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EMERGENCY MEDICINE
Author: Amir Estephan, MD; Chief Editor: Pamela L Dyne, MD
Updated: Oct 31, 2014
BACKGROUND
Abnormal uterine bleeding is a common presenting problem in the ED.
Dysfunctional uterine bleeding (DUB) is defined as abnormal uterine bleeding in the
absence of organic disease. Dysfunctional uterine bleeding is the most common cause of
abnormal vaginal bleeding during a woman's reproductive years. Dysfunctional uterine
bleeding can have a substantial financial and quality-of-life burden. It affects women's
health both medically and socially.
PATHOPHYSIOLOGY
The normal menstrual cycle is 28 days and starts on the first day of menses. During
the first 14 days (follicular phase) of the menstrual cycle, the endometrium thickens
under the influence of estrogen. In response to rising estrogen levels, the pituitary gland
secretes follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which
stimulate the release of an ovum at the midpoint of the cycle. The residual follicular
capsule forms the corpus luteum.
After ovulation, the luteal phase begins and is characterized by production of
progesterone from the corpus luteum. Progesterone matures the lining of the uterus and
makes it more receptive to implantation. If implantation does not occur, in the absence of
human chorionic gonadotropin (hCG), the corpus luteum dies, accompanied by sharp
drops in progesterone and estrogen levels. Hormone withdrawal causes vasoconstriction
in the spiral arterioles of the endometrium. This leads to menses, which occurs
approximately 14 days after ovulation when the ischemic endometrial lining becomes
necrotic and sloughs.
intervals
Menometrorrhagia - Prolonged or excessive uterine bleeding occurring at irregular
there is an increased rate of blood loss resulting from vasodilatation of the vessels
supplying the endometrium due to decreased vascular tone, and prostaglandins have been
strongly implicated. Therefore, these women lose blood at rates about 3 times faster than
women with normal menses.
EPIDEMIOLOGY
Frequency
United States
Dysfunctional uterine bleeding is one of the most often encountered gynecologic
problems. An estimated 5% of women aged 30-49 years will consult a physician each
year for the treatment of menorrhagia. About 30% of all women report having had
menorrhagia.
International
No cultural predilection is present with this disease state.
Mortality/Morbidity
Morbidity is related to the amount of blood loss at the time of menstruation,
which occasionally is severe enough to cause hemorrhagic shock. Excessive
menstrual bleeding accounts for two thirds of all hysterectomies and most
endoscopic endometrial destructive surgery. Menorrhagia has several adverse effects,
including anemia and iron deficiency, reduced quality of life, and increased
healthcare costs.
Race
Dysfunctional uterine bleeding has no predilection for race; however, black
women have a higher incidence of leiomyomas and, as a result, they are prone to
with
complaints
of
amenorrhea,
menorrhagia,
dysmenorrhea
Postcoital bleeding
Gravida and para
Previous abortion or recent termination of pregnancy
Contraceptive use, use of barrier protection, and sexual activity (including
and syncope)
Diabetes mellitus
Thyroid disease
Endocrine problems or pituitary tumors
Liver disease
Recent illness, psychological stress, excessive exercise, or weight change
Physical
o Vital signs, including postural changes, should be assessed. Initial evaluation
should be directed at assessing the patient's volume status and degree of anemia.
Examine for pallor and absence of conjunctival vessels to gauge anemia.
o An abdominal examination should be performed. Femoral and inguinal lymph
nodes should be examined. Stool should be evaluated for the presence of blood.
o Patients who are hemodynamically stable require a pelvic speculum, bimanual,
and rectovaginal examination to define the etiology of vaginal bleeding. A
careful physical examination will exclude vaginal or rectal sources of bleeding.
The examination should look for the following:
The vagina should be inspected for signs of trauma, lesions, infection, and
foreign bodies.
The cervix should be visualized and inspected for lesions, polyps, infection,
Causes
o Systemic
disease,
including
thrombocytopenia,
hypothyroidism,
as
von
Willebrand
disease,
DIFFERENTIAL DIAGNOSES
Adenomyosis
Anovulation
Anticoagulants
Antipsychotics
Cervical Cancer
Cervicitis
Coagulopathies
Early Pregnancy Loss in Emergency Medicine
Emergent Management of Abruptio Placentae
Emergent Management of Ectopic Pregnancy
Emergent Treatment of Endometriosis
Endocervical Polyp
Endometrial Carcinoma
Endometrial Polyp
Estrogen Therapy
Fibroids (leiomyomata)
Foreign body
Hydatidiform Mole
Hyperthyroidism
Hypothyroidism
Iatrogenic Cushing Syndrome
Intrauterine devices
Liver disease
Mullerian Duct Anomalies
Oral contraceptives
Ovarian Cysts
Pelvic Inflammatory Disease
Placenta Previa
Platelet Disorders
Polycystic Ovarian Syndrome
Prolactinoma
Renal disease
Trauma
Vascular Surgery for Arteriovenous Malformations
Vulvovaginitis
von Willebrand Disease
WORKUP
Laboratory Studies
o When evaluating a woman of reproductive age with vaginal bleeding, pregnancy
must always be ruled out by urine or serum human chorionic gonadotropin.
o In a patient with any hemodynamic instability, excessive bleeding, or clinical
evidence of anemia, a complete blood count is essential.
o Coagulation studies should be considered when indicated by the history or
physical examination findings and in patients with underlying liver disease or
other coagulopathies.
o In patients with suspected endocrine disorders, other laboratory studies such as
thyroid function tests and prolactin levels may be helpful, although these results
may not be available from the ED.
