Abnormal uterine bleeding

Defnisi
Dysfunctona uterne beedng (DUB) s rreguar uterne beedng
that occurs n the absence of recognzabe pevc pathoogy, genera
medca dsease, or pregnancy. It reects a dsrupton n the norma
cycc pattern of ovuatory hormona stmuaton to the endometra
nng. The beedng s unpredctabe n many ways. It may be
excessvey heavy or ght and may be proonged, frequent, or random.
Abnorma uterne beedng s any beedng from the uterus
(through your vagna) other than your norma monthy perod. Havng
extremey heavy beedng durng your perod can aso be consdered
abnorma uterne beedng. Very heavy beedng durng a perod and/or
beedng that asts more than 7 days s caed menorrhaga (say: "men-
oh-ra|-ee-ah"). Women who have menorrhaga may, for exampe, beed
enough to soak through 1 or more tampons or santary pads every
hour.
A norma menstrua cyce s characterzed by an approxmate ow
of 30 mL per perod, whch asts for 2 to 7 days and occurs wth a mean
nterva of 21 to 35 days DUB refers to abnorma beedng from the
uterus and can be characterzed cncay by amount, duraton, and
perodcty:
Ogomenorrhea: menstruaton occurrng wth ntervas of more than
35 days
Poymenorrhea: menstruaton occurrng reguary wth ntervas of
ess than 21 days
Metrorrhaga: menstrua beedng occurrng at rreguar ntervas or
beedng between menstrua cyces
Menorrhaga: reguar menstrua cyces wth excessve ow
(techncay more than 80 mL of voume) or menstruaton astng
more than 7 days
Menometrorrhaga: menstrua beedng occurrng at rreguar
ntervas wth excessve ow or duraton
DUB can be due to anovuaton (anovuatory DUB) or to oca
defects n hemostass (ovuatory DUB). Other causes of uterne
beedng, such as pregnancy, esons of the reproductve tract (eg,
uterne brods), atrogenc causes, or other medca condtons (eg,
thrombopha, hypothyrodsm) must be excuded n order to estabsh
the dagnoss
Haf of a women who present wth menorrhaga have beedng
that s unacceptabe to them but s wthn the norma range, athough
reported menorrhaga shoud be treated as such. Ob|ectve
measurement of menorrhea s cncay meanngess outsde the
context of cnca tras. Abnorma uterne (womb) beedng s a
common probem n women. Abnorma uterne beedng can occur as
ether a change n your norma menstrua perod or as beedng n
between your norma menses.
Abnorma uterne beedng (AUB) s dened as changes n
frequency of menses, duraton of ow or amount of bood oss.
Ob|ectvey menorrhaga s dened as bood oss of more than 80 m
per cyce, the 90th percente n a study of 476 Gothenberg women
pubshed by Haberg et a. n 1966. Monthy bood oss n excess of 60
m may resut n ron decency anema and may ahect the quaty of
fe.
The dscusson of dysfunctona uterne beedng (DUB) s a
compex topc, begnnng wth termnoogy For exampe, athough
many cncans woud smpfy ths dscusson by usng the term
"menorrhaga," menorrhaga very speccay descrbes heavy but
predctabe, cycc beedng, whch generay mpes ovuaton.
However, many cncans, partcuary n the Unted States, use the
term to ncude heavy uterne beedng that occurs n the context of
menses that are unpredctabe n tmng, a stuaton that generay
Perdarahan uterus abnorma yang ter|ad tanpa keanan pada
sauran reproduks, penyakt meds tertentu atau kehaman. Dagnoss
perdarahan uterus dsfungsona (PUD) dtegakkan per eksusonam.
Manfestas kns dapat berupa perdarahan akut dan banyak,
perdarahan reguer, menoraga dan perdarahan akbat penggunaan
kontraseps. Perdarahan uterus dsfungsona (PUD) adaah perdarahan
uterus abnorma daam ha |umah, frekuens, dan amanya yang ter|ad
bak d daam maupun d uar skus had, merupakan ge|aa kns yang
semata-mata karena suatu gangguan fungsona mekansme ker|a
poros hpotaamus-hposs-ovarum endometrum tanpa adanya
keanan organk aat reproduks.
Perdarahan uterus dsfungsona merupakan saah satu keanan
yang pentng untuk dketahu dan cukup serng ter|ad tetap nformas
tentang penyakt n mash sut ddapat, dengan demkan penet
tertark untuk mengetahu karakterstk PUD yang membedakannya
dengan penyebab perdarahan pervagnam annya pada wanta,
terutama daam ha ama dan banyak perdarahan yang ter|ad.
Perdarahan yang semata-mata dsebabkan oeh gangguan fungsona
poros hpotaamus, hposs dan ovarum
Epidemiologi
Perdarahan uterus dsfungsona merupakan sebab terserng
perdarahan abnorma per vagnam pada masa reproduks wanta.
Daporkan gangguan n ter|ad pada 5-10% wanta (Dodds, 2004).
Lebh dar 50% ter|ad pada masa permenopause, sektar 20% pada
masa rema|a, dan kra-kra 30% pada wanta usa reproduktf (Chak,
1998). Ras bukan faktor pentng, tetap nsdens eomyoma pada
wanta ras Afrka ebh tngg dan mereka memk kadar estrogen yang
ebh banyak, karena tu mereka cenderung untuk ebh serng
mengaam epsode perdarahan abnorma pervagnam (Dodds, 2004).
In the U.S., anovuatory beedng s the predomnant cause of
hospta admsson (46% of cases) among adoescent patents
presentng wth menorrhaga DUB occurs n approxmatey 10% to 30%
of reproductve-aged women and has a negatve mpact on the quaty
of fe of ahected women, whether young or od. Twenty-percent of
cases of DUB occur n adoescence, and 40% of cases occur n patents
over age 40.
Patofsiologi
Struktur Organ Reproduks Wanta
Struktur organ reproduks wanta meput organ reproduks nterna
dan organ reproduks eksterna. Keduanya sang berhubungan dan tak
terpsahkan. Organ reproduks nterna terdapat d daam rongga
abdomen, meput sepasang ovarum dan sauran reproduks yang
terdr sauran teur (ovduct/tuba faop), rahm (uterus) dan vagna.
Organ reproduks uar meput mons veners, ktors, sepasang abum
mayora dan sepasang abum mnora.
Ovarum.
|umah sepasang, bentuk ova dengan pan|ang 3-4 cm, menggantung
bertaut meau mesentrum ke uterus. Merupakan gonade perempuan
yang berfungs menghaskan ovum dan mensekreskan hormon
keamn perempuan yatu estrogen dan progesteron. Ovarum
terbungkus oeh kapsu pendung yang kuat dan banyak mengandung
foke. Seorang perempuan kurang ebh memk 400.000 foke dar
kedua ovarumnya se|ak a mash daam kandungan bunya. Namun
hanya beberapa ratus sa|a yang berkembang dan meepaskan ovum
seama masa reproduks seorang perempuan, yatu se|ak menarche
(pertama mendapat menstruas) hngga menophause (berhent
menstruas). Pada umumnya hanya sebuah foke yang matang dan
meepaskan ovum tap satu skus menstruas (kurang ebh 28 har)
dar saah satu ovarum secara bergantan.
Seama mengaam pematangan, foke mensekreskan hormone
estrogen. Seteah foke pecah dan meepaskan ovum, foke akan
berubah men|ad korpus uteum yang mensekreskan estrogen dan
hormon progesteron. Estrogen yang dsekreskan korpus uteum tak
sebanyak yang dsekreskan oeh foke. |ka se teur tdak dbuah
maka korpus uteum akan ss dan sebuah foke baru akan mengaam
pematangan pada skus berkutnya.
Tuba faop/ovduct (sauran teur)
|umah sepasang, u|ungnya mrp corong ber|umba yang dsebut
nfundbuum berfungs untuk menangkap ovum yang depas dar
ovarum. Eptheum bagan daam sauran n bersa, gerakan sa
akan mendorong ovum untuk bergerak menu|u uterus.
Uterus (rahm)
|umah satu buah, berotot poos teba, berbentuk sepert buah pr,
bagan bawah mengec dsebut cervx. Uterus merupakan tempat
tumbuh dan berkembangnya embro, dndngnya dapat mengembang
seama kehaman dan kemba berkerut seteah meahrkan. Dndng
sebeah daam dsebut endometrum, banyak mengaskan endr dan
pembuuh darah. Endometrum akan meneba men|eang ovuas dan
meuruh pada saat menstruas.
