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Dysfunctional Uterine Bleeding, Emergency Medicine

Basics

Description

- 2 classifications - Dysfunctional uterine bleeding (DUB) - Hormonally related - Anovulatory and ovulatory categories - Not due to organic or iatrogenic causes - Diagnosis of exclusion

- Anovulatory (most common): - Unopposed estrogen stimulation of proliferative endometrium - Alteration of neuroendocrine function due to: - Polycystic ovarian syndrome (PCOS) - Very low calorie diets, rapid weight change, intense exercise, anorexia - Psychological stress - Obesity - Drugs - Hypothyroidism - Primary hypothalamic dysfunction

- Excessive uterine prostacycline - Diminishes platelet function and increases uterine vasodilation

- Pregnancy complications: - Threatened, incomplete, or spontaneous abortion - Ectopic pregnancy - Molar pregnancy

- Infectious: - Vaginitis - Cervicitis - Pelvic inflammatory disease (PID)

- Coagulopathies: - von Willebrand disease - Idiopathic thrombocytopenic purpura - Platelet defects - Thalassemia

  • Abnormal uterine bleeding is an alteration in pattern or volume of normal mensesTypical blood loss during a normal menstrual cycle is 30-80 mLNormal interval between menses 28 (+/- 7) days
  • 2 classificationsDysfunctional uterine bleeding (DUB)Hormonally relatedAnovulatory and ovulatory categoriesNot due to organic or iatrogenic causesDiagnosis of exclusionOrganic uterine bleedingBleeding related to systemic illness or disease of the reproductive tract

Etiology

  • Anovulatory (most common):Unopposed estrogen stimulation of proliferative endometriumAlteration of neuroendocrine function due to:Polycystic ovarian syndrome (PCOS)Very low calorie diets, rapid weight change, intense exercise, anorexiaPsychological stressObesityDrugsHypothyroidismPrimary hypothalamic dysfunction
  • Ovulatory:Inadequate uterine PGF2О±Increased uterine contractilityExcessive uterine prostacyclineDiminishes platelet function and increases uterine vasodilation

Anovulatory bleeding common in adolescence owing to immaturity of the hypothalamic-pituitary-ovarian axis пїЅ

Diagnosis

Signs and Symptoms

History

  • Abnormal uterine bleeding in the absence of systemic or structural disease
  • Most common in perimenarcheal, perimenopausal women
  • Typically painless
  • Anovulatory presentations:Metrorrhagia:Irregular bleeding between periodsMenorrhagia:Regular periods with excess flow (>80 mL) or >7 days of bleedingOligomenorrhea:Periods with intermenstrual cycles >35 daysMenometrorrhagia:Excessive bleeding with and between menses

Physical Exam

  • Acne, hirsutism, obesity suggest PCOS
  • Mild to moderate bleeding on pelvic exam
  • Pallor, tachycardia, hypotension, orthostasis in severe cases
  • Evaluate for trauma, foreign bodies

It is rare for women to be hemodynamically unstable simply from DUB; if such instability is present, concern is for ectopic pregnancy or other cause for hemorrhage. пїЅ

Essential Workup

Pregnancy test пїЅ

Diagnosis Tests & Interpretation

Lab

  • Pregnancy test, CBC, PT/PTT
  • May send iron studies, TSH, LH, FSH, prolactin level, cervical cultures for routine follow-up by primary medical doctor (PMD)/gynecology

Imaging

Pelvic ultrasound may show uterine, tubal, or ovarian abnormality; may be needed to rule out other organic or iatrogenic causes on differential diagnoses. пїЅ

Diagnostic Procedures/Surgery

  • Dilation and curettage (D&C) may be required for heavy bleeding unresponsive to other interventions
  • Refer for endometrial biopsy if >35 yr of age

Differential Diagnosis

Organic/Iatrogenic

  • Pregnancy complications:Threatened, incomplete, or spontaneous abortionEctopic pregnancyMolar pregnancy
  • Infectious:VaginitisCervicitisPelvic inflammatory disease (PID)
  • Coagulopathies:von Willebrand diseaseIdiopathic thrombocytopenic purpuraPlatelet defectsThalassemia
  • Medications:WarfarinAspirinOral contraceptivesTricyclic antidepressantsMajor tranquilizers
  • Systemic illness:Adrenal, hepatic, renal or thyroid dysfunction, diabetes mellitus, other endocrinopathies
  • Anatomic lesions:FibroidsEndometriosisPolypsEndometrial hyperplasiaNeoplasm
  • Intrauterine devices
  • Trauma

