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Download 0 Go BackComment Link Embed of 25 Readcast 0inShare Dysfunctional UterineDysfunctional UterineBleedingBleeding JenniferJenniferBergquistBergquistM.D.M.D.September 6, 2005September 6, 2005 Case #1Case #1 You are evaluating a 13yr old girl in your office. You are evaluating a 13yr ol d girl in your office.She is c/o heavy menstrual bleeding. SheShe is c/o heavy m enstrual bleeding. Sheexperienced menarche ~1yr ago and says herexperienced mena rche ~1yr ago and says herperiods never occur at the same time. They lastperiods never occur at the same time. They last~10days. Her previous menses occurred ~2 ~10days. Her previous menses occurred ~2months ago. She deniesmonths ago. She de niesdysmenorrheadysmenorrhea. Her. Hercurrent period started 2 days ago and iscu rrent period started 2 days ago and isespecially heavy. She denies sexual activi ty orespecially heavy. She denies sexual activity orh/oh/oSTDs.STDs. Physical exam findings are notable for mildPhysical exam findings are notable fo r mildorthostatic hypotension and pallor; Exam isorthostatic hypotension and pal lor; Exam isotherwise normalotherwise normal

Case #2Case #2 You are evaluating a 13yr old girl in your office. You are evaluating a 13yr ol d girl in your office.She is c/o heavy menstrual bleeding. SheShe is c/o heavy m enstrual bleeding. Sheexperienced menarche ~1yr ago and says herexperienced mena rche ~1yr ago and says herperiods never occur at the same time. They lastperiods never occur at the same time. They last~10days. Her previous menses occurred ~2 ~10days. Her previous menses occurred ~2months ago. She deniesmonths ago. She de niesdysmenorrheadysmenorrhea. Her. Hercurrent period started 2 days ago and iscu rrent period started 2 days ago and isespecially heavy. She denies sexual activi ty orespecially heavy. She denies sexual activity orh/oh/oSTDs.STDs. Physical exam is notable for mild orthostaticPhysical exam is notable for mild o rthostatichypotension and pallor. She is mildlyhypotension and pallor. She is mi ldlyoverweight and is noted to have acne. Exam isoverweight and is noted to have acne. Exam isotherwise normalotherwise normal Case #3Case #3 You are evaluating a 13yr old girl in your office. You are evaluating a 13yr ol d girl in your office.She is c/o heavy menstrual bleeding. SheShe is c/o heavy m enstrual bleeding. Sheexperienced menarche 6 months ago and saysexperienced mena rche 6 months ago and saysher periods have always been heavy and last upher peri ods have always been heavy and last upto 12 days. Although, she thinks they occu r atto 12 days. Although, she thinks they occur atregular intervals. She frequen tly experiencesregular intervals. She frequently experiencesdysmenorrheadysmenor rhea. She denies sexual activity or. She denies sexual activity orh/oh/oSTDs.STD s. Physical exam findings are notable for mildPhysical exam findings are notable fo r mildorthostatic hypotension, pallor and a largeorthostatic hypotension, pallor and a largeamount of menstrual blood at the vaginalamount of menstrual blood at the vaginalintroitusintroitus. Exam is otherwise normal.. Exam is otherwise nor mal. Case #3Case #3 You are evaluating a 13yr old girl in your office. You are evaluating a 13yr ol d girl in your office.She is c/o heavy menstrual bleeding. SheShe is c/o heavy m enstrual bleeding. Sheexperienced menarche 6 months ago and saysexperienced mena rche 6 months ago and saysher periods have always been heavy and last upher peri ods have always been heavy and last upto 12 days. Although, she thinks they occu r atto 12 days. Although, she thinks they occur atregular intervals. She frequen tly experiencesregular intervals. She frequently experiencesdysmenorrheadysmenor rhea. She denies sexual activity or. She denies sexual activity orh/oh/oSTDs.STD s. Physical exam findings are notable for mildPhysical exam findings are notable fo r mildorthostatic hypotension, pallor and a largeorthostatic hypotension, pallor and a largeamount of menstrual blood at the vaginalamount of menstrual blood at the vaginalintroitusintroitus. Exam is otherwise normal.. Exam is otherwise nor mal. QuestionsQuestions 1.1. What is the differential diagnosis?What is the differential diagnosis?2.2.What a dditional information would be helpful?What additional information would be help ful? 3.3. What laboratory evaluation would you pursue?What laboratory evaluation would you

