Dysfunctional uterine bleeding case file

Dysfunctional uterine bleeding case file

Eugene C. Toy, MD, Barry C. Simon, MD, Terrence H. Liu, MD, MHP, Katrin Y. Takenaka, MD, Adam J. Rosh, MD, MS

Case 50

A 24-year-old Gravida 0, Para 0 woman is brought in the emergency center with a history of heavy vaginal bleeding for 8 days. The patient says that the bleeding has been heavier than normal and that she has used up to 20 pads per day that are soaked. She has been passing clots the size of “golf balls” also. She feels faint and lightheaded. The patient’s mother states that her daughter has had irregular menses throughout her life, with menses every 30 to 70 days, and bleeding heavy at times and light at other times. On examination, the BP is 90/60 mm Hg, and HR is 120 beats per minute. Generally, she is anxious. The mucous membranes are moist and skin turgor is normal. There is a 2-second capillary refill. The heart and lung examinations are normal. The abdominal examination reveals slight obesity with no scars or tenderness. The pelvic examination shows active bright red bleeding. The vagina has 30 cc of blood in the vault. The cervix appears normal. Pelvic examination reveals a normal-sized uterus and no adnexal masses. There is slight tenderness but no cervical motion tenderness. The hemoglobin level is 8 g/dL, and platelet count 160 000/mm3. The pregnancy test is negative.

⯈ What is the most likely diagnosis?

⯈ What is the initial management?

⯈ What is the most likely etiology for the patient’s condition?

⯈ What are the options in treating the patient’s hemorrhage?

ANSWER TO CASE 50:

Dysfunctional Uterine Bleeding

Summary: A 24-year-old nulligravid woman is brought into the emergency center with significant menometrorrhagia for 8 days. The patient has had a long history of oligomenorrhea. On examination, the BP is 90/60 mm Hg, and HR is 120 beats per minute. Generally, she is anxious. The skin turgor, mucous membranes, and capillary refill are normal. The pelvic examination shows active bright red bleeding. The vagina has 30 cc of blood in the vault. There are no abnormalities noted on pelvic examination. The hemoglobin level is 8 g/dL, and platelet count 160 000/mm3. The pregnancy test is negative.

• Most likely diagnosis: Dysfunctional uterine bleeding
• Initial management: ABCs—intravenous isotonic saline infusion, urgent pelvic ultrasound examination, gynecological consultation
• Most likely etiology: Anovulatory state leading to proliferative endometrium and fragmented endometrial desquamation
• Treatment options of hemorrhage: Intravenous estrogen versus dilatation and curettage

ANALYSIS

Objectives

1. Be able to define dysfunctional uterine bleeding (DUB) and be aware that it is associated with normal uterine anatomy.
2. List the common etiologies of abnormal vaginal bleeding.
3. Describe a logical approach to abnormal vaginal bleeding and be aware that dysfunctional uterine bleeding is the most common cause of non–pregnancy-related abnormal vaginal hemorrhage.
4. Be aware of common treatments for DUB.

Considerations

This is a 24-year-old woman with a long history of oligomenorrhea, possibly due to polycystic ovarian syndrome. The patient is noted to be obese but there is no mention of hirsutism or glucose intolerance. The initial attention should be toward assessment of the patient’s volume status, and resuscitation of intravascular volume as needed. Pregnancy should be ruled out, since pregnancy-associated vaginal bleeding is usually incomplete abortion, and typically treated by diltation and curettage (D and C) and not amenable to medical therapy. The emergency physician should also entertain coagulopathy as an etiology with questions about easy bruising and bleeding tendencies. Once pregnancy is ruled out, in the absence of significant contraindications (active liver disease, breast cancer, suspicion of endometrial cancer, thrombophilia), intravenous estrogen can be initiated. Typically, the bleeding will dissipate within several hours, and be markedly decreased within 8 hours. Gynecological consultation is paramount since consideration should be given for endometrial sampling when there is suspicion of endometrial hyperplasia or cancer. In this individual, her age makes these conditions less likely. After intravenous estrogen such as conjugated equine estrogen (Premarin) 25 mg intravenously every 6 hours is given for 3 to 4 doses, then the patient is usually transitioned to an oral contraceptive agent and menses regulated with these medications.

Approach To:

Dysfunctional Uterine Bleeding

DEFINITIONS

MENORRHAGIA: Excessive vaginal bleeding, classically exceeding 80 mL during menses, or greater than 7 days in duration, which leads to anemia without iron supplementation. Menorrhagia is not associated with irregular menses but heavy menses.

MENOMETRORRHAGIA: Prolonged and/or excessive vaginal bleeding that occurs at irregular intervals, usually due to anovulation.

OLIGOMENORRHEA: Menses occurring at intervals of greater than 35 days.

AMENORRHEA: Absence of menses for greater than 6 months.