Vagna
Merupakan akhr dar sauran reproduks wanta. Suatu seaput
berpembuuh darah yang dsebut hymen menutup sebagan sauran
vagna. Membran n dapat robek akbat aktvtas sk yang berat atau
saat ter|ad hubungan badan. Vagna berfungs sebaga aat kopuas
wanta dan |uga sebaga sauran keahran. Dndngnya berpat-pat,
dapat mengembang saat meahrkan bay. Pada dndng sebeah daam
vagna bermuara keen|ar barthon yang mensekreskan endr saat
ter|ad rangsangan seksua.
Oogeness dan Skus Menstruas
Oogeness
Oogeness merupakan proses pembentukan ovum d daam
ovarum. D daam ovarum atau ndung teur terdapat oogonum
(oogona = |amak). Oogonum bersfat dpod (2n = mengandung 23
pasang kromosom atau 46 buah kromosom). Oogeness teah dmua
se|ak bay perempuan mash daam kandungan bunya berusa sektar
5 buan. Oogonum akan memperbanyak dr dengan membeah
beruang ka secara mtoss, membentuk oost prmer. Oost prmer
terbungkus daam foke yang penuh dengan caran nutrs yang
dperukan untuk pertumbuhan ovum.
Pada saat bay perempuan ahr, d daam tap ovarumnya
mengandung sektar satu |uta oost prmer. Oost prmer n mengaam
dorman atau mengaam fase strahat beberapa tahun hngga anak
perempuan tersebut mengaam pubertas. Seama pertumbuhan anak
perempuan, beberapa oost prmer akan mengaam degeneras,
hngga ketka mencapa usa pubertas |umah oost prmer hanya
tngga sektar 200.000 buah.
Memasuk usa pubertas sekres hormon estrogen akan memacu
oost prmer untuk mean|utkan proses oogeness; oost prmer
mengaam meoss pertama menghaskan 2 se berbeda ukuran yatu
oost sekunder (berukuran besar) dan poost prmer (berukuran kec).
Oogeness terhent hngga ter|ad ovuas, ba tdak ter|ad
fertsas oost sekunder akan mengaam degeneras. Namun ba ada
penetras sperma dan ter|ad fertsas, oogeness akan dan|utkan
dengan pembeahan meoss kedua; oost sekunder membeah men|ad
2 yatu ootd (berukuran besar) dan poost sekunder (berukuran kec).
Sedangkan poost prmer membeah men|ad 2 poost sekunder.
Sehngga pada akhr oogeness dhaskan 3 poost dan 1 ootd yang
berkembang men|ad ovum.
Seama perkembangan oost prmer hngga men|ad oost sekunder
berada daam foke, yatu suatu kantung pembungkus yang penuh
caran yang menyedakan nutrs bag oost. Semua oost prmer
berada daam foke prmer kemudan berkembang men|ad foke
sekunder. Ketka terbentuk oost sekunder, foke teah berkembang
men|ad foke terser dan akhrnya men|ad foke de Graaf (foke
yang teah matang) Seteah ovuas atau epasnya oost sekunder
foke teur akan berubah men|ad korpus uteum. Korpus uteum
mengaam degeners membentuk korpus abkan
Skus Menstruas
Menstruas atau had merupakan pendarahan yang ter|ad akbat
uruhnya dndng sebeah daam rahm (endometrum) yang banyak
mengandung pembuuh darah. Lapsan endometrum dpersapkan
untuk menerma mpantas embro. |ka tdak ter|ad mpantas embro
apsan n akan uruh, darah keuar meau cervx dan vagna.
Pendarahan n ter|ad secara perodk, |arak waktu antara menstruas
yang satu dengan menstruas berkutnya dkena dengan satu skus
menstruas.
Skus menstruas wanta berbeda-beda, namun rata-rata berksar 28
har. Har pertama menstruas dnyatakan sebaga har pertama skus
menstruas. Skus n terdr atas 4 fase: fase menstruas, fase pra-
ovuas, fase ovuas, fase pasca-ovuas.
1. Fase menstruas
Ter|ad ba ovum tdak dbuah sperma, sehngga korpus uteum
menghentkan produks hormon estrogen dan progesteron. Turunnya
kadar estrogen dan progesteron menyebabkan epasnya ovum dar
endometrum dserta robek dan uruhnya endometrum, sehngga
ter|ad pendarahan. Fase menstruas berangsung kurang ebh 5 har.
Darah yang keuar seama menstruas berksar antara 50 - 150 m ter
2. Fase pra-ovuas atau fase poferas
Hormon pembebas gonadotropn yang dsekreskan hpotaamus akan
memacu hpose untuk mensekreskan FSH. FSH memacu pematangan
foke dan merangsang foke untuk mensekreskan hormon estrogen.
Adanya estrogen menyebabkan pembentukan kemba (poferas)
dndng endometrum. Penngkatan kadar estrogen |uga menyebabkan
sevks (eher rahm) untuk mensekreskan endr yang bersfat basa.
Lendr n berfungs untuk menetrakan suasana asam pada vagna
sehngga mendukung kehdupan sperma.
3. Fase Ovuas
|ka skus menstruas seorang perempuan 28 har, maka ovuas ter|ad
pada har ke 14. Penngkatan kadar estrogen menghambat sekres FSH,
kemudan hpose mensekreskan LH. Penngkatan kadar LH
merangsang peepasan oost sekunder dar foke, perstwa n dsebut
ovuas.
4. Fase pasca ovuas atau fase sekres
Berangsung seama 14 har sebeum menstruas berkutnya. Waaupun
pan|ang skus menstruas berbeda-beda, fase pasca-ovuas n seau
sama yatu 14 har sebeum menstruas berkutnya. Foke de Graaf
(foke matang) yang teah meepaskan oost sekunder akan berkerut
dan men|ad korpus uteum. Korpus uteum mensekreskan hormon
progesteron dan mash mensekreskan hormon estrogen namun tdak
sebanyak ketka berbentuk foke. Progesteron mendukung ker|a
estrogen untuk memperteba dan menumbuhkan pembuuh-pembuuh
darah pada endometrum serta mempersapkan endometrum untuk
menerma mpantas embro |ka ter|ad pembuahan atau kehaman.
|ka tdak ter|ad pembuahan, korpus uteum akan berubah men|ad
korpus abkan yang hanya sedkt mensekreskan hormon, sehngga
kadar progesteron dan estrogen men|ad rendah. Keadaan n
menyebabkan ter|adnya menstruas demkan seterusnya.
Abnormal uterine bleeding

Usia
Women n
ther
teens, 20s
and 30s
trauma, rrtaton
of the genta
area (due to
bubbe bath,
soaps, otons, or
nfecton)
medca ness,
sexua abuse.
Women
after
menopause
Hormone
repaceme
nt therapy
Women n the
menopausa
transton
norma hormona
cycng change
progesterone
secreton
estrogen secreton
the endometrum
grow
produce excess
tssue
endometra
hyperpasa
(thckened nng of
the uterus)
Etiologi dan Faktor
Resiko
Anovulatory
DUB
(Dysfunctiona
l uterine
bleeding
Cancer or
precancer of the
cervx or the
endometrum
(nng of the
uterus),
Infecton or
nammaton of
the cervx or
endometrum
uterne brods
or poyps,
rreguar growths
and bengn
tumors are
composed of
uterne tssue
that dstort the
structure of the
uterus,
Abrupt changes n
hormone eves, use
hormona brth
contro methods,
experence
ntermttent ght or
heavy vagna
beedng, decnng
ovaran functon
Women n
ther 40s
and eary
50s
Anovuatory
beedng s common
among adoescents
due to the
mmaturty of the
hypothaamc-
ptutary-ovaran
axs
The corpus uteum
does not form n an
anovuatory cyce
faure of the cycca
secreton of
progesterone
contnuous
unopposed
producton of
estrado
stmuates
overgrowth of the
endometrum
The endometrum
grows thck
necross
.
Reproductiv
e tract
problems
Uterne brods and
poyps (growths) or
nfectons.
Precancer or
cancer n the
uterus, cervx
(openng of the
uterus), or vagna.
Any hstory of
abnorma
Papancoaou (Pap)
smears, sexuay
transmtted
dsease,
gynecoogc
surgery, trauma, or
sexua abuse
shoud be ected.
Adenomyoss,
endometra
hyperpasa and
atypa,
!edications
Many medcatons,
ncudng over-the-
counter drugs and
herba remedes.
hormones, psychatrc
(menta heath) drugs,
and bood thnners.
