PCD Me esc} DYSFUNCTIONAL UTERINE BLEEDING Definition: Dysfunctional uterine bleeding is defined as the spectrum of abnormal menstrual bleeding patterns that may ‘occur in anovulatory women who have no medical illness or pelvic pathology. History + Abnormal uterine bleeding © Excessive menses-Duration of menstrual low> 7days or menstrual blood loss > 80m! © Frequent menses-Duration of menstrual cycle <24days © Irregular /acyclical uterine bleeding (rarely) + Ingestion of hormonal medications like © Progestin only pills e Tamoxifen « Lowerabdominal pain/Pregnancy © Chronic pelvic pain © Chronicabdominal pain © Dyspareunia Examination + Absence of © Lump lowerabdomen © Pregnancy related bleeding © Adnexal mass or tenderness © Uterine enlargement + Pregnancy elated bleeding © Abortions © Ectopic pregnancy ° Gestational trophoblastic disease «Fibroid uterus + Endometrial cancer + Endometrial Hyperplasia Adenomyosi LEVEL 1 & LEVEL 2: AT SOLO PHYSICIAN CLINIC/ AT 6-10 BEDDED PRIMARY HEALTH CENTRE : Diagnosis: + Suspect the condition on basis of symptoms /signs as enumerated SW Rite imi TaN} EyDa ah Mens Tes ‘© Rule outthe following on clinical examination © Thyroid enlargement 2 Haematological disorders on clinical examination like bruises, petechial_ hemorrhages, contusions, etc © Lumpin lower abdomen © Pregnancy associated bleeding © Adnexal mass or tenderness © Uterineenlargement © Severeanemia Investigation: ‘+ Haemoglobin estimation, urine pregnancy test Treatment: ‘+ Identification of patients for presumptive treatment: ‘+ Patients who seek medical help for abnormal uterine bleeding with following symptoms and without above mentioned risk factors © Frequent(<24days) /Delayed(>3Sdays) cycles © Regular cycles with bleeding lasting >7 days © Cyclical bleeding with history of passage of clots during menses © Presence of dysmenorrhoea ‘+ Presumptive treatment: All the patients after exclusion from above mentioned conditions may be offered following treatment for atleast three months «Tab IFAcontaining Ferrous Sulphate 200 mgs + Folic Acid 400megs BD x 30days ‘+ NSAIDS /Antiibrinolytics (During periods) © Tab Mefenamic acid 500 mg TDS x Sdays OR © Tab Tranexamic acid 1gmTDS x5 days OR Combination of both the above: ‘© Check forimprovement ° _ Symptomaticimprovementin bleeding, dysmenorrhea and feeling of general well being 2 Repeat Hb estimation one month after starting IFAtherapy ‘Identity failure of treatment Noreliefofsymptoms oN provement of Hb despite presumptive treatment Referral criteria: + Bleeding PV associated with acute / persistent pain abdomen + Acyclical bleeding + Prolongedbleeding> 10 days ‘+ Anemia with hemoglobin s 8 gm% or with following symptoms of anaemia like easy fatigabilty, breathlessness, palpitations ete 86 SW Rite imi TaN}POA en Mn esc} ‘+ Presence of thyroid enlargement + Evidence of hematological disorders on clinical examination like bruises, petechial hemorrhages, contusions, etc * Presence of co-morbid diseases like hypertension, diabetes mellitus, valvular heart disease with anticoagulation LEVEL 3: AT 30-100 BEDDED COMMUNITY HEALTH CENTRE Diagnosis: + Suspect the condition on basis of symptoms /signs as enumerated + Rule out the following on clinical examination © Thyroid enlargement » Haematological disorders on clinical examination like bruises, petechial hemorrhages, contusions, ete < — Lumpinlowerabdomen © Pregnancy associated bleeding © Adnexal mass or tenderness e Uterine enlargement ° Severe anemia © Uterine /Pelvic pathology on bimanual examination Investigations: + Haemoglobin estimation + Total & Differential WBC counts * Urine pregnancy testing + PAPsmearfor Carcinoma Cervix ‘+ Perform endometrial sampling and send endometrium in formalin saline solution to Distt Hospital for histopathological diagnosis ‘+ Onreceipt of histopathological diagnosis the following approach is to be followed © Ondetection of speci pathology the patientis referred to level 4 for further management © On detection of no specific cause the patient is considered to have Dysfunctional Uterine Bleeding, These patients may benefit from drug therapy at the CHC Treatment: + Confirm the diagnosis and compliance for medication, + Drugtherapy: for minimum three months © High dose progesterone initially to control uterine bleeding followed by continuous prolonged low dose progesterone for total 21 days (eg Medroxyprogesterone acetate 10 mg TDS for 3 days for stoppage of uterine bleeding followed by 10mg OD X 18 days) © COCpillsin patients of age <35 yrs © TabEthinyl oestradiol 0.03mg+levonorgestrol 0.15mg or 21days © Cyclic Tab Medroxyprogesterone acetate, 10mg OD, in subsequent cycles from D14 for 12 - 14 days depending upon the patients menstrual cycle patterns SW Rite imi TaN} vdPye a LMU Desc} Referral criteria: + Transfer to Distt/ Tertiary hospital © Onfailure of medical or drug treatment for three cycles © Detection of specific pathology on examination or endometrial Biopsy LEVEL 4: AT 100 OR MORE BEDDED HOSPITAL Diagnosis: ‘+ Further evaluation of abnormal uterine bleeding with Ultrasound / Hysteroscopy (if available)/ Hormonal evaluation (Hypothyroidism / PCOS) / Hematologic evaluation ‘+ Treatas per specific underlying pathology detected. Investigations: + Haematological investigations © Haemoglobin, Bld grouping © Total & Differential WBC counts © Plateletcount © Tests of coagulation + Urine pregnancy testing + Endometrial histopathology * Ultrasonography + Diagnosticlaparoscopy + Diagnostic hysteroscopy * Cervical cytology + Thyroid function tests + Liverfunction tests Treatment: + Ifa patient with Dysfunctional uterine bleeding has not responded to medical management then suitable endometrial ablation procedure / hysterectomy can be offered to the patient for permanent cure 4, Novak's Gynaecology. Ed Berek JS, Fourteenth edition. 2007 2. Te Linde's Operative Gynaecology. Eds Rock JA, Jones III HW. Ninth edition. 2003 3. Clinical Gynecologic Endocrinology and Infertility by Leon Speroff,Marc A. Fritz,7th edition,2005,Published by Lippincott Williams & Wilkins, 530 Walnut Street, Philadelphia, PA 19106 USA, LWW.com 4. Shaw's Textbook of Gynaecology.Ed Padubidri V G,Daftary SN, 13th edition 2004 88 SW Rite imi TaN}