Imaging Studies
o Pelvic ultrasonography is an important imaging modality for nonpregnant
patients with abnormal vaginal bleeding. It may determine the etiology of the
performed.
Depending on the urgency to determine the etiology of bleeding and on the
reliability of outpatient follow-up, ultrasonography may be deferred for
outpatient evaluations because for the majority of nonpregnant patients,
Procedures
o Before instituting therapy, many consulting gynecologists perform endometrial
sampling or biopsy to diagnose intrauterine pathology and to exclude
endometrial malignancy.
o Endometrial biopsy is indicated for the following patients with abnormal uterine
bleeding:
Women older than 35 years
Obese patients
Women who have prolonged periods of unopposed estrogen stimulation
Women with chronic anovulation
o Hysteroscopy is the definitive way to detect intrauterine lesions. It offers a more
complete examination of the surface of the endometrium. However, it is usually
reserved for treating lesions that were detected by other less invasive means.
include musculoskeletal pain, breast atrophy, hirsutism, weight gain, oily skin,
and acne. Because of the significant androgenic side effects, this drug is usually
reserved as a second-line treatment for short-term use prior to surgery.
o Gonadotropin-releasing hormone agonists may be helpful for short-term use in
inducing amenorrhea and allowing women to rebuild their red blood cell mass.
They produce a profound hypoestrogenic state similar to menopause. Side
effects include menopausal symptoms and bone loss with long-term use.
o Tranexamic acid is an antifibrinolytic drug that exerts its effects by reversibly
inhibiting plasminogen. It diminishes fibrinolytic activity within endometrial
vessels to prevent bleeding. It has been shown effective in reducing bleeding in
up to half of women with dysfunctional uterine bleeding. Tranexamic acid is not
approved for the treatment of dysfunctional uterine bleeding in the United
States.
Consultations
o Seek an emergency
gynecologic
consultation
for
patients
requiring
MEDICATION
Medication Summary
The goals of pharmacotherapy are to control the bleeding, reduce morbidity, and prevent
complications.
o Steroid hormones
Class Summary
These agents may help control bleeding. Some of them are used when bleeding is
profuse and the patient is unresponsive to initial fluid management.
Ethinyl estradiol 35 g and norethindrone 1mg (Necon 1/35, Nortrel 1/35,
Ortho-Novum 1/35, Norinyl 1 + 35)
Reduces secretion of LH and FSH from pituitary by decreasing amount of
GnRH. Contraceptive pills containing estrogen and progestin have been
advocated for nonsmoking patients with DUB who desire contraception.
Therapy also used to treat acute hemorrhagic uterine bleeding but not as
effective as other treatments perhaps because may take longer to induce
endometrial proliferation when progestin is present.
Suggested mechanisms by which hormonal therapy might affect bleeding
include improvement in coagulation, alterations in the microvascular circulation,
and improvements in endothelial integrity. In long-term management of DUB,
ethisterone,
with
strong
bleeding. These regimens offer no real advantage over other regimens and might
cause irreversible signs of masculinization in the patient. They seldom are used
for this indication today.
Use of androgens might stimulate erythropoiesis and clotting efficiency.
surface.
Medroxyprogesterone acetate (Provera)
DOC for most patients with anovulatory DUB. After acute bleeding episode
controlled, can be used alone in patients with adequate amounts of endogenous
estrogen to cause endometrial growth. Progestin therapy in adolescents produces
regular cyclic withdrawal bleeding until positive feedback system matures.
Progestins stop endometrial growth and support and organize endometrium to
allow organized sloughing after their withdrawal. Bleeding ceases rapidly
because of an organized slough to the basalis layer. These drugs usually do not
stop acute bleeding episodes, yet produce a normal bleeding episode following
their withdrawal.
o Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
Class Summary
These agents can decrease DUB through inhibition of prostaglandin synthesis.
NSAIDs only need to be taken during menstruation.
Naproxen (Naprosyn, Aleve, Naprelan)
For relief of mild to moderate pain; inhibits inflammatory reactions and pain by
decreasing activity of cyclooxygenase, which is responsible for prostaglandin
synthesis. NSAIDs decrease intraglomerular pressure and decrease proteinuria.
o Gonadotropin Releasing Hormone Analog
Class Summary
These agents are generally used for short-term use to induce amenorrhea and allow
the rebuilding of the red blood cell mass.
Leuprolide acetate (Lupron, Eligard)
Suppresses ovarian and testicular steroidogenesis by decreasing LH and
FSH levels.
Works by reducing concentration of GnRH receptors in the pituitary via
FOLLOW-UP
basis.
Further Inpatient Care
Patients with severe, acute abnormal uterine bleeding and hemodynamic instability
Patient Education
o Instruct patients to continue prescribed medications, although bleeding may still
be occurring during the early part of the cycle. Also, patients should be told to
expect menses after cessation of the regimen.
o Young patients with small amounts of irregular bleeding need reassurance and
observation only prior to instituting a drug regimen. Express to patients that
pharmacologic intervention will not be necessary once menstrual cycles become
regular.
o Discuss ways the patient can avoid prolonged emotional stress and maintain a
normal body mass index.
o For excellent patient education resources, visit eMedicineHealth's Women's
Health Center. Also, see eMedicineHealth's patient education articles Vaginal
Bleeding and Painful Ovulation (Mittelschmerz).