Brth contro methods
such as ps, mpants,
shots, and ntrauterne
devces (IUDs).
!edical
condition
s
, thyrod
probems, bood
cottng
probems, and
ver dsease
Spontaneous
pregnancy oss
(mscarrage),
ectopc pregnancy,
pacenta preva,
abrupton pacentae,
and trophobastc
dsease
Pregnancy
"vulatory
DUB
(Dysfunction
al uterine
bleeding
prostagandn
mbaance
prostagandn
E2(vasodatng
propertes and
antpateet ehects)
prostagandn F2
(constrcton of spra
arteres)
ead to ncreased
brnoytc actvty
menorrhaga
"besit
y
resuts from atered
estrogen-to-
progesterone ratos
and ncreased
perphera
converson of
androgens to
estrogens
The estrogen-drven
endometra
proferaton
endometra
overgrowth
Polycystic
ovary
syndrome
(P#"$
unopposed
estrogen
stmuaton,
eevated
androgen eves,
and nsun
resstance,
ead to
endometra
proferaton and
hyperpasa
fa to reguary
stmuate the LH
surge
anovuaton
mmature of the
hypothaamc-
ptutary ovaran
axs
Abnormal
Uterine
Faktor resiko
Hemogobn
Nutrs
Anema
%eleti&an
Abnorma uterne
beedng
Kebershan
perneum tdak
d|aga
Bakter
berkembang
Resiko
infeksi
norma hormona
cycng change
progesterone
secreton
estrogen secreton
the endometrum
grow
produce excess
tssue
endometra
hyperpasa
(thckened nng of
the uterus)
Resiko
Pendara&an
Most condtons that cause abnorma uterne beedng can occur at any
age, but some are more key to occur at a partcuar tme n a
woman's fe.
Abnormal uterine bleeding in young girls - Beedng before
menarche (the rst perod n a gr's fe) s aways abnorma. It may be
caused by trauma, a foregn body (such as toys, cons, or toet tssue),
rrtaton of the genta area (due to bubbe bath, soaps, otons, or
nfecton), or urnary tract probems. Beedng can aso occur as a resut
of sexua abuse.
Adolescents - Many grs have epsodes of rreguar beedng durng
the rst few months after ther rst menstrua perod. Ths usuay
resoves wthout treatment when the gr's hormona cyce and
ovuaton normazes. If beedng perssts beyond ths tme, or f the
beedng s heavy, further evauaton s needed. Abnorma beedng n
ths age group can aso be caused by any of the condtons that cause
beedng n a premenopausa women, ncudng: pregnancy, nfecton,
and beedng dsorder or other medca nesses.
Premenopausal 'omen - Many dherent condtons can cause
abnorma beedng n women between adoescence and menopause.
Abrupt changes n hormone eves at the tme of ovuaton can cause
vagna spottng, or sma amounts of beedng. Breakthrough beedng
can aso occur n premenopausa women who use hormona brth
contro methods.
Some women do not ovuate reguary and may experence ntermttent
ght or heavy vagna beedng. Athough anovuaton s most common
when perods rst begn and durng permenopause, t can occur at any
tme durng the reproductve years. Some women who ovuate normay
experence excessve bood oss durng ther perods or beed between
perods. The most common causes of such beedng are uterne brods
or poyps. These rreguar growths and bengn tumors are composed of
uterne tssue that dstort the structure of the uterus and ead to
abnorma uterne beedng. Fbrods and poyps can aso occur n
anovuatory women. Other causes of abnorma uterne beedng n
premenopausa women ncude:
Pregnancy
Cancer or precancer of the cervx or the endometrum (nng of
the uterus)
Infecton or nammaton of the cervx or endometrum
Cottng dsorders such as von Webrand dsease, pateet
abnormates, or probems wth cottng factors
Medca nesses such as hypothyrodsm, ver dsease, or
chronc rena dsease
(ormonal birt& control - Grs and women who use hormona brth
contro (eg, ps, rng, shot, patch) may experence "breakthrough"
beedng between perods. If ths occurs durng the rst few months, t
may be due to changes n the nng of the uterus. If t perssts for more
than a few months, evauaton may be needed and/or a dherent brth
contro p may be recommended. Breakthrough beedng can aso
happen f a hormona brth contro method s forgotten or taken ate. In
ths stuaton, there s a rsk that the woman coud become pregnant f
she has sex. Another form of brth contro (eg, condoms) s
recommended f the p/patch/shot s not taken on tme.
)omen in t&e menopausal transition - Before the menstrua
perods end, a woman passes through a perod caed the menopausa
transton. Durng the menopausa transton, norma hormona cycng
begns to change and ovuaton may be nconsstent. Whe estrogen
secreton contnues, progesterone secreton decnes. These hormona
changes can cause the endometrum to grow and produce excess
tssue, ncreasng the chances that poyps or endometra hyperpasa
(thckened nng of the uterus) w deveop and potentay cause
abnorma beedng. Women n the menopausa transton are aso at
rsk for other condtons that cause abnorma beedng, ncudng
cancer, nfecton, and bodywde nesses. Further evauaton s needed
n women wth persstent rreguar menstrua cyces or an epsode of
profuse beedng. Women n the menopausa transton st ovuate
some of the tme and can become pregnant; pregnancy can cause
abnorma beedng. In addton, women n permenopause may use
hormona brth contro medcatons, whch can cause breakthrough
beedng.
!enopausal 'omen - A number of condtons can cause abnorma
beedng durng the menopause. Women who take hormone
repacement therapy may experence cycca beedng. Any other
beedng that occurs durng menopause s abnorma and shoud be
nvestgated. Causes of abnorma beedng durng menopause ncude:
Atrophy (excessve thnnng) of the tssue nng the vagna and
uterus
Cancer of the uterne nng (endometrum)
Poyps or brods
Endometra hyperpasa
Infecton of the uterus
Use of bood thnners or antcoaguants
Sde ehects of radaton therapy
Many dherent thngs can cause abnorma uterne beedng.
Pregnancy s a common cause. Poyps or brods (sma and arge
growths) n the uterus can aso cause beedng. Rarey, a thyrod
probem, nfecton of the cervx or cancer of the uterus can cause
abnorma uterne beedng.
In most women, abnorma uterne beedng s caused by a
hormone mbaance. When hormones are the probem, doctors ca the
probem dysfunctona uterne beedng, or DUB. Abnorma beedng
caused by hormone mbaance s more common n teenagers or n
women who are approachng menopause.
These are |ust a few of the probems that can cause abnorma
uterne beedng. These probems can occur at any age, but the key
cause of abnorma uterne beedng usuay depends on your age.
)omen in t&eir teens* +,s and -,s
A common cause of abnorma beedng n young women and teenagers
s pregnancy. Many women have abnorma beedng n the rst few
months of a norma pregnancy. Some brth contro ps or the
ntrauterne devce can aso cause abnorma beedng.
Some young women who have abnorma uterne beedng do not
reease an egg from ther ovares (caed ovuaton) durng ther
menstrua cyce. Ths s common for teenagers who have |ust started
gettng ther perods. Ths causes a hormone mbaance where the
estrogen n your body makes the nng of your uterus (caed the
endometrum) grow unt t gets too thck. When your body gets rd of
ths nng durng your perod, the beedng w be very heavy. A
hormone mbaance may aso cause your body not to know when to
shed the nng. Ths can cause rreguar beedng ("spottng") between
your perods.
)omen in t&eir .,s and early /,s
In the years before menopause and when menopause begns, women
have months when they don't ovuate. Ths can cause abnorma uterne
beedng, ncudng heavy perods and ghter, rreguar beedng.
Thckenng of the nng of the uterus s another cause of beedng n
women n ther 40s and 50s. Ths thckenng can be a warnng of
uterne cancer. If you have abnorma uterne beedng and youre n ths
age group, you need to te your doctor about t. It may be a norma
part of gettng oder, but t's mportant to make sure uterne cancer
sn't the cause.
)omen after menopause
Hormone repacement therapy s a common cause of uterne beedng
after menopause. Other causes ncude endometra and uterne
cancer. These cancers are more common n oder women than n
younger women. But cancer s not aways the cause of abnorma
uterne beedng. Many other probems can cause beedng after
menopause. For ths reason, ts mportant to tak to your doctor f you
have any beedng after menopause.
