Abnormal Uterine Bleeding - Management of Normal and Altered Female Physiologic Processes

ABNORMAL UTERINE BLEEDING

Dysfunctional uterine bleeding is abnormal bleeding that does not have a known organic cause. This can occur at any age but is most common at opposite ends of the reproductive life span. Dysfunctional uterine bleeding is defined as irregular, painless bleeding of endometrial origin that may be excessive, prolonged, or without pattern. It is usually secondary to anovulation (lack of ovulation) and is common in adolescents and women ap-proaching menopause. Adolescents account for many cases of abnormal uterine bleeding since they often do not ovulate as their pituitary-ovarian axis matures. Perimenopausal women also experience this condition due to irregular ovulation because of their decreasing ovarian hormone production. The remaining causes are often related to cysts, obesity, or hypothalamic dysfunction.

Abnormal or unusual vaginal bleeding that is atypical in time or amount must be evaluated because it may be a manifestation of a major, life-threatening disorder. Physical examination is per-formed and the patient is evaluated for conditions such as preg-nancy, neoplasm, infection, anatomic abnormalities, endocrine disorders, trauma, blood dyscrasias, platelet dysfunction, and hy-pothalamic disorders. Women of any age require evaluation for a specific cause of uterine bleeding. Pregnancy testing and hor-monal evaluation are usually part of the initial assessment. Treat-ment usually consists of hormones or oral contraceptives.

Menorrhagia

Menorrhagia is defined as prolonged or excessive bleeding at the time of the regular menstrual flow. In early life the cause is usu-ally related to endocrine disturbance, whereas in later life it usu-ally results from inflammatory disturbances, tumors of the uterus, or hormonal imbalance. Emotional disturbances may also affect bleeding.

The nurse encourages a woman with menorrhagia to see her primary health care provider and to describe the amount of bleed-ing by pad count and saturation (ie, absorbency of perineal pad or tampon and number saturated hourly). Persistent heavy bleed-ing can result in anemia.

Metrorrhagia

Metrorrhagia (vaginal bleeding between regular menstrual peri-ods) is probably the most significant form of menstrual dysfunc-tion because it may signal cancer, benign tumors of the uterus, or other gynecologic problems. This condition warrants early diag-nosis and treatment. Although bleeding between menstrual peri-ods by a woman taking oral contraceptives is usually not serious, irregular bleeding by a woman taking HRT should be evaluated. Menometrorrhagia is heavy vaginal bleeding between and during periods and requires evaluation.

Postmenopausal Bleeding

Bleeding 1 year after menses cease at menopause must be inves-tigated, and a malignant condition must be considered until proved otherwise. An endometrial biopsy or a D & C is indicated. A vaginal ultrasound can also be used in postmenopausal bleed-ing to measure the thickness of the endometrial lining. The uter-ine lining in postmenopausal women should be thin because of low estrogen levels. A lining thicker than 5 mm usually warrants evaluation by endometrial biopsy.