Volume 39Number 1 br AbstractLearn how to find the source of abnormal bleeding and help his patient again track.Doris Lappin, 45, walks into the ED triage desk and the states, # 147, I # 39; m large clots and have consumed two pills of Maxi in half an hour. I just don # 39; know what to do for the bleeding to stop # 33, I went to see my gynecologist next week, but this is only # 39, t wait until then. # 148, most women who experience menstruation a consistent pattern of menstrual bleeding every month. Uterine bleeding that varies in amount, duration or frequency of a patternor womanusual example, spotting between menstrual periodss considered abnormal, such as postmenopausal bleeding (bleeding that occurs 12 months or more after the menstrual period womanlast). The term dysfunctional uterine bleeding (DUB) is applied to abnormal bleeding in relation to changes in hormones that directly affect the menstrual cycle in the absence of any information organic, systemic or structural disease. May occur with or without 3Using Mrs. ovulation.1Lappincase as an example, we analyze the causes of HUD pointers evaluation and treatment options. Letstart with a quick review of normal menstruation.Menstruation: A complex eventThe menstrual cycle is a complex series of hormonal events that is based on a balance between the hypothalamus, the functions of the pituitary, ovary and uterus. When doesnoccur pregnancy mensesloughing endometrial linings result.A an expected normal menstrual cycle occurs every 21 to 35 days and lasts 2 to 7 days. On average, women lose 30 to 80 ml of menstrual blood in each cycle, with most of that loss occurring during the first 3 days1 For more information, see For a definition normal menstrual Dubby cycle.Understanding , dub womannormal occurs when a menstrual cycle is interrupted, usually due to anovulation (lack of ovulation). Women who experience cycles that vary in length by more than 10 days from one cycle to another are usually anovulatory. Women under age 20 and older than 40 years of age are at particular risk for SUD because women are more prone to hormonal imbalance and anovulation at the beginning or end of their reproductive lives. (See the risk factors for DUB.) Signs and symptoms vary DUB. For example, a woman may bleed more heavily during a period and more lightly the next, the ground between periods, or have a shorter or longer interval between two periods. Or she may bleed for less than 2 days or more than 7 days.Examples DUB include: * menorrhagia: the blood flow of more than 80 ml or lasts more than 7 days * polymenorrhea: menstrual cycles of less than 21 Days * oligomenorrhea: cycles lasting 35 days * Metrorrhagia: bleeding at irregular but frequent * menometrorrhagia: Prolonged or excessive bleeding, irregular or unpredictable intervals.The most common reasons for abnormal bleeding in women of childbearing age are pregnant and conditions related to pregnancy (including miscarriage). But many other possible causes such as genital tract infections, uterine fibroids, endometrial cancer, certain medications and herbal products (such as anticoagulants, corticosteroids, and ginkgo), blood dyscrasias, disorders of the thyroid and adrenal glands (hypothyroidism or hyperthyroidism and hyperandrogenism), liver disease or kidney disease, and even stress. If the underlying pathology is excluded, the diagnosis of DUB DUB.Most cases can be classified into one of two types: * DUB anovulation, which represents about 90f cases, 4 women is common in the beginning or end of life reproductive. In anovulatory DUB, estrogen is secreted continuously, but never an egg ripens in the follicle. Because isnreleased an egg, the corpus luteum stops producing progesterone to counter the proliferation of the lining of the uterus and the patient experiences heavy bleeding.In irregular and possibly the lack of ovulation, menstruation and premenstrual symptoms that wonexperience and typical symptoms such as cramps , mood swings, and breast tenderness. However, the effects of unopposed estrogen in the uterine lining have been directly related to endometrial hyperplasia and cancer. * Ovulatoria DUB is most likely to occur during the peak reproductive years. Associate prolonged progesterone secretion or release of prostaglandins inadequate, usually resulting in heavy bleeding, but predictable. Ovulatory DUB can also coexist with tumors or polyps that can contribute to excessive bleeding. Women with DUB experience signs of ovulation and menstruation and premenstrual symptoms, which are associated with ovulation and lessonsMrs progesterone.5History. Lappin reports that # 39; s had three viable pregnancies without complications. In between pregnancies, she was at a low dose oral contraceptive. After her last pregnancy, had a tubal ligation done and now routinely take medications. She has no history of bleeding disorders or thyroid or other endocrine diseases and has no personal or family history of cancer.Mrs. Lappin said that her period started when I was 13 years and were regular until last year when he began to have periods of heavy blood flow lasts 7 to 10 days. She reports using at least # 147, two boxes of pills # 148; per