CLINICAL APPROACH

Initial Approach

The initial condition of the patient dictates the rapidity of the evaluation, and therapeutic maneuvers employed. A patient who presents to the emergency center in frank shock due to excessive vaginal bleeding should have urgent management of hypovolemia and blood products en route while very basic diagnostic information is sought. Establishing whether the patient is pregnant is critical, and this should be determined by a reliable hospital/office test, and not by patient history (contraception, abstinence, home pregnancy test). Screening questions and examination about amount of vaginal bleeding and presence or absence of clots, number of pads, and degree that each pad is soaked may be helpful, but multiple research studies have highlighted the unreliability of an individual’s assessment of their menstrual bleeding. This initial patient assessment should address the following questions:

1. Is the patient in hypovolemia shock?
2. Is the patient pregnant?
3. Is the patient actively bleeding and to what degree?
4. Is there an obvious etiology for the vaginal bleeding (uterine fibroids, coagulopathy, cervical cancer, genital tract laceration)?

Because the amount of vaginal bleeding is difficult to characterize, women with DUB may sometimes present with profound anemia, or volume depletion that is well compensated. A systematic assessment of volume status will prevent undue delay in these patients. Also, in older women, myocardial infarction and stroke should be considered if hypotension is prolonged. The treatment for hypovolemic shock is the same as that of other conditions, such as trauma.

Pregnancy must be reliably ruled in or out early in the evaluation of patients with DUB. A complication of pregnancy usually indicates an incomplete abortion, such that a uterine dilation and curettage should be performed to stop the bleeding. Other conditions that should be considered include molar pregnancy, and antepartum vaginal bleeding such as placenta previa or placental abruption. When the uterus is above the level of the umbilicus in a pregnant woman with vaginal bleeding, a speculum examination or digital examination should be avoided since these actions may exacerbate placenta previa. An ultrasound examination instead is helpful in conditions of pregnancy-related vaginal hemorrhage.

Active vaginal bleeding necessitates more aggressive management. Upon examining the woman, blood stains down the legs indicates significant bleeding, and the probable need for transfusion. The speculum examination should be performed to assess for degree of bleeding, lesions of the vagina or cervix, and ascertaining whether the bleeding is coming from within the uterus (supracervical) versus the cervix or vagina. Lacerations of the vagina or cervix may indicate instrumentation or trauma. A digital pelvic examination is performed to assess for cervical pathology, and also uterine size and shape. In the face of DUB, once structural abnormalities of the genital tract are ruled out, active bleeding will usually necessitate high-dose estrogen parenteral therapy or uterine D and C. In situations of less active bleeding, oral hormonal therapy may be considered.

A systematic approach should be undertaken to assess for underlying causes of DUB. A history of medication use such as oral contraceptives, IUD use, depoprovera, family history of coagulopathy, structural lesions of the uterus or cervix (see Table 50–1), and differential diagnosis of ovulatory dysfunction should also be considered (see Table 50–2).

Dysfunctional Uterine Bleeding

The diagnosis of DUB is one of exclusion after other disorders are ruled out. The bleeding is due largely to anovulation, that is, unopposed estrogen effect on the endometrium leading to overgrowth of the endometrium without progesterone to arrest the growth. Fragments of endometrium slough off leading to bleeding from

denuded endometrium. Polycystic ovarian syndrome (PCOS) is a common condition associated with DUB. PCOS is a constellation of obesity, anovulation, hirsutism, glucose intolerance, oligomenorrhea, and hyperandrogenism. In a woman older than age 35, or in a younger patient with persistent and prolonged unopposed estrogen, endometrium sampling should be performed to assess for endometrial hyperplasia or cancer. A reasonable workup for anovulatory DUB is listed in Table 50–3.

Acute treatment of DUB is principally estrogen-containing hormonal therapy. With significant bleeding, IV premarin causes re-epithelialization of the denuded endometrium to arrest bleeding from these “raw surfaces.” Nevertheless, after three to four doses of parenteral estrogen, the bleeding should be significantly diminished, and the patient transitioned to an oral combination estrogen/progestin regimen. In most situations where there is less active bleeding, oral contraceptive agents can be used. Various regimens are used, and one common method is to use 3 tablets a day of a combination OC (such as ortho novum 1/35) for 7 days, and then after the 7 days, the patient should begin the same oral contraceptive 1 tablet a day. Bleeding should improve within 2 days, and be very minimal within 4 to 5 days. Follow-up should be arranged within a week. Hormonal therapy should not be initiated until pregnancy and structural lesions of the uterus are ruled out. Endometrial sampling should be performed prior to initiation of hormonal treatment if possible. Notably, bleeding due to uterine fibroids will typically not respond to hormonal manipulation.

In some individuals, estrogen therapy will be contraindicated, such as those with active liver disease, active breast cancer, or high risk for thrombosis. In those women, inflation of a Foley balloon in the uterus has been described as a temporarizing measure, and may be life-saving for those patients who cannot receive estrogen and also are not suitable surgical candidates. However, most of these patients will undergo uterine D and C, both for diagnostic purposes, and also to acutely arrest the hemorrhage. It is important to note that the underlying pathological process that induced the bleeding is not addressed with a D and C, and the patient may return to the emergency center in several months if the cause is not addressed. Women who have PCOS for whom oral conceptive agent, or progestins are contraindicated may need surgical therapy for the bleeding, such as endometrial ablation or hysterectomy.