pursue?4.4.What initial therapy would help the patientWhat initial therapy woul d help the patient sssymptoms?symptoms? QuestionsQuestions 1.1. What is the differential diagnosis?What is the differential diagnosis?2.2.What a dditional information would be helpful?What additional information would be help ful? 3.3. What laboratory evaluation would you pursue?What laboratory evaluation would you pursue?4.4.What initial therapy would help the patientWhat initial therapy woul d help the patient sssymptoms?symptoms? DefinitionDefinition Dysfunctional uterine bleeding (DUB) is definedDysfunctional uterine bleeding (D UB) is definedas abnormal uterine bleeding that is excessive oras abnormal uteri ne bleeding that is excessive oroccurs outside the normal cycleoccurs outside th e normal cycle In Adolescents, 95% is secondary toIn Adolescents, 95% is secondary to anovulation anovulation Patterns of abnormal bleeding:Patterns of abnormal bleeding: MenorrhagiaMenorrhagia prolonged bleeding at regular intervalsprolonged bleeding at regular intervals Me trorrhagiaMetrorrhagia uterine bleeding at irregular intervalsuterine bleeding at irregular intervals Me nometrorrhagiaMenometrorrhagia uterine bleeding that isuterine bleeding that isprolonged, excessive and occurri ng at irregularprolonged, excessive and occurring at irregularintervalsintervals MenarcheMenarche Mean age of menarche in the UnitedMean age of menarche in the UnitedStates:State s: 12.88 years for Caucasian girls12.88 years for Caucasian girls 12.16 years for Af rican American girls12.16 years for African American girls 90% reach menarche by the time breast90% reach menarche by the time breastand pu bic hair development has reachedand pubic hair development has reachedSMR stage 4.SMR stage 4. On average, menarche occurs 2 yearsOn average, menarche occurs 2 yearsafterafter thelarchethelarche Menstrual CycleMenstrual Cycle Follicular PhaseFollicular Phase PulsatilePulsatileGnRHGnRH FSH and LH stimulate ovarianFSH and LH stimulate ovari anfollicle growthfollicle growth Predominant follicle secretesPredominant follicl e secretesestrogenestrogen EndometriumEndometriumproliferatesproliferates OvulationOvulation LH > FSHLH > FSH Occurs 12hrs after LH surgeOccurs 12hrs after LH surge LutealLutealPhasePhase

 CorpusCorpusLuteumLuteumsecretessecretesprogesteroneprogesterone SecretorySecreto ryendometriumendometrium CorpusCorpusluteumluteumregresses if noregresses if noim plantation occursimplantation occurs Estrogen/progesterone fall;Estrogen/progeste rone fall;endometrial lining sloughsendometrial lining sloughs Anovulatory AnovulatoryMenstrual CycleMenstrual Cycle EndometriumEndometriumexperiences continued estrogenexperiences continued estrog enstimulation that is unopposed by progesteronestimulation that is unopposed by progesterone Increased estrogen should cause a negative feedback onIncreased estrogen should cause a negative feedback onthe Hthe H--P axis; estrogen levels fall;P axis; est rogen levels fall;endometriumendometriumsloughssloughsand mimics anand mimics an ovulatoryovulatorycyclecycle In DUB, impairments in the feedback system cause theIn DUB, impairments in the f eedback system cause theendometriumendometriumto be continuously stimulated, thi ckenedto be continuously stimulated, thickenedand