cycle, and says she spends a lot of large clots. She also has bleeding, with this event is the worst so far. Under further questioning, she reveals she # 39; s often tired and only # 147; doesn # 39; feel good in general. # 148; Get a detailed obstetric and gynecological history is the first step in identifying the underlying cause of uterine bleeding patientexcessive. This includes investigating if you have any vaginal discharge, abdominal pain or pain during intercourse (dyspareunia), or urination (dysuria). By obtaining your health history, specifically exploring whether she has a bleeding disorder or bleeding (such as von Willebrand's disease), chronic liver disease, kidney disease or endocrine disease. Ask about a family history of cancer, endocrine disorders, or bleeding diseases that could be associated with abnormal uterine bleeding. Also ask if shetaking any excess of nonprescription drugs or nonprescription or if you use herbal remedies. Explore your diet and exercise patterns and see if any unusual stress and if sheunder recently.To shegained weight loss or help evaluate his patienthemodynamic, ask if you ever feel dizzy, tired, shortness of breath, or dizziness, which can indicate anemia related to blood loss. Take his vital signs reference and assess orthostatic BP if she has signs and symptoms of physical evaluation hypovolemia.During, inspect your patientskin, noting the color and signs of bleeding disorders, including bruises and petechiae. Also check out the clinical or laboratory evidence of hyperandrogenism such as acne, hirsutism, or abdominal striae. Check your thyroid gland for enlargement and abdomen for tenderness, rigidity, and the masses. Proof of their height and weight and calculate body mass index. To track their menstrual cycles and the signs and symptoms related to teach you how to use a calendar of menstruation. (See monitoring the signs and symptoms, every day.) Following the initial assessment, the nurse is Ms. Lappin be pale and sweaty. Ms. Lappin said he feels dizzy. Vital signs are: temperature, 99.0F (37.2C) 110 thready pulse, and respiration, 24. Orthostatic BP results: supine, 110/78 and pulse 110; standing, 82/60 and pulse of 130. The patient says sheeeling faintwith change of position. The notes of the nurse who has no bruises, petechiae, or signs of hyperandrogenism. On the basis of their history and clinical findings, including orthostatic hypotension, the professional Mrs Lappin admits the nurse inserted an intravenous catheter hospital.The and manages 1,000 ml of chloride 0.9odium more than 4 hours, as ordered. The practitioner orders a complete blood count, coagulation studies, and a pregnancy test. The nurse Mrs Lappin prepares for a pelvic exam with Pap test and pelvic exam ultrasound.Delving deeperA complete lab work and imaging studies reveal more about patientproblem.Pelvic consideration. With a bimanual pelvic examination, the doctor evaluates for the masses of ovarian and uterine cancer and signs of pelvic inflammatory disease. Also, take samples to test for cervical cancer (Pap) and Neisseria gonorrhoeae and Chlamydia trachomatis, even when the bleeding is present.The examine patienturethra practitioner, vagina, cervix and uterus to assess injuries and the endometrium for polyps. You should also assess the rectal area and run a fecal occult blood to determine if the gastrointestinal tract is the source of bleeding.The American College of Obstetricians and Gynecologists recommends an evaluation of the endometrium, as a biopsy for women over 35 years of age and those at high risk of endometrial cancer.6 risk factors for endometrial cancer include morbid obesity, diabetes, hypertension, and duration of work anovulation.Lab. All women of childbearing age should take a pregnancy test and a complete blood count. Depending on the patienthistory and physical, the doctor may order additional blood tests as a platelet count, coagulation studies and ferritin levels and hormones such as thyroid stimulating hormone, progesterone, testosterone, and studies prolactin.Imaging. Your patient may undergo a pelvic ultrasound to rule out tumors, cysts and polyps. Transvaginal ultrasound helps the practitioner to assess structural abnormalities, such as the position and size of fibroids and to determine the thickness of the endometrium. If you detect uterine abnormalities may be ordered to help sonohysterography in diagnosis. This involves infusing saline into the endometrial cavity during a pelvic or transvaginal ultrasound diagnosis examination.After, a patient like Mrs. Lappin treatment needs to stop bleeding, restore and maintain hemodynamic stability, and restore a normal menstrual cycle. See response to hemodynamic instability for details on the acute treatment bleeding.Treatment goals include treatment of any underlying cause, control bleeding, prevent recurrence and to preserve fertility in women of childbearing age. Most cases of DUB are successfully with medication. Letconsider treatment options that vary depending on the type of patient is experiencing.Treating DUB DUBThe main treatment for anovulatory anovulatory DUB is combined oral contraceptives containing estrogen and