Dysfunctional uterine bleeding (DUB) is abnormal uterine bleeding in terms of amount, duration, or timing during the menstrual cycle, with no discernible organic cause. The normal menstrual cycle is dependent on the influence of four hormones: estrogen, which predominates during the proliferative phase (generally days 1 to 14); progesterone, which predominates during the secretory phase (generally days 15 to 28); and follicle-stimulating hormone (FSH) and luteinizing hormone (LH), both of which stimulate the ovarian follicle to mature. Disrupting the balance of these four hormones usually results in anovulation and dysfunctional uterine bleeding. During an anovulatory cycle, the corpus luteum does not form and thus progesterone is not secreted. Failure of progesterone secretion allows continuous unopposed production of estradiol, which stimulates the overgrowth of the endometrium. This results in an overproduction of the uterine blood flow. Complications of dysfunctional uterine bleedinginclude anemia, infection from prolonged use of tampons, and in rare situations, hemorrhagic shock. As many as 10% of women with normal ovulatory cycles experience dysfunctional uterine bleeding.
The cause of dysfunctional uterine bleeding is unknown. The term dysfunctional uterine bleeding indicates that abnormal bleeding is occurring without an organic cause. It is associated with polycystic ovarian disease and obesity; in both of these conditions, the endometrium is chronically stimulated by estrogen. Other possible associated factors are: cancer of the vagina, cervix, ovaries, and uterus; polyps, ectopic pregnancy, or molar pregnancy; and excessive weight gain, stress, and increased exercise performance.
Nursing care plan assessment and physical examination
Determine the duration of the present bleeding, the amount of blood loss, and the presence of associated symptoms such as cramping, nausea, and vomiting, fever, abdominal pain, or passing of blood clots. Ask the patient to compare the amount of pads or tampons used in a normal period with the amount they are presently using. Obtain a menstrual and obstetric history. Recent episodes of easy bruising or prolonged, heavy bleeding may indicate abnormal clotting times. The use of contraceptives, especially an intrauterine device (IUD), may contribute to abnormal uterine bleeding. Other possible causative factors, such as pregnancy, pelvic inflammatory disease, or other medical conditions, can be ruled out through a complete history.
A complete examination is essential to eliminate organic causes of bleeding. A pelvic speculum and bimanual examination should be done, with particular attention to the presence of cervical erosion, polyps, presumptive signs of pregnancy, masses, tenderness or guarding, or other signs of pathology that may cause abnormal uterine bleeding. Assess for petechiae, purpura, and mucosal bleeding (gums) to rule out hematologic pathology. Check for pallor and absence of conjunctival vessels to gauge anemia.
For many women, dysfunctional uterine bleeding results in distress related to the uncertainty of the timing, duration, and amount of bleeding. A woman may feel that her usual activities need to be curtailed, a situation that may contribute to feelings of loss of control. Assess the woman’s concerns and coping patterns to establish a framework for determining appropriate interventions.
Nursing care plan primary nursing diagnosis: Fluid volume deficit related to blood loss.
Nursing care plan intervention and treatment
The patient may be confronted with a prolonged evaluation and a variety of treatments before uterine bleeding resumes a more normal pattern or stops completely. Activities are not restricted and can be continued as the woman tolerates them. If infection or anemia is identified, appropriate pharmacologic therapy is initiated. Hormonal manipulation may be indicated, requiring careful dosing and attention to compliance with the treatment plan. Surgical management typically begins with dilation and curettage to remove excessive endometrial buildup, but may include intrauterine cryosurgery, laser ablation of the endometrium, or as a last resort, a hysterectomy.
Important interventions include strategies to assist the woman in maintaining normal activities during the evaluation. Instruct the woman about the signs and symptoms of toxic shock syndrome (fever, joint and muscle aches, malaise, weakness) if she continues to use tampons; more frequent than normal changes of the tampon may be indicated. The use of incontinence pads may be more beneficial than the standard feminine napkin in the presence of heavy bleeding.
Issues related to sexuality, especially if hysterectomy is indicated, require an accepting, open attitude of the nurse. The woman may feel her femininity is threatened but may have difficulty expressing these feelings. You may need to initiate discussions regarding the impact of evaluation and treatment on the woman. If appropriate, consider the effect on the woman’s partner and include the partner in all discussions.
Nursing care plan discharge and home health care guidelines
Provide a list of prescribed medications, if any, that includes the name, dosage, route, and side effects and the signs and symptoms of potential complications, including hypotensive episodes. Explain the need for careful monitoring and follow-up of the bleeding. Encourage the patient to keep a “menstrual calendar” and record daily bleeding patterns. Teach the patient to have appropriate laboratory follow-up of the complete blood count if indicated.