Anovulatory DUB0
The corpus uteum does not form n an anovuatory cyce,
resutng n a faure of the cycca secreton of progesterone
Wthout progesterone, there s contnuous unopposed producton
of estrado, whch stmuates overgrowth of the endometrum.
The endometrum grows thck unt t outgrows ts bood suppy,
resutng n necross and rreguar beedng
In adoescents and n permenopausa women, the beedng may
be trggered by estrogen wthdrawa
"vulatory DUB0
Presents as menorrhaga
A ess common cause of DUB; beeved to be caused by a defect
n oca endometra hemostass
The mechansm s unknown, but theores ncude prostagandn
mbaance and ateratons n brnoyss. Prostagandn F2 causes
constrcton of spra arteres found n the endometrum, whereas
prostagandn E2 has vasodatng propertes and antpateet
ehects. Ateratons n prostagandn producton, wth a shft
toward more prostagandn E2 and ess prostagandn F2, ead to
ncreased brnoytc actvty noted n the endometrum of
women wth menorrhaga
Rsk factors assocated wth the deveopment of DUB ncude the
foowng:
Adoescence:
o Anovuatory cyces occur n 55% to 82% of femae
adoescents at menarche and typcay contnue unt 2 years
after menarche
o Anovuatory beedng s common among adoescents due
to the mmaturty of the hypothaamc-ptutary-ovaran axs
Permenopause:
o DUB n permenopausa women s reated to decnng
ovaran functon
o Observatona data show ncreased varabty of the
menstrua pattern n women approachng menopause
Obesty:
o DUB n overweght women resuts from atered estrogen-
to-progesterone ratos and ncreased perphera converson of
androgens to estrogens. The estrogen-drven endometra
proferaton eventuay eads to endometra overgrowth and
abnorma beedng patterns
o Weght oss n obese patents presumaby restores reguar
menstrua cyces by decreasng the adpose tssue avaabe
for converson of androgens to estrogen
Poycystc ovary syndrome (PCOS):
o Menstrua rreguarty s seen n two thrds of adoescents
wth PCOS and typcay presents wth anovuatory symptoms
mmckng DUB
Cgarette smokng:
o Women who smoke cgarettes have a 47% rsk of
experencng abnorma uterne beedng due to the
antestrogenc ehect of cgarette smoke
There are many causes of abnorma uterne beedng, ncudng the
foowng:
Pregnancy
Some women experence vagna beedng eary n ther pregnances,
even when the pregnancy s norma. Sometmes vagna beedng can
sgna mportant probems, such as a mscarrage or an ectopc (tuba)
pregnancy. Aways te your heath care provder f you have beedng
whe you are pregnant.
Reproductve tract probems
Uterne brods and poyps (growths) or nfectons are common causes
of abnorma beedng. Precancer or cancer n the uterus, cervx
(openng of the uterus), or vagna can aso cause abnorma beedng.
Medca condtons
Obesty, thyrod probems, bood cottng probems, and ver dsease
can a contrbute
to abnorma beedng.
Medcatons
Many medcatons, ncudng over-the-counter drugs and herba
remedes, can cause
abnorma beedng. In partcuar, hormones, psychatrc (menta heath)
drugs, and bood thnners are assocated wth abnorma beedng. Brth
contro methods such as ps, mpants, shots, and ntrauterne devces
(IUDs) can aso cause a change n your beedng.
Dysfunctona uterne beedng
When no cause can be found for abnorma beedng, t s caed
dysfunctona uterne beedng.
!anifestasi klinis
You mght have abnorma uterne beedng f you have one of the
foowng symptoms. If you have any of these symptoms, you shoud
dscuss t wth your heath care provder:
Beedng for more than 7 days-
Norma menstrua beedng (your perod) asts for 2 to 7 days. Beedng
that asts for more than 7 days may ndcate a probem.
Frequent epsodes of beedng-
Your menstrua cyce ength s determned by countng the number of
days from the start (day 1 of beedng) of one menstrua perod to the
start (day 1) of the next menstrua perod. Most women have a cyce
ength of 21 to 35 days. Beedng more often than every 21 days or
ess often than every 35 days may ndcate a probem.
Beedng between menstrua perods-
Any beedng at tmes other than durng your norma menstrua perod
s consdered abnorma.
Beedng after sexua actvty-
If you have vagna beedng after havng sexua actvty, especay
after vagna ntercourse, t mght be a sgn of a probem.
Cots-
An occasona sma bood cot durng your menses, the sze of a
quarter or smaer, s nothng to worry about. However, there may be a
probem f you reguary pass arger cots or many sma cots when you
have your perod.
Beedng that changes your fe-
If your menstrua beedng makes you avod soca events, mss work or
schoo, seep on towes, or set your aarm to get up n the mdde of the
nght to change your pad or tampon, you may have too much beedng.
If you nd yoursef askng the queston, Am I beedng too much?,
you shoud dscuss your beedng wth your heath care provder.
Beedng after menopause
After you stop havng menstrua perods, any vagna beedng s
consdered abnorma and must be dscussed wth your heath care
provder.
Pemeriksaan dignostik
1nitial assessment - Whe takng a woman's medca hstory, a
cncan w revew the duraton and amount of beedng; factors that
seem to brng the beedng on; symptoms that occur aong wth the
beedng such as pan, fever, or vagna odor; f beedng occurs after
sexua ntercourse; whether there s a persona or famy hstory of
beedng dsorders; the woman's medca hstory and medcatons she
s takng; recent weght changes, stress, a new exercse program, or
underyng medca probems.
The cncan w perform a physca examnaton to evauate the
woman's overa heath, and a pevc examnaton to conrm that the
beedng s from the uterus and not from another ste (eg, the externa
gentas or rectum). Durng the pevc exam, the cncan w ook for
any obvous esons (cuts, sores, or tumors) and w examne the sze
and shape of the uterus. He or she w examne the cervx to ook for
sgns of cervca beedng, and a Pap smear may be obtaned to
examne the ces of the cervx (the ower end of the uterus, where t
opens to the vagna).
2ab tests - In premenopausa women, a pregnancy test s performed.
If there s any abnorma vagna dscharge, a cervca cuture may be
performed. Bood tests may aso be done to determne f there are
probems wth bood cottng or other bodywde condtons, such as
thyrod dsease, ver dsease, or kdney probems.
3ests to determine ovulatory status - Because hormona
rreguartes can contrbute to abnorma uterne beedng, testng may
be recommended to determne f the woman ovuates (produce an egg)
durng each monthy cyce.
Endometrial assessment - Tests that assess the endometrum
(nng of the uterus) may be performed to rue out endometra cancer
and structura abnormates such as uterne brods or poyps. Such
tests ncude:
Endometrial biopsy - An endometra bopsy s often
performed n women over age 35 to rue out endometra cancer
or abnorma endometra growths. A bopsy may aso be
performed n women younger than 35 f they have rsk factors
for endometra cancer. Rsks ncude obesty, chronc
anovuaton, hstory of breast cancer, tamoxfen use or a famy
hstory of breast cancer or coon cancer. Durng the bopsy, a
thn nstrument s nserted through the vagna nto the uterus to
obtan a sma sampe of endometra tssue. The bopsy can be
performed n a heathcare provder's omce wthout anesthesa.
Because ony a sma porton of the endometrum s samped, the
bopsy may mss some causes of beedng and other tests are
sometmes necessary.
3ransvaginal ultrasound - An utrasound uses sound waves
to measure an organ's shape and structure. In a transvagna
utrasound, a sma utrasound probe s nserted nto the vagna
so that t s coser to the uterus and can provde a cear mage of
the uterus. The nng of the uterus s evauated and measured;
postmenopausa women normay have a very thn endometra
nng (usuay ess than 4 or 5 mm). Utrasound cannot
dstngush between dherent types of abnormates (eg, poyp
versus cancer) and further testng may be necessary.
$aline infusion sonograp&y ( sono&ysterograp&y) - In ths
test, a transvagna utrasound s performed after stere sane s
nsted nto the uterus. Ths procedure gves a better pcture of
the nsde of the uterus, and sma esons can be more easy
detected. However, because tssue sampes cannot be obtaned
durng the procedure, a na dagnoss s not aways possbe and
addtona evauaton, usuay ncudng hysteroscopy wth
daton and curettage (D&C) may be necessary.
1maging tests - A magnetc resonance mage (MRI) s a non-
nvasve test that s sometmes used to determne f brods or
other structura abnormates of the uterus are present.
