Standard Treatment Guidelines For Dysfunctional Uterine Bleeding

DUB affects 22 to 30% of women and accounts for 12% of gynaecological referrals.

DUB is not one condition of one etiology, it is a group of disorders characterized by dysfunction of any part of the reproductive system: uterus, ovary, pituitary, hypothalamus, higher centers.

In clinical practice, the diagnosis of DUB is usually made by exclusion of organic disease of the genital tract or systemic organic disease.

Ministry of Health and Family Welfare, Government of India has issued the Standard Treatment Guidelines for Dysfunctional Uterine Bleeding. Following are the major recommendations.

Definition

It is defined as abnormal uterine bleeding without any clinically detectable organic pathology.

How to make diagnosis?

History:

1. H/o Abnormal Uterine Bleeding:

a) Excessive menses-duration of menstrual flow > 7 days or menstrual blood loss > 80 ml

b) Frequent menses-duration of menstrual cycle < 21 days

c) Irregular / acyclical uterine bleeding.

2. H/o Symptoms Suggestive Of:

a) Pregnancy

b) Dysmenorrhoea/ dyspareunia/ infertility may suggest endometriosis and PID, fibroids, adenomyosis

c) H/o contraceptive practice, HRT

d) Symptoms suggestive of hypothyroidism, bleeding disorders, other systemic illness

e) Ingestion of drugs, like antiplatelet drugs (aspirin, clopedrogel)

Examination:

1. A general examination for signs of anemia, thyroid disease or bleeding disorders.

2. Abdominal examination for masses.

3. All women with abnormal genital tract bleeding must have a speculum examination to visualize the cervix, vagina and exclude any local cause.

4. Per vaginal examination look for uterine enlargement (fibroids), tenderness/fixity (PID, endometriosis), any adnexal mass.

Incidence:

1. Pubertal or adolescent DUB – usually women less than 20 yrs, incidence – 4%

2. Reproductive DUB – seen in women from 20 to 40 yrs, incidence – 57%

3. Perimenopausal DUB – women aged above 40 yrs, incidence – 39%

4. Postmenopausal DUB – incidence around 10%

Differential Diagnosis

1. Pregnancy related bleeding

a) Abortions

b) Ectopic pregnancy

c) Guestational trophoblastic disease

2. Fibroid uterus

3. Endometrial cancer

4. Thyroid abnormalities

5. PID, Endometriosis.

6. Endometrial TB

7. PCOS

Situation 1:

Diagnostic Criteria, Investigation, Treatment & Referral Criteria

Clinical diagnosis is made by history and examination as explained above. Final diagnosis is only made after investigations.

Investigations:

a) Urine pregnancy test

b) Complete blood count

c) Platelet count, BT, CT, PT, PTT especially in puberty menorrhagia not responding to treatment

d) Thyroid profile

e) LFT & RFT only in strongly suspected cases

f) USG – TAS/TVS: Ultrasound is the first-line diagnostic tool for identifying structural abnormalities.

g) Pap smear

h) Sonohysterography

i) Endometrial biopsy – by Novac curette, By Pipelle aspirator

 Women with irregular menstrual bleeding should be investigated for endometrial polyps and/or submucous fibroids.

 Clinicians should perform endometrial sampling based on the methods available to them. An office endometrial biopsy should be obtained if possible in all women presenting with abnormal uterine bleeding over 40 years of age or weighing more than or equal to 90 kg to exclude endometrial cancer or atypical hyperplasia, treatment failure or ineffective medical treatment

 D & C- mandatory in perimenopausal age group (>40 years) and is contraindicated in unmarried girls, puberty menorrhagia.

j) Hysteroscopy – with hysteroscopic guided biopsy sensitivity is 98%. Hysteroscopy should be used as a diagnostic tool only when ultrasound results are inconclusive, for example, to determine the exact location of a fibroid or the exact nature of the abnormality. [A] Hysteroscopically-directed biopsy is indicated for women with persistent erratic menstrual bleeding, failed medical therapy or transvaginal saline sonography suggestive of focal intrauterine pathology such as polyps or myomas.

k) Laparoscopy – to exclude unsuspected pelvic pathology such as endometriosis, PID/Ovarian tumor. The indication is urgent is associated with pelvic pain.

l) Saline infusion sonography should not be used as a first-line diagnostic tool.

m) Magnetic resonance imaging (MRI) should not be used as a first-line diagnostic tool.

