Disfunction utrine bleeding

 

 

 

 

General objectives: 

At the end of lecture the students will be able to upgraded knowledge and practice regarding dysfunctional uterine bleeding. 

Specific objectives:

At the end of this lecture the students will be able to:

-  Define incidence of dysfunctional uterine bleeding.

-  Describe cause of dysfunctional uterine bleeding.

-  Enumerate signs and symptoms of dysfunctional uterine bleeding.

-  Define diagnosis of dysfunctional uterine bleeding.

-  Identify management of dysfunctional uterine bleeding. 

-  Identify nursing management of dysfunctional uterine bleeding.

 

 

 

 

 

 

 

-  Introduction.

-  Definition.

-  Age of incidence.

-  Causes.

-  Signs and symptoms.

-  Diagnosis.

-  Medical management.

-  Nursing management.

 

 

 

 

 

 

 

 

 

 

 

Introduction:

Each menstrual cycle, the endometrium (uterine lining) prepares with

itself to nourish a fetus. If fertilization doesn’t occur, the body sheds the endometrium during the monthly (on average) cycle. In some cases, irregularity can occur in this cycle, indicating any of the following menstrual disorders:

-  Disorders of cycle length: 

Normal menstrual cycle length is 21- 35 days average 28 days 

1)             Oligomenorrhea: is a condition in which you have infrequent menstrual periods more than 35 days. 

2)             Polymenorrhea: is a term used to describe a menstrual cycle that is shorter than 21 days.

- Disorders of cycle flow:

Normal menstrual cycle flow length is 3-7 days

1)             Hypomenorrhea: is a menstrual bleeding lasting less than 2 days or the loss of less than 30 mL of blood heavy flow.

2)             Menorrhagia: is a menstrual bleeding lasting more than 7 days or the loss of more than 80 mL of blood heavy flow.

3)             Metrorrhagia: irregular frequent bleeding of varying amounts but not excessive.

- Disorders of ovulation:

Disorders of ovulation include anovulation and oligoovulation.

1) Anovulation: is the absence of ovulation when it would be normally expected, anovulation usually manifests itself as irregularity of menstrual periods, that is, unpredictable variability of intervals, duration or bleeding

. Anovulation can also cause cessation of periods or excessive bleeding

"Dysfunctional uterine bleeding"

-   Non-menstrual bleeding: 

Post coital bleeding: is bleeding from the vagina in women after sexual intercourse and may or may not be associated with pain.

-   AUB classification according to age:

❖  Childhood and adolescence bleeding:

1) Foreign body.      2) Hormonal changes.

❖  Childbearing period bleeding.

❖  Perimenopausal bleeding:

1)  Atrophy “most common”

2)  Malignancy “most serious”:  - Cervical tumor.

-        Endometruim tumor.

-        Ovarian tumor.

❖  Postmenopausal bleeding.

 

Childbearing period

1)    Exclusion of contraceptive method.

2)    Exclusion of pregnancy:

N.B in case of positive pregnancy test may be:

➢ Abortion.

➢ Vesicular mole.

➢ Ectopic pregnancy.

N.B in case of negative pregnancy test:

1)   Organic lesion: referred to as PALM

➢ Uterine polyp.

➢ Malignancy.

➢ Leiomayoma.

➢ Adenomyosis.                                                                                                            

2)   Inorganic lesion:

➢ Systemic.

➢ Chronic disease.

➢ Anovulation. “DUB”.

- Definition of DUB:

Is defined as AUB that occurs in absence of recognizable pelvic pathology, medications, systemic disease, trauma, or pregnancy.

➢ Age incidence: 20% at adolescence, 40% in patients >40 years, 60% in child bearing period

➢ Causes of DUB:

Most of the time, DUB happens because of changes in the body’s hormone levels.

For teen girls, one of the most common causes of hormone changes is when the body doesn’t release an egg from one of the ovaries. This is called anovulation.

The release of an egg is part of the hormone process that makes up the menstrual cycle. If a girl’s body doesn’t release an egg, too much extra blood and tissue can build up in the lining of her uterus. When that lining eventually leaves the body, a girl can have more than normal amounts of bleeding. This bleeding might happen as part of a period or in between periods.

Anovulation is most likely to happen after a girl first starts getting her period. That’s because the ovaries aren’t fully developed yet. It can last for several years until a girl’s periods become regular.

Other things can lead a girl to develop DUB:

-  Some illnesses (like thyroid disease or polycystic ovary syndrome) can mess with the body’s hormones. 

-  Problems like compulsive exercise, not eating healthy foods, or too much stress can cause hormone changes.

➢ Signs and symptoms of DUB: 

 Symptoms that can occur with DUB are:

-  Breast tenderness.  

-  Bloating.   

-  Pelvic pain or pressure.