(ysteroscopy - Durng hysteroscopy, a sma scope s nserted
through the cervx and nto the uterus. Ar or ud s n|ected to
expand the uterus and to aow the physcan to see the nsde of
the uterus. Tssue sampes may be taken. Anesthesa s used to
mnmze dscomfort durng the procedure. In most cases,
hysteroscopy s performed aong wth a D&C.
Dilation and curettage (D4# - In a D&C, the cervx or
openng of the uterus s dated and nstruments are nserted and
used to remove endometra or uterne tssue. A D&C usuay
requres anesthesa. It can sometmes be used as a treatment for
proonged or excessve beedng that s due to hormona changes
and that s unresponsve to other treatments.
The tests your doctor orders may depend on your age. If you
coud be pregnant, your doctor may order a pregnancy test. If your
beedng s heavy, n addton to other tests, your doctor may want to
check your bood count to make sure you don't have anema (ow ron)
from the bood oss. An utrasound exam of your pevc area shows both
the uterus and the ovares. It may aso show the cause of your
beedng. Your doctor may want to do an endometra bopsy. Ths s a
test of the uterne nng. It's done by puttng a thn pastc tube (caed
a catheter) nto your uterus. A tny pece of the uterne nng s taken
out and sent to a ab for testng. The test w show f you have cancer
or a change n the ces. A bopsy can be done n the doctor's omce and
causes ony md pan.
Another test s a hysteroscopy. A thn tube wth a tny camera
n t s put nto your uterus. The camera ets your doctor see the nsde
of your uterus. If anythng abnorma shows up, your doctor can get a
bopsy.
The senstvty of endometra bopsy for the detecton of
endometra abnormates has been reported to be as hgh as 96
percent. However, ths omce-based procedure may mss up to 18
percent of foca esons, ncudng poyps and brods, because ony a
sma part of the endometrum may be samped at any one tme.
Athough endometra bopsy has hgh senstvty for endometra
carcnoma, ts senstvty for detectng atypca endometra hyperpasa
may be as ow as 81 percent.
Transvagna utrasonography may revea eomyoma,
endometra thckenng, or foca masses. Athough ths magng
modaty may mss endometra poyps and submucous brods, t s
hghy senstve for the detecton of endometra cancer (96 percent)
and endometra abnormaty (92 percent). Compared wth dataton
and curettage, endometra evauaton wth transvagna
utrasonography msses 4 percent more cancers, but t may be the
most cost-ehectve nta test n women at ow rsk for endometra
cancer who have abnorma uterne beedng that does not respond to
medca management.
Sane-nfuson sonohysterography bosters the dagnostc
power of transvagna utrasonography. Ths technque entas
utrasound vsuazaton after 5 to 10 mL of stere sane has been
nsted n the endometra cavty. Its senstvty and speccty for
endometra cancer are comparabe wth the hgh senstvty and
speccty of dagnostc hysteroscopy. Sane-nfuson
sonohysterography s more accurate than transvagna utrasonography
n dagnosng ntracavtary esons and s more accurate than
hysteroscopy n dagnosng endometra hyperpasa. The combnaton
of drected endometra bopsy and sane-nfuson sonohysterography
resuts n a senstvty of 95 to 97 percent and a speccty of 70 to 98
percent for the dentcaton of endometra abnormaty.
Athough dataton and curettage has been the god standard
for dagnosng endometra cancer, t no onger s consdered to be
therapeutc for abnorma uterne beedng; furthermore, t s mted n
ts abty to access the tuba cornua of the uterus. Hysteroscopy wth
bopsy provdes more nformaton than dataton and curettage aone
and rvas the combnaton of sane-nfuson sonohysterography and
endometra bopsy n ts abty to dagnose poyps, submucous
brods, and other sources of abnorma uterne beedng.
Postmenopausa women wth abnorma uterne beedng,
ncudng those who have been recevng hormone therapy for more
than 12 months, shoud be ohered dataton and curettage for
evauaton of the endometrum (96 percent senstvty for the detecton
of cancer, wth a 2 to 6 percent fase-negatve rate). Postmenopausa
women who are poor canddates for genera anesthesa and those who
decne dataton and curettage may be ohered transvagna
utrasonography or sane-nfuson sonohysterography wth endometra
bopsy.
Further research s necessary to determne the best method for
evauatng the endometrum n patents wth abnorma uterne
beedng. However, based on current evdence, sane-nfuson
sonohysterography wth endometra bopsy appears to provde the
most compete evauaton wth the east rsk.
Laboratory evauaton of patents who present wth acute AUB
s recommended (Tabe 1). A adoescents and women wth ether
abnormates n nta aboratory testng or postve screenng resuts
for dsorders of hemostass shoud be consdered for specc tests for
von Webrand dsease and other coaguopathes, ncudng von
Webrand-rstocetn cofactor actvty, von Webrand factor antgen,
and factor VIII (2, 5). Based on the cnca presentaton, a workup for
thyrod dsorders, ver dsorder, sepss, or eukema may be ndcated.
Endometra tssue sampng shoud be performed n patents
wth AUB who are oder than 45 years as a rst-ne test. Endometra
sampng aso shoud be performed n patents younger than 45 years
wth a hstory of unopposed estrogen exposure (such as seen n
patents wth obesty or poycystc ovary syndrome), faed medca
management, and persstent AUB (2). In a stabe patent, a decson
whether to perform a pevc utrasound examnaton shoud be based
on the cnca |udgment of the examnng cncan.
Table 1. Laboratory Testing for the Evaluation of Patients
With Acute Abnormal Uterine Bleeding
Laboratory Evaluation Specific Laboratory Tests
Initial laboratory testing Complete blood count
Blood type and cross match
Pregnancy test
Initial laboratory evaluation for disorders
of hemostasis
Partial thromboplastin time
Prothrombin time
Activated partial thromboplastin
time
ibrinogen
Initial testing for von Willebrand disease! von Willebrand factor antigen"
#istocetin cofactor assay"
actor $III"
%ther laboratory tests to consider Thyroid&stimulating hormone
'erum iron( total iron binding
capacity( and ferritin
Liver function tests
Chlamydia trachomatis
*Adut women who receve postve resuts for rsk of beedng
dsorders or who have abnorma nta aboratory test resuts for
dsorders of hemostass shoud undergo testng for von Webrand
dsease. Adoescents wth heavy menses snce menarche who
present wth acute abnorma uterne beedng aso shoud
undergo testng for von Webrand dsease.
Consutaton wth a hematoogst can ad n nterpretng these
test resuts. If any of these markers are abnormay ow, a
hematoogst shoud be consuted.
Data from |ames AH, Koudes PA, Abdu-Kadr R, Detrch |E,
Edund M, Federc AB, et a. Evauaton and management of acute
menorrhaga n women wth and wthout underyng beedng
dsorders: consensus from an nternatona expert pane. Eur |
Obstet Gyneco Reprod Bo 2011;158:124-34; Natona Heart,
Lung, and Bood Insttute. The dagnoss, evauaton, and
management of von Webrand dsease. NIH Pubcaton No. 08-
5832. Bethesda (MD): NHLBI; 2007. Avaabe
at http://www.nhb.nh.gov/gudenes/vwd/vwd.pdf. Retreved
December 5, 2012; and Dagnoss of abnorma uterne beedng n
reproductve-aged women. Practce Buetn No. 128. Amercan
Coege of Obstetrcans and Gynecoogsts. Obstet Gyneco
2012;120:197-206.
(istory
It s mportant to dstngush anovuatory AUB, whch s more key
to ead to endometra hyperpasa, from ovuatory AUB.
Women presentng wth ovuatory AUB w key have heavy cycca
menstrua bood oss over severa consecutve cyces wthout any
ntermenstrua or postcota beedng.
They may have dysmenorrhea assocated wth passng of cots.
Premenstrua symptoms aso suggest ovuatory cyces.
The hstory shoud ncude symptoms suggestve of other pathoogy,
such as rreguar beedng, postcota beedng, and pevc pan.
Poyps or submucous brods are present n 25 to 50 percent of
women who present wth rreguar beedng
D1A56"$1$
A thorough abdomna and pevc examnaton s essenta.
Cervca cytoogy shoud be obtaned f ndcated.
A compete bood count (CBC ferrtn) s needed to determne
degree of anema.
Other nvestgatons to be consdered ncude: Thyrotropn
stmuatng hormone, when other symptoms of thyrod dysfuncton
are present; Proactn; day 21 to 23 progesterone to verfy ovuatory
status; focuar stmuatng hormone and utenzng hormone to
verfy menopausa status or support a dagnoss of poycystc
ovaran dsease;
a coaguaton proe when menorrhaga s present at puberty or f
there s a cnca suspcon for acoaguopathy.
