation only prior to instituting a drug regimen Express to patients that pharmacologic intervention will not be necessary once menstrual cycles become regularDiscuss ways the patient can avoid prolonged emotional stress and maintain a normal body mass indexFor excellent patient education resources visit medicines Womens Health Center
- Dysfunctional uterine bleeding
- Terms frequently used to describeabnormal uterine bleeding
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Treatment
- Treatment cont
- Slide 21
- Slide 22
- Slide 23
- Medication
- Slide 25
- Slide 26
- Slide 27
-
Treatment contConsultationsSeek an emergency gynecologic consultation for patients requiring hemodynamic stabilization If parenteral therapy does not completely arrest vaginal bleeding in the hemodynamically unstable patient an emergency DampC may be warrantedConsultation with or urgent referral to a gynecologist for surgical treatment may be necessary for patients who do not desire fertility and in whom medical therapy fails Both endometrial ablation and hysterectomy are effective treatments in women with dysfunctional uterine bleeding with comparable patient satisfaction rates
Endometrial ablation is( a medical procedure that is used to remove (ablate) or destroy the endometrial lining of a uterus) may be performed using laser electrocautery or roller ball
Treatment contAmenorrhea is seen in approximately 35 of women treated and decreased flow is seen in another 45 although treatment failures increase with time following the procedure due to endometrial regeneration A substantial number of patients receiving endometrial ablation require reoperation (30 by 48 months)
Hysterectomy is the most effective treatment for bleeding However it is associated with more frequent and severe adverse events compared with either conservative medical or ablation procedures Operating time hospitalization recovery times and costs are also greater Hence hysterectomy is reserved for selected patient populations
MedicationThe goals of pharmacotherapy are to control the bleeding reduce morbidity and prevent complications Steroid hormonesContraceptive pills Medroxyprogesterone acetate (Provera)After acute bleeding episode controlled can be used alone in patients with adequate amounts of endogenous estrogen to cause endometrial growth Progestin therapy in adolescents produces regular cyclic withdrawal bleeding until positive feedback system matures Progestins stop endometrial growth and support and organize endometrium to allow organized sloughing after their withdrawal Bleeding ceases rapidly because of an organized slough to the basalis layer These drugs usually do not stop acute bleeding episodes yet produce a normal bleeding episode following their withdrawal
ComplicationsAnemia (may become severe)Adenocarcinoma of the uterus (if prolonged unopposed estrogen stimulation)PrognosisHormonal contraceptives reduce blood loss by 40-70 when used long termAlthough medical therapy is generally used first over half of women with menorrhagia undergo hysterectomy within 5 years of referral to a gynecologist[2 ]
Patient EducationInstruct patients to continue prescribed medications although bleeding may still be occurring during the early part of the cycle Also patients should be told to expect menses after cessation of the regimenYoung patients with small amounts of irregular bleeding need reassurance and observation only prior to instituting a drug regimen Express to patients that pharmacologic intervention will not be necessary once menstrual cycles become regularDiscuss ways the patient can avoid prolonged emotional stress and maintain a normal body mass indexFor excellent patient education resources visit medicines Womens Health Center
- Dysfunctional uterine bleeding
- Terms frequently used to describeabnormal uterine bleeding
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Treatment
- Treatment cont
- Slide 21
- Slide 22
- Slide 23
- Medication
- Slide 25
- Slide 26
- Slide 27
-
Treatment contAmenorrhea is seen in approximately 35 of women treated and decreased flow is seen in another 45 although treatment failures increase with time following the procedure due to endometrial regeneration A substantial number of patients receiving endometrial ablation require reoperation (30 by 48 months)
Hysterectomy is the most effective treatment for bleeding However it is associated with more frequent and severe adverse events compared with either conservative medical or ablation procedures Operating time hospitalization recovery times and costs are also greater Hence hysterectomy is reserved for selected patient populations
MedicationThe goals of pharmacotherapy are to control the bleeding reduce morbidity and prevent complications Steroid hormonesContraceptive pills Medroxyprogesterone acetate (Provera)After acute bleeding episode controlled can be used alone in patients with adequate amounts of endogenous estrogen to cause endometrial growth Progestin therapy in adolescents produces regular cyclic withdrawal bleeding until positive feedback system matures Progestins stop endometrial growth and support and organize endometrium to allow organized sloughing after their withdrawal Bleeding ceases rapidly because of an organized slough to the basalis layer These drugs usually do not stop acute bleeding episodes yet produce a normal bleeding episode following their withdrawal