Treatment:

1. Assurance and sympathetic handling of physiological or emotional problems

2. Normal routine activities

3. Correction of anemia by diet, haematinic and even by blood transfusion

4. Clinically evident systemic/endocrine abnormalities should be investigated and treated accordingly

Medical Management:

Non hormonal methods:

1. Anti fibrinolytic agents oral/IV tranexemic acid 500 mg-1gm twice or thrice daily till severe bleeding. Effective in ovulatory DUB, iatrogenic menorrhagia secondary to insertion of IUCD, Von Wilibrand’s disease

2. Prostaglandin synthetase inhibitors (NSAIDS) Mefenamic acid 250 mg - 500 mg twice or thrice daily, effective in ovular DUB

3. Ethamsylate 250 – 500 mg TDS oral/IV

4. Anti tubercular treatment when disease is confirmed

Hormonal Method:

To stop acute episodes of bleeding and to regulate the cycles

1. Progestins

a. Tab nonethisterone 20 – 30 mg/day in divided doses. It arrests bleeding in 24 – 48 hrs; later dose is tapered and continued in cyclical fashion from 5 th day of withdrawal flow in subsequent cycles for 3 to 4 cycles.

b. Similarly Medroxy progesterone acetate (MPA) can also be used.

2. Cyclical therapy:

In ovular bleeding:

1. OCP is given from 5th to 25th day of cycle for 3 consecutive cycles. In ovular bleeding where patients wants pregnancy or in case of irregular shedding or ripening dydrogesterone 10 mg per day from 16th to 25th day. In anovular bleeding:

a) MPA 10mg 5th to 25th day, NE 5mg 5th day to 25th day for 3 consecutive cycles

b. DMPA – 150 mg I.m every three months useful in maintenance therapy in woman who have difficulty with or cannot take OCPs.

c. Ormeloxifene (Sevista) – 2 tab of 60 mg/week that is on Sunday and Wednesday for 12 weeks, 1 tab of 60 mg on following Sunday or Wednesday for 12 weeks

d. Levonorgestrol – Releasing IUD(Mirena)

Surgical Management

Hysterectomy – TAH/vaginal hysterectomy/laparoscopic hysterectomy.

Hysterectomy should not be used as a first-line treatment solely for HMB. Hysterectomy should be considered only when:

• Other treatment options have failed, are contraindicated or are declined by the woman

• There is a wish for amenorrhoea

• The woman (who has been fully informed) requests it

• The woman no longer wishes to retain her uterus and fertility

Referral Criteria

a) Puberty menorrhagia where bleeding disorders are suspected and further investigation are to be done.

b) Young women who want to preserve the uterus and facilities for endometrial destruction and ablation are not available.

c) Associated comorbid medical conditions in which surgery is required.

Situation 2

Diagnostic Criteria, Investigation And Treatment

Diagnosis: As in situation 1

Investigations:

In addition to investigations as in situation 1, certain specific tests like Specific tests for bleeding disorders :Testing for coagulation disorders (for example, von Willebrand disease) should be considered in women who have had HMB since menarche and have personal or family history suggesting a coagulation disorder. [NICE GUIDELINE 2007]

Treatment:

1. Along with the general and medical treatment as mentioned in situation 1.

2. conservative surgeries:

like Endometrial destruction or ablation – hysteroscopic and non hysteroscopic methods are available (TCRE, uterine thermal balloon ablation, radio frequency induced endometrial ablation, etc.)

3. Pre-requisite for undergoing these procedures:

a) To exclude atypical endometrium

b) CIN, Ca cervix, Ca endometrium has to be ruled out

c) Not expecting 100% amenorrhea

d) Uterus size less than 12 weeks

e) No pelvic inflammatory disease

f) Completed family

g) If necessary patient should be ready to undergo hysterectomy

h) Ready for regular follow up

i) Surgically fit

j) Patient should know that its not effective contraception

4. Associated co morbid medical conditions in which surgery is required:

(Hysterectomy).