A$$E$$!E63 "F 3(E E6D"!E3R1U!
Endometra assessment s performed to dagnose magnancy or
pre-magnant condtons
Sampng of the endometrum shoud be consdered n a women:
>40 years wth abnorma beedng;
n women who are at hgher rsk of endometra cancer, ncudng:
nuparty wth
a hstory of nfertty;
new onset of heavy,
rreguar beedng; obesty (> 90 kg);
poycystc ovares; a famy hstory of endometra and coonc
cancer; and on
tamoxfen therapy.
a woman who has no mprovement n her beedng pattern
foowng a course of
therapy of three months.
D12A3A31"6 A6D #URE33A5E
In 10 to 25 percent of women D&C aone does not uncover
endometra pathoogy.
D&C was assocated wth uterne perforaton n 0.6 to 1.3 percent of
cases and hemorrhage n 0.4 percent of cases.
D&C s a bnd procedure wth sgncant sampng errors; t aso
requres anesthesa whch carres a rsk of compcatons.
It shoud be reserved for those stuatons where omce bopsy or
drected hysteroscopc bopsy are not avaabe or feasbe.
U23RA$"U6D E7A!16A31"6 "F 3(E E6D"!E3R1U!
Transvagna sonography (TVS) assesses endometra thckness and
detects poyps and myomata wth a senstvty of 80 percent and
speccty of 69 percent.
Athough there s evdence that endometra thckness may be
ndcatve of pathoogy n the postmenopausa woman, such
evdence s ackng for the woman n her reproductve years.
Meta-anayss of 35 studes showed that n menopausa women,
endometra thckness of ve mm at utrasound has a senstvty of
92 percent for detectng endometra dsease and 96 percent for
detectng cancer.
$A216E $"6"(8$3ER"5RAP(8
The ntroducton of ve to 15 m of sane nto the uterne cavty usng a
sane prmed catheter or apedatrc feedng tube may mprove the
dagnoss of ntrauterne masses durng TVS.
3E#(619UE$ F"R E6D"!E3R1A2 $A!P2165
Omce endometra bopsy resuts n adequate sampes 87 to 97
percent of the tme and detects 67 to 96 percent of endometra
carcnomas.
Athough the choce of sampng devce may ahect accuracy, no
exstngmethod w sampe the entre endometrum.
Hysteroscopcay-drected sampng detects a hgher percentage of
abnormates when compared drecty wth dataton and curettage
(D&C) as a dagnostc procedure.
Even f the uterne cavty appears norma at hysteroscopy,the
endometrum shoud be samped snce hysteroscopy aone s not
sumcent to excude endometra neopasa and carcnoma.
Penatalaksanaan
Ora contraceptve ps (OCPs) are used for cyce reguaton and
contracepton. In patents wth rreguar cyces secondary to chronc
anovuaton or ogoovuaton, OCPs hep to prevent the rsks
assocated wth proonged unopposed estrogen stmuaton of the
endometrum. OCPs ehectvey manage anovuatory beedng n
premenopausa and permenopausa women. Treatment wth cycc
progestns for ve to 12 days per month s preferred when OCP use s
ontrandcated, such as n smokers over age 35 and women at rsk for
thromboembosm (Table 4).
Presumed Dysfunctional Uterine Bleeding in Women of Childbearing
Age: Evaluation Based on Risk actors for Endometrial Cancer
!"URE #$ Evaluation of women of childbearing age with presumed
dysfunctional uterine bleeding, based on risk for endometrial cancer.
%&U'A(%R) D)*U+C(!%+A' U(ER!+E B'EED!+"
Medca therapy for menorrhaga prmary ncudes nonsteroda ant-
nammatory drugs (NSAIDs) and the evonorgestre reeasng
ntrauterne system (Mrena). The U.S. Food and Drug Admnstraton
has approved the use of mefenamc acd (Ponste), an NSAID, for the
treatment for menorrhaga; ths agent s we toerated. The
evonorgestre contraceptve devce has been shown to decrease
menstrua bood oss sgncanty and to be superor to cycc
progestns for ths purpose.
Abnormal Uterine Bleeding in Postmeno,ausal Women
!"URE -$
Evaluation of abnormal uterine bleeding in postmenopausal women.
TABLE 4
edical anagement of Anovulatory !ysfunctional "terine Bleeding
Athough the ehect of OCPs on menorrhaga has not been we studed,
one sma randomzed tra comparng OCPs, mefenamc acd,
naproxen, and danazo showed no sgncant dherence n ther
ehectveness n treatng menorrhaga. Sde ehects and cost mt the
use of androgens such as danazo and gonadotropn-reeasng hormone
agonsts n the treatment of menorrhaga, but these agents may be
used for short-term endometra thnnng before abaton s performed.
*urgical .anagement of Abnormal Uterine Bleeding
SURGICAL PROCEDURE REASON FOR SURGERY
Operatve hysteroscopy Intracavtary structura abnormates
Myomectomy (abdomna,
aparoscopc, hysteroscopc)
Leomyoma
Transcervca endometra
resecton
Treatment-resstant menorrhaga or
menometrorrhaga
Endometra abaton (usng
varous energy systems,
prncpay therma baoon
or roerba)
Treatment-resstant menorrhaga or
menometrorrhaga; secondary for
management of treatment-resstant acute
uterne hemorrhage
Uterne artery embozaton Leomyoma
Hysterectomy Atypca hyperpasa, endometra cancer,
or beedng that does not respond to ess
nvasve uterus-sparng surgeres
Antbrnoytcs sgncanty reduce heavy menstrua beedng.
However, these agents are used nfrequenty because of concerns
about safety . Intravenous admnstraton of con|ugated estrogens
(Premarn) may be requred n women wth acute uterne hemorrhage.
$urgical !anagement
When medca therapy fas or s contrandcated, surgca nterventon
may be requred. Hysterectomy s the treatment of choce when
adenocarcnoma s dagnosed, and ths procedure aso shoud be
consdered when bopsy specmens contan atypa. Hysterectomy and
varous uterus-sparng surgca procedures for the treatment of
abnorma uterne beedng are beyond the scope of ths artce but are
sted n
The treatment of abnorma beedng s based upon the underyng
cause.
Birt& control pills - Brth contro ps are often used to treat uterne
beedng that s due to hormona changes or hormona rreguartes.
Brth contro ps may be used n women who do not ovuate reguary
to estabsh reguar beedng cyces and prevent excessve growth of
the endometrum. In women who do ovuate, they may be used to treat
excessve menstrua beedng. Nonsteroda ant-nammatory drugs
(NSAIDS, eg buprofen, naproxen sodum) may aso be hepfu n
reducng bood oss and crampng n these women.
Durng the menopausa transton, brth contro ps or other hormona
therapy may be used to reguate the menstrua cyce and prevent
excessve growth of the endometrum. Progesterone - Progesterone
s a hormone made by the ovary that s ehectve n preventng
excessve beedng n women who do not ovuate reguary. A synthetc
form of progesterone, caed progestn, may be recommended to treat
abnorma beedng. Progestns are usuay gven as ps (eg,
medroxyprogesterone acetate, norethndrone), and are taken once a
day for 10 to 12 days each month or two. Progestns can be taken for
onger perods f there has been overgrowth of the uterne nng.
Vagna beedng w begn before the seventh day of progestn
treatment f the uterne nng s overgrown; otherwse, t may not be
seen unt severa days after the ast progestn tabet s taken. In some
cases, the progestn s gven on a reguar bass (eg, every few months)
to prevent excessve growth of the uterne nng and heavy menstrua
beedng. If no beedng s seen after progestn treatment, the
possbty of an unntended pregnancy shoud be expored. Progestns
may aso be gven n other ways, such as n an n|ecton, an mpant, or
an ntrauterne devce. These treatments are dscussed n deta n a
separate topc revew.
1ntrauterine device - An ntrauterne contraceptve devce (IUD) that
secretes progestn (eg, Mrena) may be recommended for women who
do not ovuate reguary. IUDs are nserted by a heathcare provder
through the vagna and cervx nto the uterus. Most are made of
moded pastc and ncude an attached pastc strng that pro|ects
through the cervx, enabng the woman to check that the devce
remans n pace.
