COMMON PROBLEMS IN

WOMEN‘S HEALTH

Lisnadiyanti
Dysfunctional Uterine Bleeding
 DUB : Abnormally Heavy, light or irregular
bleeding
 Most problems are related to endocrine
disruptions that alter normal cyclic changes
in endometrium
 DUB also may due to organic disease, such
as neoplasms and infections
 DUB can be chronic problem contributing to
iron deficiency anemia
 Continu…..
 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.
Dysfunctional Uterine Bleeding (DUB)
 It is an abnormal bleeding from the uterus in the
absence of organic disease of the genital tract.
 It is characterized by dysfunction of the uterus,
ovary, pituitary, hypothalamus or other part of
reproductive system.
 the pattern of bleeding is mainly heavy &
regular ( menorrhagia ) but it could be irregular
uterine bleeding or intermenstrual bleeding.
Continue….
 Introduction
•Dysfunctional uterine bleeding (DUB) is defined
as ABNORMAL uterine bleeding with no demonstrable
organic cause, genital or extragenital.
•Patients present with “abnormal uterine bleeding”

•DUB occurs most often shortly after menarche and

at the end of the reproductive years.
– 20% of cases are adolescents
– 50% of cases in 40-50 year olds
Introduction
 DUB is most frequently associated with
chronic anovulation.
 Heavy menses, prolonged menses, or
frequent irregular bleeding are the most
common complaints.
 Up to 20% of women will experience irregular
cycles in their lifetimes.
What is abnormal uterine bleeding
Bleeding in any of the following situations is
abnormal :
-Bleeding after periods
-Bleeding after sex
-Spotting anytime in the menstrual cycle
-Bleeding heavier or for more days than
normal
-Bleeding after menopause
Continu….
 The cycle lasts about 28 days in most
women ( normal ) ,7 days, 80 ml
 Longer than 35 days or shorter than 21
days is abnormal
 Lack of periods for 3 – 6 months

( amenorrhea )
Continue…
Physiology
Contunue…..
 Normal Menstruation
 Estradiol and progesterone levels decrease several
days prior to the onset of menses.
 Endometrial blood flow decreases
 Endometrial height decreases and vascular stasis occurs.
 Tissue ischemia occurs.
 Arterial relaxation
 Sloughing of the endometrium.
 Uterine bleeding occurs

 In women with DUB secondary to anovulation,

endometrial blood flow is variable and follows no
orderly pattern
Common Risk Factors of DUB
 DUB may be caused by an imbalance of
hormones -- estrogen or progesterone.
Risk factors include:
1. Emotional stress
2. Excessive exercise
3. Obesity
 Menorraghia
 Is excessive menstrual flow, usually lasting longer
than 7 to 8 days with blood loss of more than 80 –
100 ml
 Most common cause is inadequate hormone
support for the endometrium constant estrogen
stimulation produces endometrial overgrowth
 Sporadic and abnormal loss of endometrial tissue
 Administration of progesterone acetate (provera) or
combined estrogen progestine therapy regulate the
hormone balance
DUB image ( age 14 + )
Common causes of DUB age 25 +


