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updated 8/03
Abnormal uterine bleeding, usually associated with anovulatory cycles, in the absence of pathological or organic lesions. The source of the bleeding is uterine and the mechanism is hormonal. Speroff, et al’s (1994) categories: Estrogen breakthrough bleeding, estrogen withdrawal bleeding and Progestin breakthrough bleeding.
Terms and Patterns of Abnormal Bleeding:
Exact incidence is unknown, but it is a common disorder in women.
Pathogenesis:
Anovulatory or estrogen breakthrough bleeding is caused by production of estrogen without surges of LH and secretion of progesterone from the corpus luteum. May occur in high or low estrogen states. This is the cause of most of the DUB and occurs at the extremes of the reproductive cycle. Midcycle spotting is caused by a decrease in estrogen at midcycle following ovulation. Luteal phase defect is associated with premenstrual spotting or polymenorrhea. Prolonged luteal phase is caused by extended corpus luteal activity and prolonged progesterone production leading to prolonged cycles or long episodes of bleeding.
Predisposing Factors:
Essentially unknown except of pathological states identified below.
"My periods are irregular or too heavy or too often or too few" I haven’t had a period for two months." I have started spotting a few days before I am supposed to start my period."
Subjective Data:
What is the usual pattern of flow? How has it changed? Is it regular and much heavier? irregular periods? spotting at midcycle? spotting prior to the onset of the expected menstrual period? number of pads or tampons used? Is she sexually active? type of contraception? associated symptoms of pain, nausea and vomiting? Discharge? color and odor? patterns of eating disorders? athletic or exercise patterns? menopausal symptoms? recent weight loss? use of herbs? what kind?
Dysfunctional uterine bleeding is a diagnosis of exclusion. Hormonal imbalance (hyperthyroidism or hypothyroidism); pregnancy disorder; cervical lesions; medications (OCP’s, corticosteroids, hypothalamic depressants, anticholinergics, anticoagulants); uterine fibroids; polyps, renal or liver disease, coagulation disorders; anabolic steroids, IUD’s; trauma, herbs such as gensing (phytoestrogen).
Not to be Missed:
Complications of pregnancy such as ectopic, spontaneous abortion, retained placental tissue; trauma such as sexual abuse, foreign body, carcinoma of the vagina, cervix, endometium or ovary; functional ovarian cysts, missed abortion. hirsutism, acne, galactorrhea, thyroid enlargement,
Assessment:
Plan:
Endometrial biopsy for perimenopausal women.
Reproductive Age (anovulatory):
Medroxyprogesterone acetate (Provera/Cycrine) 10 mg for 14 days. to stabilize predecidual stroma. May need to follow this regimen for 3 or more months. Bleeding decreases monthly.
Medroxyprogesterone acetate (Provera/Cycrine) 5 -10 mg for 10-14 may need to be prescribed for maintenance.
*New micronized progestin (Prometria) dose comes in 100 mg. Will need 200-400 mg for last two weeks.
OR
Norethendrone or norethindrone acetate 1 - 5 mg/day for 10- 14 days.
OR
Combined oral contraceptives 1/day 21 day or 28 day regimen.
Reproductive Age (estrogen breakthrough bleeding):
1.Patient on longstanding OCP’s and begins heavy bleeding. Conjugated estrogens 1.5 mg or estradiol 2.0 mg daily for 7 days and usual OCP’s. This rejuvenates the endometrium and intermenstrual flow stops.
2. Antiprostaglandins 400-600 mg ibuprofin q 4-6 hours with full glass of water and food during the bleeding episode.
3. Progestin IUD delivers progestin directly to the endometrium.
4. Intermenstrual bleeding is acute and heavy. High dose estrogen therapy with conjugated estrogen (Premarin or equivalent) 1.25 or estadiol 2 mg q 4 hours for 24 hours or QID or 2.5 mg QID for a few days, followed by the dingle daily dose for 7 - 10 days. Follow with progestin coverage and a withdrawal bleed Other regimen:
OR
Intermenstrual bleeding is acute and very heavy. High dose estrogen therapy up to 25 mg conjugated estrogens IV q 4 hrs until bleeding abates or for 12 hours. Progesterone treatment also. Note: Requires physician consultation.
Perimenopausal
Conjugated estrogens (Premarin) 0.625 mg-1.25 mg day 1 - 25 or Esterified estrogen (Estratab) 0.625 mg - 1.25 mg or estradiol (Estrace) day 1 through 25 with progestin 2.5 mg continuously or 5 mg day last 10 - 14 days.
Heavy Vaginal Bleeding
May use 1 Oral Contraceptive Pill BID for 5-7 days or until 24 hrs after bleeding has stopped.
Primary Points: Teach patients to expect heavy vaginal bleeding when they discontinue progestin or estrogen/progestin.
Other Considerations/Individual Considerations
Pregnancy: Rule out before initiating hormone regimen. Consider possibility of ectopic pregnancy or spontaneous abortion:
Pediatrics: NA until child is menarchal. Does occur at the initiation of menarche age 9-12.
Adults: Affects females in the reproductive years and perimenopausally.
Geriatrics: NA unless on a regimen of HRT.
Partners: Frequent, heavy menstrual periods may interfere with sexual expression.
ICD 9: 626.8
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