Progestn-reeasng IUDs decrease menstrua bood oss by 40 to 50
percent and decrease pan assocated wth perods. Some women
competey stop havng menstrua beedng as a resut of the IUD,
whch s reversbe when the IUD s removed.
$urgery - Surgery may be necessary to remove abnorma uterne
structures (eg, brods, poyps). Women who have competed
chdbearng and have heavy menstrua beedng can consder a
surgca procedure such as endometra abaton. Ths procedure s
done whe the woman s under genera or regona anesthesa, and
uses heat, cod, or a aser to destroy the nng of the uterus. More
nformaton about endometra abaton s avaabe n a separate topc
revew.
Women wth brods can have surgca treatment of ther brods,
ether by removng the brod(s) (eg, myomectomy) or by reducng the
bood suppy of the brods (eg, uterne artery embozaton). More
nformaton about these treatments s avaabe separatey.
Lmted evdence and expert opnon support recommendatons for
treatment. Choce of treatment for acute AUB depends on cnca
stabty, overa acuty, suspected etoogy of the beedng, desre for
future fertty, and underyng medca probems. The two man
ob|ectves of managng acute AUB are: 1) to contro the current
epsode of heavy beedng and 2) to reduce menstrua bood oss n
subsequent cyces. Medca therapy s consdered the preferred nta
treatment (Tabe 2). However, certan stuatons may ca for prompt
surgca management . Studes of treatments of acute AUB are mted,
and ony one treatment (ntravenous |IV| con|ugated equne estrogen)
s speccay approved by the U.S. Food and Drug Admnstraton for
the treatment of acute AUB.
!edical !anagement
(ormonal management s consdered the rst ne of medca
therapy for patents wth acute AUB wthout known or suspected
beedng dsorders. Treatment optons ncude IV con|ugated equne
estrogen, combned ora contraceptves (OCs), and ora progestns. In
one randomzed controed tra of 34 women, IV con|ugated equne
estrogen was shown to stop beedng n 72% of partcpants wthn 8
hours of admnstraton compared wth 38% of partcpants treated wth
a pacebo (7). Ltte data exst regardng the use of IV estrogen n
patents wth cardovascuar or thromboemboc rsk factors.
#ombined "#s and oral progestins, taken n mut-dose regmens,
aso are commony used for acute AUB. One study compared
partcpants who underwent therapy wth OCs admnstered three tmes
day for 1 week wth those who underwent therapy wth
medroxyprogesterone acetate admnstered three tmes day for 1
week for the treatment of acute AUB (8). The study found that beedng
stopped n 88% of women who took OCs and 76% of women who took
medroxyprogesterone acetate wthn a medan tme of 3 days. For a
patents, the contrandcatons to these therapes need to be
consdered before admnstraton. Consutaton wth the Centers for
Dsease Contro and Preventons Medical Eligibility Criteria for
Contraceptive Use (9, 10) and U.S. Food and Drug Admnstraton
abeng nformaton (11) can be hepfu n determnng whch patents
may or may not be treated wth OCs or progestn aone. Other OC and
progestn formuatons and dose schedues may be equay ehectve.
Antifbrinolytic drugs, such as tranexamc acd, work by preventng
brn degradaton and are ehectve treatments for patents wth
chronc AUB. They have been shown to reduce beedng n these
patents by 30-55%. Tranexamc acd ehectvey reduces ntraoperatve
beedng and the need for transfuson n surgca patents and s key
ehectve for patents wth acute AUB, athough t has not been studed
for ths ndcaton. Experts recommend usng ether ora or IV
tranexamc acd for the treatment of acute AUB. Intrauterne
tamponade wth a 26F Foey catheter nfused wth 30 mL of sane
souton has been reported to contro beedng successfuy and aso
may be consdered.
3able +: Medca Treatment Regmens
Drug $ource
$uggeste
d Dose
Dose
$c&edu
le
Potential
#ontraindicatio
ns
and
Precautions
According to
FDA 2abeling;
Con|ugated
equne
estrogren
DeVore GR, Owens
O,
Kase N. Use of
ntravenous
Premarn
n the treatment of
dysfunctona
uterne
beedng-a doube-
bnd randomzed
contro study.
Obstet Gyneco
1982;59: 285-91.
25 mg IV Every
4-6
hours
for 24
hours
Contrandcatons
ncude, but are
not mted, to
breast
cancer, actve or
past venous
thromboss or
artera
thromboemboc
dsease, and ver
dysfuncton or
dsease.The
agent shoud be
used wth cauton
n patents wth
cardovascuar or
thromboemboc
rsk factors.
Combned
ora
contraceptv
es
Munro MG, Manor
N, Basu R, Brsnger
M, Barreda L. Ora
medroxyprogestero
Monophasc
combned
ora
contracept
Three
tmes
per day
for 7
Contrandcatons
ncude, but are
not mted to,
cgarette smokng
ne
acetate and
combnaton
ora contraceptves
for
acute uterne
beedng: a
randomzed
controed
tra. Obstet
Gyneco
2006;108:924-9.
ve that
contans 35
mcrograms
of ethny
estrado
days (n women aged
35
years or oder),
hypertenson,
hstory of deep
ven thromboss
or pumonary
embosm, known
thromboemboc
dsorders,
cerebrovascuar
dsease,
schemc heart
dsease, mgrane
wth aura, current
or past breast
cancer, severe
ver dsease,
dabetes wth
vascuar
nvovement,
vavuar heart
dsease wth
compcatons,
and ma|or
surgery wth
proonged
mmobzaton.
Medroxypro-
gesterone
acetate
Munro MG, Manor
N, Basu R, Brsnger
M, Barreda L. Ora
medroxyprogestero
ne acetate and
combnaton ora
contraceptves for
20 mg
oray
Three
tmes
per
day for
7 days
Contrandcatons
ncude, but are
not mted to,
actve or past
deep ven
thromboss or
pumonary
acute uterne
beedng: a
randomzed
controed tra.
Obstet Gyneco
2006;108:924-9.
embosm, actve
or recent artera
thromboemboc
dsease, current
or past breast
cancer, and
mpared ver
functon or ver
dsease.
Tranexamc
acd
|ames AH, Koudes
PA, Abdu-Kadr R,
Detrch |E, Edund
M, Federc AB, et a.
Evauaton and
management of
acute menorrhaga
n women wth and
wthout underyng
beedng dsorders:
consensus from an
nternatona expert
pane. Eur | Obstet
Gyneco Reprod Bo
2011;158:124-34.
1.3 g
oray
or
10 mg/kg
IV
(maxmum
600
mg/dose)
Three
tmes
per day
for 5
days
(every
8
hours )
Contrandcatons
ncude, but are
not mted to,
acqured mpared
coor vson and
current
thrombotc or
thromboemboc
dsease. The
agent shoud be
used wth cauton
n patents wth a
hstory of
thromboss
(because of
uncertan
thrombotc rsks),
and concomtant
admnstraton of
combned ora
contraceptves
needs to be
carefuy
consdered.
Abbrevatons: FDA ndcates U.S. Food and Drug Admnstraton; IV,
ntravenousy.
*The U.S. Food and Drug Admnstratons abeng contans exhaustve
sts of contrandcatons for each of these therapes. In treatng women
wth acute abnorma uterne beedng, physcans often must wegh the
reatve rsks of treatment aganst the rsk of contnued beedng n the
context of the patents medca hstory and rsk factors. These
decsons must be made on a case-by-case bass by the treatng
cncan.
Other combned ora contraceptve formuatons, dosages, and
schedues aso may be ehectve.
Other progestns (such as norethndrone acetate), dosages, and
schedues aso may be ehectve.
Other dosages and schedues aso may be ehectve.
Once the acute epsode of beedng has been controed, mutpe
treatment optons are avaabe for ong-term treatment of chronc AUB.
Ehectve medca therapes ncude the evonorgestre ntrauterne
system, OCs (monthy or extended cyces), progestn therapy (ora or
ntramuscuar), tranexamc acd, and nonsteroda ant-nammatory
drugs. If a patent s recevng IV con|ugated equne estrogen, the
heath care provder shoud add progestn or transton to OCs.
Unopposed estrogen shoud not be used as ong-term treatment for
chronc AUB.
Patents wth known or suspected beedng dsorders may
respond to the hormona and nonhormona management optons sted
earer n ths secton. Consutaton wth a hematoogst s
recommended for these patents, especay f beedng s dmcut to
contro or the gynecoogst s unfamar wth the other optons for
medca management. Desmopressn may hep treat acute AUB n
patents wth von Webrand dsease f the patent s known to respond
to that agent. It may be admnstered by ntranasa nhaaton,
ntravenousy, or subcutaneousy. Ths agent must be used wth cauton
because of the rsks of ud retenton and hyponatrema and shoud not
be admnstered to patents wth massve hemorrhage who are
recevng IV ud resusctaton because of ssues wth ud overoad.