Anovulasi
 Failure of the ovaries to release or
produce mature eggs
 Causes about 90% of DUB
 Common causes :
1. Pituitary adenoma
2. Polycystic ovarium syndrome
3. Contraceptives
4. Endometrial infections
5. Cervicitis
Hypomenorrhea
 Short, scant menstrual flow, may result
from endocrine dysfunction]
 Menstrual flow may be light or consist only
of spotting for 1 to 2 days
 Short cycles ( 17 – 20 days )
 Women younger than 30 years with
consistent are more prone to infertility and
increased risk for endometrial carcinoma
 Oral contraceptives and cervical stenosis
can lead to Hypomenorrhea
Common causes of DUB
 Endometriosis
 The normal tissue lining the uterine cavity is called the
endometrium.
 Endometriosis is a condition in which the presence
of this endometrial tissue moves outside the uterus.
The most common places for implantation are the
ovaries, fallopian tubes, bladder and intestines, uterine
wall, and the lining of the pelvis.
 Medical treatment : oral contraceptives to suppress
estrogen production and tinning the endometrial lining,
 Danazol and nafarelin
Endometriosis image
Endometriosis image
 The symptoms of endometriosis
 Painful periods (dysmenorrhea)
This pain can vary. It may start just prior to menstruation or
even several days before menstruation begins. The pain is
generally at its worst during the point of heaviest flow.
Frequently, large clots are seen. Pain can also be present in
other locations during the period
 Pain During Intercourse (Dyspareunia)
This usually results from tissue implants deep in the pelvic wall
that have infiltrated the lining of the abdomen (peritoneum),
and from adhesion (scar tissue) formation.
 Pelvic Pain
This usually results from a collection of shed (regurgitated)
menstrual blood in the abdominal cavity causing local
abdominal (peritoneal) inflammation. Pelvic pain can be very
similar to that of appendicitis; patients complain of pain in the
lower right region of their abdomens.
 Back pain
 Intermenstrual Bleeding
 Intermenstrrual bleeding is vaginal bleeding (other than post-coital) at
any time during the menstrual cycle other than during normal menstruation.
 Bleeding between periods (intermenstrrual bleeding) may be associated with
sexual intercourse - bleeding during intercourse
 Bleeding between periods may be in the middle of the menstrual cycle - mid
cycle bleeding or mid cycle spotting.
 Women on the pill may experience break through bleeding.
This is not strictly intermenstrual bleeding because the monthly bleeding
experienced by those women taking the pill is correctly called 'withdrawal
bleeding' and is not spontaneous menstruation.
 Intermenstrual bleeding may amount to no more than spotting between
periods or it may be heavy.

 When intermenstrrual bleeding is reported, care should be taken to exclude

pregnancy bleeding - ectopic pregnancy.
 What causes intermenstrual bleeding?
1. Physiological (hormone fluctuations) - 1-2% spot around ovulation (mid-cycle)

2. Iatrogenic (Medically Induced):

 Combined oral contraceptive pill
 Progesterone-only pill
 Contraceptive depot injections
 Intrauterine systems
 Emergency contraception
 Tamoxifen
 Following smear or treatment to the cervix
 Drugs altering clotting parameters e.g. anticoagulants, SSRIs, corticosteroids
 Alternative remedies e.g. ginseng, ginkgo, and soy supplements
2. Vaginal causes:
 Vaginitis (bleeding uncommon before the menopause)
 Infection - e.g chlamydia.
 Cervical causes:

 Cervical polyps
 Cervical erosion - ectropion
 Cervicitis (most commonly causes blood-tinged discharge)
 Condylomata acuminata of the cervix
 Cancer (but bleeding is most often post-coital)
 What causes intermenstrual bleeding?
4. Uterine causes:

 Endometrial polyps
 Fibroids
 Adenomyosis (usually only symptomatic in later reproductive
years)

 Endometrial adenocarcinoma
5. Oestrogen-secreting ovarian cancers
Clinical Assessment
 A reproductive history should always be obtained,
including the following: Age of menarche and menstrual
history and regularity
 Last menstrual period (LMP), including flow, duration,
and presence of dysmenorrhea
 Postcoital bleeding
 Gravida and para
 Previous abortion or recent termination of pregnancy
 Contraceptive use, use of barrier protection, and
sexual activity (including vigorous sexual activity
or trauma)
 History of sexually transmitted diseases (STDs)
or ectopic pregnancy
 Treatment of DUB

 Goals
 control bleeding
 prevent recurrence
 preserve fertility
 correct associated conditions
 induce ovulation in patients who want to
conceive
Nursing Assessment
 Menstrual History :

1. Date of onset of bleeding

2. How many days of bleeding
3. How this relates to the woman‘s menstrual
cycle
4. Amount of bleeding
5. Presence of clot and odor of discharge
6. Pattern of discomfort, pain, cramping or any
related symptoms
Physical examination
 Pap smear
 Vaginal or cervical smears for culture
 Complete blood count
 Urinalysis, urine culture
 Pregnancy test
 Gonorhea or chlamydia culture
 USG pelvic
Planning and intervention

 Focuses on knowledge deficits to understand

the problem cause, treatment and aoutcomes
 Anxiety and fear
 Sexual dysfunction, self-esteem and body
image
 Developing effective coping strategies
 Nutrition
Evaluation

 The client expresses a clear understanding of

the causes, treatment and outcomes of
bleeding
 Expresses her fear and concerns openly
 Develops a plan for integrating changes into her
life style
 Seeking assistance appropriately from family,
health providers and other community
resources