unstableand unstable Uterine bleeding occurs whenUterine bleeding occurs whenendometriumendometriumou tgrows itsoutgrows itsblood supplyblood supply Uterine bleeding becomes asynchronous, prolonged andUterine bleeding becomes asy nchronous, prolonged andsometimes profusesometimes profuse Dysfunctional Uterine BleedingDysfunctional Uterine Bleeding differential diagnosis differential diagnosis PregnancyPregnancy--relatedrelated EctopicEctopicpregnancypregnancy Abortion Abortion PhysiologicPhysiologic Anovulation Anovulation PostPost--menarchalmenarchal(immature H(immature H--PP--O Axis)O Axis) Hormonal contraceptivesHormonal contraceptives HypothalamicHypothalamic--relatedrelated Systemic illness (DM, renal,Systemic illness (DM, renal,liver disease)liver dise ase) Functional (diet, stress,Functional (diet, stress,exercise)exercise) Eating d isordersEating disorders HypothyroidHypothyroid PituataryPituatary--relatedrelated prolactinomaprolactinoma Outflow tractOutflow tract--relatedrelated TraumaTrauma Foreign bodyForeign body PolypsPolyps UterineUterinemyomasmyomas smsNeoplasms Androgen Excess Androgen Excess PCOSPCOS Adrenal or ovarian tumor Adrenal or ovarian tumor Adrenal hyperplasia ( non Adrenal hyperplasia (non--classic type)classic type) Coagulation defectsCoagulation defects Clotting factor deficiencyClotting factor deficiency Von VonWillebrandWillebrand diseasedisease InfectiousInfectious PID,PID,cervicitiscervicitis,,vaginitisvaginitis

EvaluationEvaluation Detailed menstrualDetailed menstrualhistoryhistory Age of menarche Age of menarche Menstrual patternMenstrual pattern Amount of blo od loss Amount of blood loss Duration of mensesDuration of menses +/+/--menstrual crampsmenstrual cramps Recent changes inRecent changes incyclescycles symptoms of symptoms of hypovolemiahypovolemia Genital traumaGenital trauma Weight loss or gainWeight loss or gain NonNon--menstrual bleedingmenstrual bleeding (easy bruising)(easy bruising) Emotional stressEmotional stress Exercise patternsExercise patterns Sexual historySexual history Gestational eventsGestational events Symptoms of chronicSymptoms of chronicillnessillness Family history of Family history of menstrual or bleedingmenstrual or bleedingdi sordersdisorders Physical ExamPhysical Exam Vital signs (including Vital signs (includingorthostaticsorthostatics)) Gen: obesity,Gen: obesity,cachexiacachexia HEENT:HEENT:fundoscopicfundoscopicexam/visual field testingexam/visual field tes ting Neck: thyroidNeck: thyroid Breasts: SMR, evaluate forBreasts: SMR, evaluate forgalactorrheagalactorrhea Abdominal: uterine/ovarian mass Abdominal: uterine/ovarian mass Skin:Skin:hirsutismhirsutism, acne,, acne,acanthosisacanthosisnigransnigrans External genital exam: SMR, clitoral sizeExternal genital exam: SMR, clitoral si ze Internal genital examInternal genital exam (if sexually active or has painful(if sexually active or has painfulbleeding):bl eeding): uterine/adnexaluterine/adnexalmasses, motion tenderness,masses, motion tendernes s,trauma, cervicaltrauma, cervicalosos(size, color, discharge)(size, color, disc harge) Laboratory AssessmentLaboratory Assessment Urine BUrine B--HCG*HCG* Even in adolescents who claim they are not sexually active!Even in adolescents w

ho claim they are not sexually active! HematocritHematocrit** CBC, PT/PTTCBC, PT/PTT Should be performed in pts with + family history of bleedingShould be performed in pts with + family history of bleedingd/od/oand/or personaland/or personalh/oh /oexcessive nonexcessive non--menstrual bleedingmenstrual bleeding Secondary eval uation includes a vonSecondary evaluation includes a vonWillebrandWillebrandpane l (panel (vWFvWFantigen;antigen;ristocetinristocetincofactor activity)cofactor a ctivity) Other tests (depending on history/physical)Other tests (depending on history/phy sical) FSH, LH,FSH, LH,prolactinprolactin, androgen