Dysfunctional Uterine Bleeding, help!!

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I'm in over my head here and need some timely advice from the pros. I'm a psych nurse and have been working on and off with a pt that has been on my unit a couple weeks already. She was admitted for a suicide attempt and is there because she has her final hearing on her detainment (which will probably be dropped) in a few days. She tried to drink herself to death, BAL was 0.45 on admission.

Her meds: Prozac 60 mg q day

Ferrous Sulfate 325 mg q day (new)

Medroxyprogesterone 10 mg q day (new)

Labs: H&H borderline low but in range

MCH low

TSH in the 4's

Urine preg = neg

A day or two after she was admitted and after her detox, she began her menses and asked for fem supplies. I feel bad for not catching this sooner, but I just realized a couple days ago (2 weeks into her stay), that she was continuing to ask for fem supplies. According to the pt, she has had a hx in the last couple years of missing her periods about 2-3 times/yr. This month was the first time she had a long menses, and this time was passing large clots/bleeding heavily.

Called OB, relayed above info. Pt was consulted, had CBC/TSH/urine preg (above). Ob did endo biopsy (not resulted yet) for pt, and started her on the iron/Medroxyprogesterone. Prelim DX: DUB.

Here's the question. She just started these meds and complained of terrific headaches. OB called on day 2, advice given to push fluids. Problem is, pt already drinks plenty. Pt very unhappy, refuses medroxyprogesterone but continues iron, headaches have stopped. Of course, pt has now started bleeding again. Called again, same advice given to push fluids.

I need to advocate something on behalf of the pt, but I don't know what that is?? Help!

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Some options you could ask about (trying to avoid offering medical advice here):

Treating the headaches with something beyond fluids - they may lessen over time

NSAIDs - obviously can help headaches, but also acts to decrease menstrual bleeding

GnRH agonists - often used in women who can't do hormones

Estrogen metabolism can be affected by liver damage, causing DUB. Something else to think about.

Hope that helps you.

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Specializes in NICU, Infection Control.

Gyn needs to see her again, and help your docs manage her. You don't state her age, but if she's peri-menopausal, could be a fibroid or some other pathology.

I googled "heavy menstrual bleeding", this is one thing I got: http://www.nlm.nih.gov/medlineplus/ency/article/003263.htm

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Just wanted to add:

Pt age: 39

She said she hasn't been too worried about irregular menses since hubby has vasectomy. She said she thought it was just perimenopause. Apparently the OB said not a chance, she was too young.

Anyway, we did give Naprosyn as often as we could (with other analgesics) but headache never got below an 8/10 while taking the hormones.

The OB at this time believes she has:

  • "Estrogen breakthrough bleeding

    • Anovulatory cycles have no corpus luteal formation. Progesterone is not produced. The endometrium continues to proliferate under the influence of unopposed estrogen.

    • Eventually, this out-of-phase endometrium is shed in an irregular manner that might be prolonged and heavy. This pattern is known as estrogen breakthrough bleeding and occurs in the absence of estrogen decline."

Since this isn't my area of expertise, I've been trying to google some info so I can call the doc back confidently and suggest something else for her, since nothing has worked so far.

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Specializes in NICU, Infection Control.

IMO, 39 is not too young for perimenopause. There is actually an over the counter urine test that can tell you where you are re: menopause.

If possible, try to get an gyn endocrinologist. I went to one after I got "spayed", it did help. An endometrial ablation proceedure can control severe bleeding.

http://www.mayoclinic.com/health/perimenopause/DS00554

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

Sure sounds like Prmenrs is onto something. Perimenopause/fibroids? Endocrine problems?

I agree also, time to see the GYN for a consult stat---and perhaps referral to an endoncrinologist if it's not purely a GYN problem. I wish this poor gal well.

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Specializes in Cardiac.

The OB at this time believes she has:

  • "Estrogen breakthrough bleeding

    • Anovulatory cycles have no corpus luteal formation. Progesterone is not produced. The endometrium continues to proliferate under the influence of unopposed estrogen.

    • Eventually, this out-of-phase endometrium is shed in an irregular manner that might be prolonged and heavy. This pattern is known as estrogen breakthrough bleeding and occurs in the absence of estrogen decline.".


This makes total sense and correlates with her personal menstrual history. If she is anovulatory, then she isnt' making a corpus luteum that cycle, and not getting natural progesterone. She needs the progesterone to balance the estrogen. She just needs something else to help manage the headaches as well.

This is a good website that really explains a lot about progesterone.

http://www.wdxcyber.com/nmood11.htm

Interestingly, that site mentions something about a correlation about depression and progesterone..

Progestogens, probably more so than natural progesterone, increase MAO concentration thus producing depression and irritability. Pure progestogen treatment without estrogen, such as DepoProvera® is know to worsen depression in women who already have a tendency toward or clinical signs of depression..

I personally take progesterone also, but only in a cream form. I don't get the headaches, but I know of many women who get them. They can be awful. (I get my headaches with estrogen).

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Thanks to all that responded, your insights and expertise are appreciated. I did go to the websites you mentioned and copied a few things for the pt, she was thankful to receive this info. Her endo biopsy came back negative, but she did have proliferative endometrium. She will be following up q3 mos with the Gyn for awhile, and her meds were switched from medroxyprogesterone to Prometrium, MD says many women tolerate it better.

This is such a different thing for me to deal with, I appreciate the resources here!

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I forgot to mention, weight gain, especially around midriff and hip areas is extremely common in my research for this condition, and MD pointed out to pt that weight loss is necessary to mitigate further endocrine problems.

I found this interesting because in this case, this gal did have a hormonal imbalance causing her weight gain, I know this is often brushed aside as an excuse, but in this pt it was real. So if anyone else runs across an apple shaped body with menstrual irregularities, maybe this will be a red flag for them in their assessments.

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Specializes in Cardiac.

Every time I see apple shaped women, I assume that they at least have heavy periods! Estrogen is stored in fat...

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Has she had thyroid function testing done? This, too, can cause irregular bleeding.

CJ

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