progesterone or progesterone cyclical. Very effective in controlling excessive anovulatory bleeding, oral contraceptives are available in different doses for each patient to meet contraceptive needs.Oral treatment is generally prescribed for at least 3 months before other treatment options or diagnostic consideration. The following regimens are common: * bleeding. The patient may be placed under a normal birth, beginning with their menstrual cycle. * Moderate to heavy bleeding. The patient may take progestin for 10 to 21 days, then start a normal contraceptive regimen with the next cycle. Alternatively, you can take a monophasic oral contraceptive (deliver the same amount of estrogen and progestin every day) four times daily for 5 to 7 days, then reduce daily dosing.7If combination hormones are contraindicated in a patient with anovulatory DUB, the practitioner may order the progestin, such as medroxyprogesterone (Provera) and norethindrone acetate (Aygestin) to take 5 to 12 days a month from the day 11 or 14 of the menstrual cycle to oppose estrogeneffect in the endometrium. When the patient stops taking progestin each month, they have controlled withdrawal bleeding.Some women benefit from an intrauterine device containing progestin. This method works because it directly counteracts the effects of estrogen on the endometrium and reduces bleeding. At the same time, provides contraception while preserving the ability womanchildbearing. Because little is absorbed progesterone, most women have few systemic effects and acetate well.Medroxyprogesterone tolerate therapy (DepoProvera), a longacting injectable progestin, has become increasingly popular as that requires only one injection every 3 months. Itcontraindicated in patients with undiagnosed vaginal bleeding. Instruct patient to notify physician immediately if unusual bleeding becomes severe, so you can evaluate further.To the treatment of some cases of anovulatory DUB, the gonadotropinreleasing hormone leuprolide (Lupron) is prescribed to activate chemical menopause. Leuprolide reduces folliclestimulating hormone and luteinizing hormone levels to cause amenorrhea, usually within 3 months of starting treatment. Interrupt anovulatory cycle prepares the body for surgery. A woman is usually in the therapy for 6 months or less, during that time, that should be monitored for osteoporosis and the signs and symptoms of menopause such as hot flashes, night sweats, and vaginal dryness.Treating ovulatory DUB DUBIN ovulation, unanimously by continuous estrogen progesterone secretion stimulates the accumulation of the endometrium and leads to an imbalance of prostaglandins. Heavy bleeding associated with ovulatory DUB may respond well to nonsteroidal antiinflammatory drugs (NSAIDs) such as naproxen or ibuprofen. These NSAIDs decrease prostaglandin production, reduce blood flow causing vasoconstriction, and ease colic pain. The devices are more effective in reducing the amount of blood flow in patients with cyclic ovulatory bleeding, fibroids, and intrauterine. In some cases, NSAIDs are combined with oral contraceptives. Treatment with NSAIDs is contraindicated in patients with bleeding disorders or platelet dysfunction.If your patient is being treated with NSAIDs, teaching you start taking this medicine 1 to 2 days before the expected start of your period and continue taking it during your menstruation, as prescribed.Beyond MAY BE DUB medicationsIf medically, the physician may consider several invasive options.Hysteroscopy allows viewing from inside the uterus if bleeding continues. If the doctor detects fibroids or endometrial polyps during the procedure, you can remove the embolization them.Uterine direct stops blood flow to the fibroids that are causing excessive bleeding. Losing its blood supply, the fibroids ischemia and necrosis and shrink.Dilation and curettage (D # 38; C) doesncure underlying problems but will control the acute bleeding hasnresponded to medication. The effects of a D only until the beginning of the next menstrual period. AD can be done to find the cause of the bleeding and help the practitioner to decide how best to treat bleeding process.Endometrial ablation is an option if the patient doesnwant having children. The technique of microwave, radiofrequency energy or cryoablation to destroy the lining of the uterus. The ablation is highly successful in reducing or completely stopping the menstrual cycle and dub, but leaves the patient infertile.Hysterectomy is the definitive treatment for women with endometrial cancer. However, itnow used only as a last resort for the SUDrelated causes.Treatment other, teaching, and supportDuring a pelvic exam, the physician identifies many large fibroids in the uterus. Because Mrs. Lappin # 39; s severe, acute hemorrhage and hypovolemia, performing a D # 38; C immediately to reduce bleeding. She spoke in I.V. Replacement therapy (125 ml / hour) and get a unit of packed red blood cells to treat low hemoglobin level (7.6 mg / dL). She # 39; s given a single dose of conjugated estrogens (Premarin) and started on a combination of oral contraceptives. She responds well to treatment and discharged the next day with instructions to continue