Hormone related

See anovulatory and ovulatory etiologies пїЅ

Treatment

Pre-Hospital

IV crystalloid boluses as needed for hypotension, tachycardia secondary to heavy bleeding пїЅ

Initial Stabilization/Therapy

ABCs: пїЅ

  • Packed RBCs for significant bleeding unresponsive to crystalloids

Ed Treatment/Procedures

  • Observation usually adequate if bleeding mild
  • IV crystalloid, packed RBCs for continued bleeding, or hemodynamic instability
  • Gynecology consultation if bleeding is severe and unresponsive to crystalloids, medications:D&C may be necessary for hemodynamic instabilityEndometrial ablation or hysterectomy for continued heavy bleeding unresponsive to other measures

Medication

  • Conjugated estrogen (Premarin) for heavy bleeding, hemodynamic instability:2.5 mg PO q6h25 mg IV, repeat in 3 hr if needed
  • Ibuprofen 400-800 mg PO q8h (reduces prostaglandin synthesis)
  • IV dosing has not been shown to be superior to oral route:Medroxyprogesterone acetate 5-10 mg/d PO is added when bleeding subsides
  • Oral contraceptive pills:Ethinyl estradiol 35 Ојg and norethindrone 1 mg PO QID for 1 wk
  • Antifibrinolytic agents:Tranexamic acid: 1,300 mg PO TID пїЅ 5 daysMay be used in conjunction with OCPsUse limited by GI effects and allergy
  • Medications may be deferred in mild cases with referral to gynecology
  • Transdermal or long-acting estrogens are other options

Follow-Up

Disposition

Admission Criteria

  • Significant blood loss
  • Continued bleeding
  • Hemodynamic instability requiring aggressive resuscitation and/or operative intervention

Discharge Criteria

Most patients can be discharged with gynecology referral once bleeding is controlled and patient is hemodynamically stable. пїЅ

Issues for Referral

Endometrial biopsy if >35 yr old: пїЅ

  • Follow-up with either gynecologist or primary care physician is necessary for patients with DUB
  • Must evaluate for ongoing blood loss or potential malignancy as cause

Pearls and Pitfalls

  • DUB is a diagnosis of exclusion
  • Only 2% of endometrial carcinoma occur before age 40 yr
  • If hemodynamic instability, unlikely diagnosis of DUB

Additional Reading

  • Casablanca пїЅY. Management of dysfunctional uterine bleeding. Obstet Gynecol Clin North Am. 2008;35:219-234.
  • LaCour пїЅDE, Long пїЅDN, Perlman пїЅSE. Dysfunctional uterine bleeding in adolescent females with endocrine causes and medical conditions. J Pediatr Adolesc Gynecol. 2010;23:62-70.
  • Lentz пїЅG, Lobo пїЅR, Gershenson пїЅD, et al. Comprehensive Gynecology. 6th ed. Philadelphia, PA: Mosby; 2012.
  • Lethaby пїЅA, Farquhar пїЅC, Cooke пїЅI. Antifibrinolytics for heavy menstrual bleeding. Cochrane Database Syst Rev. 2000;(4):CD000249.
  • Pitkin пїЅJ. Dysfunctional uterine bleeding. BMJ. 2007;334:1110-1111.

See Also (Topic, Algorithm, Electronic Media Element)

  • Amenorrhea
  • Vaginal Bleeding

Codes

ICD9

  • 626.2 Excessive or frequent menstruation
  • 626.6 Metrorrhagia
  • 626.8 Other disorders of menstruation and other abnormal bleeding from female genital tract
  • 626.1 Scanty or infrequent menstruation
  • 626.5 Ovulation bleeding

ICD10

  • N92.0 Excessive and frequent menstruation with regular cycle
  • N92.1 Excessive and frequent menstruation with irregular cycle
  • N93.8 Other specified abnormal uterine and vaginal bleeding
  • N91.5 Oligomenorrhea, unspecified
  • N92.3 Ovulation bleeding

SNOMED

  • 19155002 Dysfunctional uterine bleeding (finding)
  • 64996003 intermenstrual bleeding - irregular (finding)
  • 386692008 Menorrhagia (finding)
  • 52073004 Oligomenorrhea (finding)
  • 266603000 Ovulation bleeding (finding)
  • 27585009 Anovular menstruation (finding)
  • 314631008 menometrorrhagia (finding)