panel (free/total testosterone,, an drogen panel (free/total testosterone,DHEA), TSH,DHEA), TSH,CortisolCortisol Pelv ic ultrasoundPelvic ultrasound--always indicated in pts suspected of havingalway s indicated in pts suspected of havingectopicectopicpregnancy, pts who have a pa lpable mass or if PCOS ispregnancy, pts who have a palpable mass or if PCOS issu spectedsuspected* Should be performed in all patients with irregular uterine* Sh ould be performed in all patients with irregular uterinebleedingbleeding Diagnostic EvaluationDiagnostic Evaluation Progesterone ChallengeProgesterone Challenge Evaluates uterine response to endogenous estrogenEvaluates uterine response to e ndogenous estrogen Progesterone is administered X 12 days to mimicProgesterone is administered X 12 days to mimicphysiologic secretionphysiologic secretion Menstr ual bleeding within 1 week after the challengeMenstrual bleeding within 1 week a fter the challengesuggests FSH/LH secretion is sufficient to maintainsuggests FS H/LH secretion is sufficient to maintainnormalnormalestradiolestradiolsecretion and endometrialsecretion and endometrialproliferation, but insufficient to cause ovulationproliferation, but insufficient to cause ovulation Lack of menstrual bl eeding suggests an endometrialLack of menstrual bleeding suggests an endometrial pathology or markedpathology or markedhypoestrogenemiahypoestrogenemia PhysiologicPhysiologic Anovulation Anovulation Immaturity of the hypothalamicImmaturity of the hypothalamic--pituitarypituitary --ovarian axisovarian axis is the most common cause (in theis the most common cause (in theabsence of pregn ancy)absence of pregnancy) Rising levels of estrogen do not cause suppression of Rising levels of estrogen do not cause suppression of FSH; sustained estrogen secretion ensuesFSH; sustain ed estrogen secretion ensues Most common during the first 2 years afterMost common during the first 2 years a ftermenarche when 55menarche when 55--80% of cycles are80% of cycles areanovulat oryanovulatory Regardless of cause,Regardless of cause,anovulationanovulationcan present ascan present aseither amenorrhea or DUBeither amenorrhea or DUB Laboratory evaluation may reveal elevatedLaboratory evaluation may reveal elevat edFSH:LH ratioFSH:LH ratio It is a diagnosis of exclusionIt is a diagnosis of exclusion Polycystic Ovarian SyndromePolycystic Ovarian Syndrome

Should be considered inShould be considered in any any adolescent girl withadolescent girl withhirsutismhirsutism, menstrual irregulari ty or obesity, menstrual irregularity or obesity 2/3 have2/3 haveanovulatoryanovulatorysymptomssymptoms Primary or secondary amenorrhea or DUBPrimary or secondary amenorrhea or DUB Metabolic abnormalitiesMetabolic abnormalities Obesity (50%), insulin resistance, glucose intolerance and lipidObesity (50%), i nsulin resistance, glucose intolerance and lipidabnormalitiesabnormalities Diagnosis (clinical + biochemical criteria)Diagnosis (clinical + biochemical cri teria) Elevated LH:FSH ratio, elevated free testosteroneElevated LH:FSH ratio, elevated free testosterone Pelvic ultrasound finding of polycystic ovaries (Pelvic ultras ound finding of polycystic ovaries ( string of string of pearlspearls );); ~45% of adolescents have normal~45% of adolescents have normal--appearing ovarie sappearing ovaries Useful to exclude tumor from the differentialUseful to exclude tumor from the di fferential Exclusion of other disorders that mimic PCOSExclusion of other disorders that mi mic PCOS Virilizing Virilizingtumors,tumors,hyperprolactinemiahyperprolactinemia, non, n on--classical CAH, Cushingclassical CAH, Cushing Coagulation DisordersCoagulation Disorders Often presents asOften presents asmenorrhagiamenorrhagiaat regular intervalsat r egular intervals When to consider bleeding disorders:When to consider bleeding disorders: extremely