-  Dizziness.

-  Fainting.

-  Weakness.

-  Low blood pressure.

-  Increased heart rate.

-  Pale skin.

-  Pain.

-  Passing large clots.

-  Soaking a pad every hour.

➢ Diagnosis of DUB:

(1) Physical diagnosis: 

The physical exam should include:

1)  Vital signs, including blood pressure and body mass index (BMI).

2)  Signs of pallor, such as skin or mucosal pallor.

3)  Signs of endocrine disorders.

4)  Examination of the thyroid for enlargement or tenderness.

5)  Excessive or abnormal hair growth patterns, clitoromegaly, acne that could indicate hyperandrogenism.

7) Moon faces, abnormal fat distribution, striae that could indicate Cushing's.

6)  Signs of coagulopathies, such as bruising or petechiae.

7)  Abdominal exam to palpate for any pelvic or abdominal masses.

8)  Pelvic exam: Speculum and bimanual.           - PAP smear if indicated.

- STI screening (such as for gonorrhea and chlamydia) and wet prep if indicated. 

)2( Local examination:

➢ Bimanual pelvic examination: To exclude uterine leiomyomas, adenomyomas, and adnexal masses.

➢ Speculum examination:  To exclude cervical polyp, erosion, ulcer, mass, or associated vaginal pathology.  

(3) Laboratory tests:

➢ Ultrasound:

 To view your reproductive organs. This examination will reveal whether you have any abnormal growths, such as polyps or fibroids. It can also help to rule out internal bleeding.

➢ Blood tests:

Blood tests are used to measure hormone levels and complete blood count. Hormone levels can often give quick insight into the cause of bleeding.

In case of heavy or prolonged bleeding, a complete blood count reveals whether red blood cell count is too low. A low red blood cell count can indicate anemia.

➢ Human chorionic gonadotropin (HCG):

For acute bleeding, a type and cross should be obtained.

 

➢ Thyroid-stimulating hormone (TSH) level and prolactin level:

If anovulation is suspected.

➢ Endometrial biopsy:

If an abnormal growth is causing the bleeding, or uterine lining is unusually thick, doctor will take a sample of the uterine tissue for testing. If there are any abnormal cell changes in the lining, a biopsy will reveal it. Abnormal cells can indicate hormone imbalances or cancer, among other things.

➢ Diagnostic Procedures:

-  Pap smear: 

❖  To screen for cervical cancer if age >21 years.

-  EMB should be performed in:

❖  Women age >35 years with AUB to rule out cancer or premalignancy.

❖  Postmenopausal women with ET ≥4 mm.

❖  Women aged 18 to 35 years with AUB and risk factors for endometrial cancer.

❖  Perform on or after day 18 of cycle, if known; secretory endometruim confirms ovulation occurred.

-  Dilation and curettage (D&C):

❖  Perform if bleeding is heavy, uncontrolled, or if emergent medical management has failed.

❖  Perform if unable to perform EMB in office.

-  Hysteroscopy:

❖  If another intrauterine lesion is suspected.

➢ Medical management:

(1)   Non-hormonal therapy: 

❖  Non-steroidal anti-inflammatory drugs "NSAIDs".

❖  Antifibrinolytic drugs: Tranexamic acid (to inhibit the increased plasminogen activators and plasmin).  

(2)   Combined oral contraceptive pills:

❖  Low-dose oestrogen-progestogen is used (regulate the cycle and reduce amount of blood loss)

❖  Progestogen dominant pills is used in progesterone deficiency and oestrogen dominant pills are used in oestrogen deficiency.

(3)   Oestrogens:

❖ Used in anovulatory cycles to reduce the blood loss. 

(4)   Levonogestrel - releasing IUCD: 

❖ Induces endometrial atrophy with reduction of blood loss 

(5)   Androgens and Gonadotropin releasing hormone: 

❖ Used when the above medical therapy has failed or surgery is contraindicated.

➢ Nursing management of DUB:

✓  Assess maternal physiological circulatory status and blood volume.

✓  Monitor vital signs including systolic and diastolic blood pressure, pulse and heart rate.

✓  Measuring the level of hemoglobin in the blood to prevent anemia.

✓  Educate the client about normal menstrual cycle and the possible causes for her abnormal pattern.

✓  Inform the woman about treatment option.

✓  Inform her about any prescribed medication.

✓  Encourage patient to comply with the medication to reduce discomfort and pain.

✓  Explain importance of iron-rich foods to supplement iron.

✓  Explain methods of quantifying blood loss and reporting to healthcare provider.

✓  Assist in and teach patient pain-relieving techniques to promote self-sufficiency in managing pain.

✓  Assess meaning of dysfunction for patient to explore self- concept issues.

✓  Encourage patient to express her feelings to increase understanding of individual coping style.