COMPREHENSION QUESTIONS

50.1 A 16-year-old adolescent girl is brought into the ED with complaints of significant vaginal bleeding with her menses. She bleeds 5 days each month with heavy flow, utilizing 25 to 30 pads. She is tired and gets dizzy during menses. On examination, her BP is 80/60 mm Hg and heart rate 120 beats per minute. Her external genitalia are normal; there are no lesions of the cervix or vagina. The uterus is normal sized and anteverted. There are no masses or tenderness. The pregnancy test is negative. Her hemoglobin level is 7 g/dL. The emergency physician orders a transfusion. Which of the following is the best next step?

A. Screen for sexually transmitted infections.

B. Begin intravenous progestin.

C. Consult a gynecologist for endometrial ablation.

D. Screen for coagulopathy.

50.2 A 32-year-old woman is seen in the ED with heavy vaginal bleeding. She states that she has had irregular menses for 3 years, and at times has “baseball-sized clots” pass vaginally. On examination, her BP is 120/70 mm Hg and heart rate 90 beats per minute. Her uterus is 4-week size and without tenderness. There are no abnormalities on pelvic examination including speculum examination of the cervix and vagina. Approximately 30 cc of dark blood is noted in the vaginal vault and a moderate fl ow of blood from the cervix. Her hemoglobin level is 10 g/dL. Which of the following is the next appropriate step?

A. Begin intravenous estrogen.

B. Administer intramuscular progestin.

C. Transfuse 2 units of packed erythrocytes.

D. Begin oral contraceptives at 3 pills per day.

50.3 A 42-year-old woman is seen in the with profuse vaginal bleeding. She has a history of diabetes mellitus. On examination, her BP is 100/60 and heart rate 105 beats per minute. Her uterus is irregular and enlarged and nontender. There is active bleeding arising from the uterus. Her hemoglobin level is

9 g/dL, glucose level 140 mg/dL and her pregnancy test is negative. Which of the following is the best management of this patient?

A. Begin IV estrogen therapy.

B. Begin oral progestin therapy.

C. Begin oral contraceptive therapy.

D. Lower the blood sugar.

E. Refer the patient for hysterectomy.

F. Perform endometrial sampling.

ANSWERS

50.1 D. In an adolescent who has significant menorrhagia requiring transfusion, the incidence of coagulopathy approaches 20% to 30%. Von Willebrand disease is the most common etiology, and will often respond to desmopressin (DDAVP). Coagulopathy should be ruled out prior to starting estrogen therapy, although sometimes this is impossible given laboratory constraints. IV progestin has no role in this condition. Endometrial ablation is appropriate for older women who have finished child bearing, and in whom the endometrium has been assessed for pathology. Endometrial ablation should not be performed on younger patients.

50.2 D. This patient is appropriate for oral combination contraceptive therapy. She does not have contraindications, does not seem to require sampling of the endometrium, and there does not seem to be a structural etiology for the bleeding. Intravenous estrogen is usually reserved for women with significant active bleeding and requires hospitalization.

50.3 F. This patient is 42 years old with DUB and hence, an endometrial sampling should be performed. In general, the endometrium should be assessed for women above age 35 years before any hormonal therapy is initiated. The blood sugar does not need to be acutely lowered. Although the uterus is enlarged and irregular indicating possible uterine fibroids, an evaluation should be performed prior to hysterectomy such as pelvic ultrasound and endometrial sampling.

CLINICAL PEARLS

⯈ Dysfunctional uterine bleeding (DUB) is a diagnosis of exclusion and indicates excessive or prolonged bleeding without structural pathology of the genital tract.

⯈ The most common reason for DUB is anovulation, the bleeding pattern is heavy and unpredictable.

⯈ Therapeutic options of acute and active significant vaginal hemorrhage due to DUB include IV estrogen therapy and uterine D and C. A clinical effect from the estrogen can be seen within 4 hours.

⯈ Pregnancy must be ruled out in any woman presenting with DUB.

⯈ Endometrial sampling should be considered in any woman over the age of 35 with DUB and in individuals at risk for endometrial hyperplasia/cancer.

⯈ Oral contraceptive agents are a reasonable option for the treatment of patients with DUB who are hemodynamically stable once pregnancy, coagulopathy, and structural lesions of the uterus are excluded.

⯈ A teenager who presents with DUB may have a bleeding diathesis such as von Willebrand.

REFERENCES

American College of Obstetricians and Gynecologists. Endometrial ablation. ACOG Practice Bulletin 81. April 2007. 

American College of Obstetricians and Gynecologists. Menstruation in girls and adolescents: using the menstrual cycle as a vital sign. ACOG Committee Opinion 349. November 2006. 

American College of Obstetricians and Gynecologists. Polycystic ovarian syndrome. ACOG Practice Bulletin 108. December 2009. 

Morrison LJ, Spence JM. Vaginal bleeding in the nonpregnant patient. In: Tintinalli JE, Stapczynski JS, Ma OJ, Cline D, Cydulka R, Meckler G, eds. Emergency Medicine: A Comprehensive Guide. 7th ed. New York, NY: McGraw-Hill; 2010:647-653.

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