heavy first menses, bleeding requiring bloodextremely heavy first mens es, bleeding requiring bloodtransfusion, refractorytransfusion, refractorymenorr hagiamenorrhagiaw/ anemiaw/ anemia All patients requiring hospitalization for uterine bleeding All patients requir ing hospitalization for uterine bleedingrequires an evaluation for a coagulation disorderrequires an evaluation for a coagulation disorder Approximately Approximately 20%20% of adolescents withof adolescents withmenorrhagiamenorrhagiawere found to have a coagulation defectwere found to have a coagulation defect Von VonWillebrandWillebranddisease was the most common defectdisease was the mo st common defect(Factor XI deficiency was second)(Factor XI deficiency was secon d) Blood for evaluation of bleeding disorders should beBlood for evaluation of blee ding disorders should beobtainedobtained before before administration of blood products oradministration of blood products orestrogen ( may elevateestrogen (may elevatevWFvWFinto the normal range)into the normal rang e) TreatmentTreatment::

Hormonal Therapy Hormonal Therapy Primary purpose is to stabilize endometrialPrimary purpose is to stabilize endom etrialproliferation and promote sheddingproliferation and promote shedding >90% of adolescents with DUB respond to>90% of adolescents with DUB respond toho rmonal therapyhormonal therapy Alternative diagnosis should be considered for non Alternative diagnosis should be considered for non--respondersresponders EstrogenEstrogen healsheals sites of bleeding by causingsites of bleeding by causi ngfurther proliferation and providingfurther proliferation and providinghemostas ishemostasis Progesterone stops proliferation and stabilizesProgesterone stops proliferation and stabilizesthe endometrial liningthe endometrial lining TreatmentTreatment:: Mild DUB Mild DUB Longer than normal menses or shortenedLonger than normal menses or shortenedcycl es for >2 monthscycles for >2 months Observation and ReassuranceObservation and Reassurance If anemia is not present/normal physical examIf anemia is not present/normal phy sical exam Menstrual calendar recommendedMenstrual calendar recommended Iron supplementation recommendedIron supplementation recommendeddespite normal h emoglobindespite normal hemoglobin FollowFollow--up in 3up in 3--6 months6 months TreatmentTreatment:: Moderate DUB Moderate DUB Moderately prolonged or frequent menses everyModerately prolonged or frequent me nses every11--3 weeks w/ moderate3 weeks w/ moderate--heavy menstrual flowheavy menstrual flow Mild anemia is often present w/out signs of Mild anemia is often present w/out s igns of hypovolemiahypovolemia Outpatient management with hormonal therapyOutpatient management with hormonal t herapy Active bleeding Active bleeding : combination oral contraceptives in: combination oral contraceptives intapering doses (minimum 30mcgtapering doses (minimum 30mcgestradiolestradiol)) 1 pill TID until bleeding ceases1 pill TID until bleeding ceases 1 pill BID X 5 days1 pill BID X 5 days 1 pill QD X 21 days1 pill QD X 21 days No Active bleeding No Active bleeding : Daily/Cyclic OCP: Daily/Cyclic OCP

progestinprogestin--only regimens are an alternative option:only regimens are an alternative option:MedroxyprogesteroneMedroxyprogesterone10mg X first 12 days o f the month10mg X first 12 days of the month TreatmentTreatment:: Severe DUB Severe DUB Heavy menstrual bleeding causing aHeavy menstrual bleeding causing adecrease ind ecrease inHgbHgb<10 with or without<10 with or withouthemodynamichemodynamicinst abilityinstability Hospitalization indications include:Hospitalization indications include: InitialInitialHgbHgb<7g/dL<7g/dL Orthostatic signsOrthostatic signs Heavy active b leeding withHeavy active bleeding withHgbHgb<10g/dL<10g/dL Girls who require hospitalization shouldGirls who require hospitalization should