Recombnant factor VIII and von Webrand factor aso are avaabe
and may be requred to contro severe hemorrhage. Other factor
decences may need factor-specc repacement.
Patents wth beedng dsorders or pateet functon abnormates
shoud avod nonsteroda antnammatory drugs because of ther
ehect on pateet aggregaton and ther nteracton wth drugs that
mght ahect ver functon and the producton of cottng factors.
$urgical !anagement
The need for surgca treatment s based on the cnca stabty
of the patent, the severty of beedng, contrandcatons to medca
management, the patents ack of response to medca management,
and the underyng medca condton of the patent. Surgca optons
ncude daton and curettage (D&C), endometra abaton, uterne
artery embozaton, and hysterectomy. The choce of surgca modaty
(eg, D&C versus hysterectomy) s based on the aforementoned factors
pus the patents desre for future fertty. Specc treatments, such as
hysteroscopy wth D&C, poypectomy, or myomectomy, may be
requred f structura abnormates are suspected as the cause of acute
AUB. Daton and curettage aone (wthout hysteroscopy) s an
nadequate too for evauaton of uterne dsorders and may provde
ony a temporary reducton n beedng (cyces after the D&C w not be
mproved). Daton and curettage wth concomtant hysteroscopy may
be of vaue for those patents n whom ntrauterne pathoogy s
suspected or a tssue sampe s desred. Case reports of uterne artery
embozaton and endometra abaton show that these procedures
successfuy contro acute AUB. Endometra abaton, athough ready
avaabe n most centers, shoud be consdered ony f other
treatments have been nehectve or are contrandcated, and t shoud
be performed ony when a woman does not have pans for future
chdbearng and when the possbty of endometra or uterne cancer
has been reaby rued out as the cause of the acute AUB.
Hysterectomy, the dentve treatment for controng heavy beedng,
may be necessary for patents who do not respond to medca therapy.
(o' is abnormal uterine bleeding treated<
There are severa treatment optons for abnorma beedng, dependng
on the cause of your beedng, your age and whether you want to get
pregnant n the future. Your doctor w hep you decde whch
treatment s rght for you. Or, f your doctor decdes that a hormone
mbaance s causng your abnorma beedng, you and your doctor may
decde to wat and see f the beedng mproves on ts own. Some
treatment optons ncude the foowng:
Birt& control pills: Brth contro ps contan hormones that can stop
the nng of your uterus from gettng too thck. They can aso hep keep
your menstrua cyce reguar and reduce crampng. Some types of brth
contro ps, especay the progestn-ony p (aso caed the "mn-
p") can actuay cause abnorma beedng for some women. Let your
doctor know f the p youre takng doesnt contro your abnorma
beedng.
1ntrauterine device (1UD: If brth contro ps dont contro your
beedng, your doctor may suggest an IUD. An IUD s a sma, pastc
devce that your doctor nserts nto your uterus through your vagna to
prevent pregnancy. One type of IUD reeases hormones, and ths type
can sgncanty reduce abnorma beedng. Lke brth contro ps,
sometmes IUDs can actuay cause abnorma beedng. Te your doctor
f ths happens to you.
A D4#* or dilatation and curettage, s a procedure n whch the
openng of your cervx s stretched |ust enough so a surgca too can
be put nto your uterus. The too s used to scrape away the nng of
your uterus. The removed nng s checked n a ab for abnorma tssue.
A D&C s done under genera anesthesa (whe you're n a seep-ke
state).
If you're havng heavy beedng, a D&C may be done both to nd out
the probem and to treat the beedng. The D&C tsef often makes
heavy beedng stop. Your doctor w decde f ths procedure s
necessary.
(ysterectomy: Ths type of surgery removes the uterus. If you have a
hysterectomy, you wont have any more perods and you wont be abe
to get pregnant. Hysterectomy s ma|or surgery that requres genera
anesthesa and a hospta stay. It may requre a ong recovery perod.
Tak to your doctor about the rsks and benets of hysterectomy.
Endometrial ablation s a surgca procedure that destroys the nng
of the uterus. Unke a hysterectomy, t does not remove the uterus.
Endometra abaton may stop a menstrua beedng n some women.
However, some women st have ght menstrua beedng or spottng
after endometra abaton. A few women have reguar menstrua
perods after the procedure. Women who have endometra abaton
st need to use some form of brth contro even though, n most cases,
pregnancy s not key after the procedure. Your doctor can do
endometra abaton n severa dherent ways. Newer endometra
abaton technques do not requre genera anesthesa or a hospta
stay. The recovery tme after ths procedure s shorter than recovery
tme after a hysterectomy.
A$%EP
I. Pengka|an
II. Anasa data
6o
:
Data Etiologi !asala&
kepera'atan
1. norma hormona cycng
change
progesterone secreton
estrogen secreton
the endometrum grow
produce excess tssue
endometra hyperpasa
(thckened nng of the
uterus)
Abnorma uterne
beedng
Resko pendarahan
Resko pendarahan
2. Abnorma uterne
beedng
Hemogobn
Nutrs
Anema
Keethan
Keethan
Abnorma uterne
beedng
Kebershan perneum
tdak d|aga
Bakter berkembang
Resko nfeks
Resko nfeks
III.Dagnosa keperawatan
1. Resko pendarahan berhubungan dengan abnorma uterne
beedng (ms. Kompkas terkat kehaman sepert pasenta
preva, kehaman moa, souso pasenta, trauma, efek sampng
terkat terap, anovuatory dan ovuatory DUB).
Pannng : Bood oss severty
Seteah dakukan ntervens seama 2x24 |am maka resko
pendarahan berkurang dengan krtera has
No
.
Indkator 1 2 3 4 5
1. Vsbe bood oss v
2. Vagna beedng v
3. Decreased systoc bood
pressure
v
4. Decreased dastoc bood
pressure
v
5. Loss of body heat v
6. Skn and mucous membrane
paor
v
7. Decreased hemogobn v
8. Decreased hematocrt v
Ket ;
1 : severe
2 : substanta
3 : Moderate
4 : Md
5 : None
Interventon : beedng reducton
- Identfy the cause of the beedng
- Montor the patent cosey for hemorrhage
- Appy drect pressure or pressure dressng, f approprate
- Montor the amount and nature of bood oss
- Note hemogobn / hematocrt eves before and after bood
oss
- Arrange avaabty of bood products for transfuson, f
necessary.
- Admnster bood product (e.g. pateets and fresh frozen
pasma) as approprate
- Instruct the patent on actvty restrcton
2. Keethan berhubungan dengan anema dan abnorma uterne
beedng dtanda dengan eah, esu , dan penngkatan keuhan
sk.
Pannng : Energy conservaton
Seteah dakukan ntervens seama 4x24 |am maka keethan
berkurang dengan krtera has
No
.
Indkator 1 2 3 4 5
1. Baances actvty and rest V
2. Mantan adequate nutrton V
3. Use energy conservaton
technque
v
Intervens : Energy management
- Use vad nstrument to measure fatgue, as ndcate
- Seect nterventons for fatgue reducton usng
combnaton of pharmacoogc and non-pharmacoogc
categores, as approprate.
- Montor nutrtona ntake to ensure adequate energy
resources.
- Montor ocaton and nature of dscomfort or pan durng
movement/ actvty
3. Resko nfeks berhubungan dengan penurunan tubuh skunder
yang tdak adekuat (ms., penurunan hemogobn, eukopena),
trauma, dan kerusakan |arngan.
Pannng : rsk contro nfecton process
Seteah dakukan ntervens seama 2x24 |am maka resko
nfeks berkurang dengan krtera has
No
.
Indcator 1 2 3 4 5
1. Acknowedges persona rsk for
nfecton
v
2. Acknowedges persona
consequences assocated wth
nfecton
v
3. Identes persona sgns and
symptoms that ndcate
potenta rsk
v
4. Montorchanges n genera
heath status
v
5. Takes mmedate actons n
reduce rsk
v
Intervens : nfecton protecton
- Montor for systemc and ocazed sgns and symptoms of
nfecton
- Montor vunerabty to nfecton
- Mantan asepss for patent at rsk
- Obtan cuture as needed
- Encourage rest