oral contraceptives and see your gynecologist in 1 patient with DUB week.A may experience considerable discomfort, including social embarrassment. The disorder can cause your willingness to participate in sexual activity, especially if they frequent or excessive bleeding. Until the cause of bleeding is determined, you can worry about a diagnosis of cancer or other serious illness. There may also be feelings of fear or pain at the possibility infertility.Give its patient and family information to help them better understand DUB, including causes, treatments, longterm effects, and prognosis. Then explain these steps to help minimize the effects of HUD in its daily operations: * Call your doctor if you clot the size of a half dollar or more if soaking a pad or tampon at least every hour, or if severe abdominal pain. * Take medications. (Tell the patient what adverse reactions they may experience and when to contact your health care professional.) * If you feel cramps or discomfort, taking ibuprofen or naproxen as directed. Avoid aspirin products because it can increase bleeding. * For a lot of iron in their diet, eating foods like liver, beans and spinach. (If the doctor prescribes an iron supplement, teaching the patient about side effects such as constipation and stool a darker color.) * Rest frequently to monitor fatigue. * If you experience dizziness or heart palpitations, which may be indicative of excessive blood loss, consult your healthcare provider immediately. * You can participate in sexual activities and other activities of daily living, including swimming and exercise, during menstruation.By help your patient understand the reasons for the LDS and support it while taking steps to control it, you help upon return to their normal routines. As for a normal menstrual cycle menstrual cycleThe is regulated by a complex interplay between the hypothalamus, anterior pituitary gland, ovaries and various target tissues, such as the endometrium. The normal menstrual function has two distinct phases, with estrogen and progesterone, hormones produced by the ovaries, which play key roles: * In the proliferative phase, estrogen levels predominate. Several ovarian follicles containing immature eggs to grow in this phase of the menstrual cycle. These follicles release estrogen acting on the uterus and cause the endometrium to become thick and vascular and proliferate. The corpus luteum develops from an ovarian follicle during the middle of the cycle, estrogen and progesterone that occurs to maintain its structure. * The secretory phase begins when an increase in progesterone triggers ovulation. If the egg isnfertilized, the corpus luteum atrophies and the production of estrogen and progesterone decrease. The endometrium breaks down and menstruation occurs.Figure. No title available.Risk factors for DUBTracking signs and symptoms, dayThe day for the use of a daily calendar of menstruation or menstrual flow may help the patient compare how your menstrual cycle that differs from their normal cycle length, frequency and intensity. Teach him to record the following: * daily temperatures, taken every morning before she gets out of bed. A rise in body temperature can indicate ovulation. * When your periods start and end * amount of bleeding (number of pads or tampons saturated) * of their contraceptive use and sexual activity * problems such as pain, blood clots, bleeding after intercourse or bleeding that requires more than one pad or tampon every hour.Your patient must also take into account whether menstruation causes social embarrassment and inconvenience, the commitments of their sexual activity or forced to change its hemodynamic lifestyle.Responding to a woman who instabilityFor experiencing acute bleeding, the primary consideration is their hemodynamic status. She required hospitalization for supporting the alphabet, signs and symptoms of hypovolemia monitor and possibly to replace fluids with volume expanders or blood products. If hemodynamic status is unstable due to acute hemorrhage, which can receive conjugated estrogens intravenously every 4 to 6 hours or until the bleeding for 12 hours. To promote the rapid regeneration of endometrial tissue in the bare surface epithelium, which also receive IV infusions of high doses of estrogen preparations such as Premarin, followed by oral therapy contraceptives.REFERENCES1. Fazio, SB, Ship AN. Abnormal uterine bleeding. South Med J. 2007, 100 (4): 37,682. [Link] 2. Bradley LD. Abnormal uterine bleeding. Nurse Pract. 2005, 30 (10): 389. [Link] 3. Vilos GA, Lefebvre G, Graves GR. Guidelines for the treatment of abnormal uterine bleeding. Can J Gynaecol Obstet. 2001, 23 (8): 70,409. [Link] 4. Dodds NR. Dyfunctional uterine bleeding. eMedicine from WebMD. www.emedicine.com/emerg/TOPIC155.htm. Updated 12 November 2007. [Link] 5. Association of Reproductive Health Professionals. What you need to know: abnormal uterine bleeding. www.arhp.org / Publications & Resources / Clinicalchips /abnormal uterine bleeding. Updated July 2008. [Link] 6. ACOG practice bulletin. Management of anovulatory bleeding. Int J Gynecol Obstet. 2001, 72:26371. 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