undergo evaluation for a bleeding disorderundergo evaluation for a bleeding diso rder TreatmentTreatment:: Severe DUB Severe DUB CombinationCombinationOCPsOCPs ((estradiolestradiol50mcg)50mcg) 1 pill Q4 until bleeding subsides (usually withi n 24 hrs)1 pill Q4 until bleeding subsides (usually within 24 hrs) 1 pill QID X 4 days1 pill QID X 4 days 1 pill TID X 3 days1 pill TID X 3 days 1 pill BID X 2 wee ks1 pill BID X 2 weeks Conjugated IV estrogen 25mg IV Q4Conjugated IV estrogen 25mg IV Q4--6 is require d for6 is required forunstable patientsunstable patients No more than 6 dosesNo more than 6 doses Bleeding subsides 4Bleeding subsides 4-24 hrs24 hrs Persistent bleeding > 24hrs requiresPersistent bleeding > 24hrs requ ireshemostatichemostatictherapy (antitherapy (anti--fibinolyticfibinolytic) or u terine curettage should be considered (rare)) or uterine curettage should be con sidered (rare) CombinedCombinedOCPsOCPsshould be initiated within 24should be ini tiated within 24--48 hrs of IV48 hrs of IVestrogenestrogen Anti Anti--emetic therapy is recommendedemetic therapy is recommended Blood transfusion is indicated in symptomatic patientsBlood transfusion is indic ated in symptomatic patients Maintenance TherapyMaintenance Therapy CombinationCombinationOCPsOCPs Without significant anemia (Without significant anemia (HgbHgb>10)>10) Cyclic therapy w/21 days + 7 days placeboCyclic therapy w/21 days + 7 days place bo With significant anemia (With significant anemia (HgbHgb<10)<10) Continuous dailyContinuous dailyOCPsOCPs(no placebo) until(no placebo) untilHgbH gbreturns toreturns tonormal (~3mo) followed by cyclic therapy for total of 6nor mal (~3mo) followed by cyclic therapy for total of 6monthsmonths Discontinue hormonal therapy after 3Discontinue hormonal therapy after 3--6 mont hs6 monthsto determine if a normal menstrual pattern hasto determine if a normal menstrual pattern hasbeen establishedbeen established ProgestinProgestin--only regimens (10mg QD X first 12only regimens (10mg QD X fi

rst 12days of the month) is an alternative in pts whodays of the month) is an al ternative in pts whodo not prefer contraceptiondo not prefer contraception TherapyTherapy:: Other Considerations Other Considerations Iron therapy should be included in ALLIron therapy should be included in ALLther apeutic regimenstherapeutic regimens NSAIDsNSAIDs Randomized control trials have shownRandomized control trials have shownreductio n in menstrual blood loss of 30reduction in menstrual blood loss of 30--50%50% Sh ould be started at onset of menstruationShould be started at onset of menstruati onand continued until end of mensesand continued until end of menses Helpful adju nct to hormonal therapy in ptsHelpful adjunct to hormonal therapy in ptswith DUB andwith DUB andmenorrhagiamenorrhagia PrognosisPrognosis DUB should resolve with maturation of theDUB should resolve with maturation of t heHH--PP--O axisO axis Duration of time to maturity appears to beDuration of time to maturity appears t o berelated to the age of menarcherelated to the age of menarche <12 years: 50% at 1 year<12 years: 50% at 1 year (% of (% of ovulatoryovulatorycycles)cycles) 1212--13 years: 50% at 3 years13 years: 50% at 3 years >13 years: 50% at 4.5 year s>13 years: 50% at 4.5 years Prognosis depends upon underlying causePrognosis depends upon underlying cause Search Search History: Searching... Result 00 of 00 00 results for result for # p. Dysfunctional Uterine Bleeding Ppt Download or Print Add To Collection 459 Reads 6 Readcasts 0 Embed Views This is a private document. Published by Nafilah Syella Follow Search TIP Press Ctrl-F F to search anywhere in the document. Info and Rating Category: Uncategorized. Rating: Upload Date: 11/25/2011 Copyright: Attribution Non-commercial Tags: This document has no tags.

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