ComplicationsAnemia (may become severe)Adenocarcinoma of the uterus (if prolonged unopposed estrogen stimulation)PrognosisHormonal contraceptives reduce blood loss by 40-70 when used long termAlthough medical therapy is generally used first over half of women with menorrhagia undergo hysterectomy within 5 years of referral to a gynecologist[2 ]
Patient EducationInstruct patients to continue prescribed medications although bleeding may still be occurring during the early part of the cycle Also patients should be told to expect menses after cessation of the regimenYoung patients with small amounts of irregular bleeding need reassurance and observation only prior to instituting a drug regimen Express to patients that pharmacologic intervention will not be necessary once menstrual cycles become regularDiscuss ways the patient can avoid prolonged emotional stress and maintain a normal body mass indexFor excellent patient education resources visit medicines Womens Health Center
- Dysfunctional uterine bleeding
- Terms frequently used to describeabnormal uterine bleeding
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Treatment
- Treatment cont
- Slide 21
- Slide 22
- Slide 23
- Medication
- Slide 25
- Slide 26
- Slide 27
-
MedicationThe goals of pharmacotherapy are to control the bleeding reduce morbidity and prevent complications Steroid hormonesContraceptive pills Medroxyprogesterone acetate (Provera)After acute bleeding episode controlled can be used alone in patients with adequate amounts of endogenous estrogen to cause endometrial growth Progestin therapy in adolescents produces regular cyclic withdrawal bleeding until positive feedback system matures Progestins stop endometrial growth and support and organize endometrium to allow organized sloughing after their withdrawal Bleeding ceases rapidly because of an organized slough to the basalis layer These drugs usually do not stop acute bleeding episodes yet produce a normal bleeding episode following their withdrawal
ComplicationsAnemia (may become severe)Adenocarcinoma of the uterus (if prolonged unopposed estrogen stimulation)PrognosisHormonal contraceptives reduce blood loss by 40-70 when used long termAlthough medical therapy is generally used first over half of women with menorrhagia undergo hysterectomy within 5 years of referral to a gynecologist[2 ]
Patient EducationInstruct patients to continue prescribed medications although bleeding may still be occurring during the early part of the cycle Also patients should be told to expect menses after cessation of the regimenYoung patients with small amounts of irregular bleeding need reassurance and observation only prior to instituting a drug regimen Express to patients that pharmacologic intervention will not be necessary once menstrual cycles become regularDiscuss ways the patient can avoid prolonged emotional stress and maintain a normal body mass indexFor excellent patient education resources visit medicines Womens Health Center
- Dysfunctional uterine bleeding
- Terms frequently used to describeabnormal uterine bleeding
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Treatment
- Treatment cont
- Slide 21
- Slide 22
- Slide 23
- Medication
- Slide 25
- Slide 26
- Slide 27
-
ComplicationsAnemia (may become severe)Adenocarcinoma of the uterus (if prolonged unopposed estrogen stimulation)PrognosisHormonal contraceptives reduce blood loss by 40-70 when used long termAlthough medical therapy is generally used first over half of women with menorrhagia undergo hysterectomy within 5 years of referral to a gynecologist[2 ]
Patient EducationInstruct patients to continue prescribed medications although bleeding may still be occurring during the early part of the cycle Also patients should be told to expect menses after cessation of the regimenYoung patients with small amounts of irregular bleeding need reassurance and observation only prior to instituting a drug regimen Express to patients that pharmacologic intervention will not be necessary once menstrual cycles become regularDiscuss ways the patient can avoid prolonged emotional stress and maintain a normal body mass indexFor excellent patient education resources visit medicines Womens Health Center
- Dysfunctional uterine bleeding
- Terms frequently used to describeabnormal uterine bleeding
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Treatment
- Treatment cont
- Slide 21
- Slide 22
- Slide 23
- Medication
- Slide 25
- Slide 26
- Slide 27
-
Patient EducationInstruct patients to continue prescribed medications although bleeding may still be occurring during the early part of the cycle Also patients should be told to expect menses after cessation of the regimenYoung patients with small amounts of irregular bleeding need reassurance and observation only prior to instituting a drug regimen Express to patients that pharmacologic intervention will not be necessary once menstrual cycles become regularDiscuss ways the patient can avoid prolonged emotional stress and maintain a normal body mass indexFor excellent patient education resources visit medicines Womens Health Center
- Dysfunctional uterine bleeding
- Terms frequently used to describeabnormal uterine bleeding
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Treatment
- Treatment cont
- Slide 21
- Slide 22
- Slide 23
- Medication
- Slide 25
- Slide 26
- Slide 27
-
- Dysfunctional uterine bleeding
- Terms frequently used to describeabnormal uterine bleeding
- Slide 3
- Slide 4
- Slide 5
- Slide 6
- Slide 7
- Slide 8
- Slide 9
- Slide 10
- Slide 11
- Slide 12
- Slide 13
- Slide 14
- Slide 15
- Slide 16
- Slide 17
- Slide 18
- Treatment
- Treatment cont
- Slide 21
- Slide 22
- Slide 23
- Medication
- Slide 25
- Slide 26
- Slide 27
-