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An Approach to DUB

An Approach to DUB. Cynthia Phelan PGY 1 2003 / 08 / 05. Dysfunctional Uterine Bleeding. Normal Menstrual Cycle 28 +/- 7 days 4 +/- 2 days Blood loss 40 +/- 20ml. Diagnosis. History Is it Uterine? Anovulatory Intermenstrual Bleeding, Irregular cycles Ovulatory

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An Approach to DUB

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  1. An Approach to DUB Cynthia Phelan PGY 1 2003 / 08 / 05

  2. Dysfunctional Uterine Bleeding • Normal Menstrual Cycle • 28 +/- 7 days • 4 +/- 2 days • Blood loss 40 +/- 20ml

  3. Diagnosis • History • Is it Uterine? • Anovulatory • Intermenstrual Bleeding, Irregular cycles • Ovulatory • Heavy blood loss, Regular Cycles, PMS • ? Pathology • Pelvic Pain, Post-coital Bleeding, Irregular Bleeding • Family History • Coagulopathy

  4. Diagnosis • Physical Exam • Abdominal Exam • Pelvic Exam • Pap Test • Lab Tests • CBC +/- Ferritin • Other • TSH • Prolactin – day 21-23 to verify ovulatory status • FSH/LH - ?menopause • Coagulation Profile

  5. Investigations • Sample endometrium in all patients at risk for endometrial cancer. • Risk Factors • Age >45 • Obesity >90kg • Family History • Nullpartiy / Infertility • PCO • Tamoxifen • New Onset Heavy Irregular Bleeding • Test all women with no symptomatic improvement after three months of therapy.

  6. Endometrial Sampling • Office Biopsy • Adequate Sample 87-97% • Detection Rate 67-96% • Hysteroscopic Directed Sampling • Detects a higher percentage of abnormalities than D&C • D&C • Reserve for patients in whom biopsy or hysteroscopy was unsuccessful. • Higher risk procedure – anesthesia, perforation

  7. Ultrasound • Used to assess endometrial thickness • Thickness most useful in postmenopausal women • >5mm suggestive of endometrial disease • Endometrial thickness much less useful in perimenopausal women and women of reproductive age • Localization of polyps and myomata

  8. Medical Management • Conjugated Estrogens • Used IV or IM or PO for management of heavy bleeding • Can be used in both ovulatory and anovulatory bleeding • NSAIDS • ↓ prostaglandins, ↓ blood loss by 20-50%, improve dysmenorrhea • Should be taken for five days during menstruation each cycle • OCP • Induce endometrial atrophy → decreased blood loss • Additional advantages – contraception, ↓ dysmenorrhea • Progestins • Cyclic progestins ineffective for heavy bleeding • Helpful for women with irregular cycles

  9. Medical Management • Progestin IUD • IUD impregnated with levonorgesterel reported to reduce menstrual bleeding • Antifibrinolytics • Tranexamic acid (cyclokapron) • Blocks plasminogen, no reported effect on coagulation • 1g q6h x4 days at onset of menstrual cycle ↓ blood loss by 40% • Danazol • Mildly androgenic • ↓ steroidogenesis in ovary → oligo or amenorrhea in 90% • GnRH Agonist • Create hypoestrogenic state → decreased uterine volume • Volume returns to normal after cessation of treatment • Side effects often not tolerated – hot flashes, bone density

  10. Surgery • D&C • Endometrial Ablation • Hysterectomy

  11. Take Home Points • Investigate for polyps and fibroids • All patients should have a pap and CBC • Endometrial biopsy should be done on all women at high risk for endometrial ca.

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