SOGC Guidelines Management of DUB

Normal menstrual cycle 
 

Interval: 28 + 7 days Flow: 4 + 2 days Average blood loss: 40 + 20 ml

Hormonal regulation

Abnormal uterine bleeding 

Changes in frequency of menses, duration of flow or amount of blood loss

Dysfunctional uterine bleeding     Diagnosis of exclusion No pelvic pathology or underlying medical cause Heavy prolonged flow with or without breakthrough bleeding With or without ovulation .

Menorrhagia (hypermenorrhea)    Heavy cyclical menstrual bleeding occurring over several cycles throughout reproductive years Blood loss of more than 80 ml per cycle In excess of 60 ml per cycle results in iron deficiency anemia and may affect quality of life .

Diagnostic approach to AUB   History and physical examination Assesment of endometrium ± ± ± ± Endometrial sampling Dilatation and curettage Transvaginal ultrasound Saline sonohysterography .

History    Polyps or submucous myoma may be present in 25 to 50% of women with irregular bleeding Distinguish between anovulatory and ovulatory DUB Anovulatory ± ± Extremes of age (adolescents and perimenopause) Polycystic ovary syndrome  Identify risk factors .

Independent risk factors for endometrial hyperplasia and carcinoma in women with AUB .

prolactin. day 21 to 23 progesterone or documentation of ovulation FSH or LH to verify menopausal status or to check for PCO Coagulation profile especially for young patients .Diagnosis      Abdomino pelvic exam necessary Pap smear and CBC TSH.

Ovulatory AUB    Heavy cyclical blood loss over several cycles without intermenstrual or postcoital bleeding Dysmenorrhea with passage of clots Premenstrual symptoms suggest ovulatory cycles .

Endometrial sampling  All women above age 40 or with higher risk for endometrial cancer ± ± ± ± ± ± Nulliparity with history of infertility New onset heavy irregular bleeding Obesity (>90 kg) Polycystic ovaries Family history of endometrial or colon cancer Tamoxifen therapy  No improvement in bleeding after 3 month medical therapy .

the endometrium should be sampled since appearance not sufficient to exclude hyperplasia or carcinoma (EvL2a) .Endometrial sampling  Office endometrial biopsy ± ± ± Adequate samples in 87 to 97% and detects 67 to 96% of endometrial carcinomas Hysteroscopically directed biopsies detects a higher percentage compared with D and C alone Even if endometrium appears normal on hysteroscopy.

3% and bleeding in 0.4% Blind procedure with significant sampling errors Requires anesthesia with a risk of complications Reserved for situations where office biopsy or hysteroscopy not feasible or available .Dilatation and curettage      No yield in 10 to 25% of women Morbidities: perforation in 0.6 to 1.

Transvaginal ultrasonography     Assess endometrial thickness Detect polyps and leiomyomata Sensitivity of 80% Specificity of 69% .

Transvaginal ultrasonography    Endometrial thickness of less than 5 mm can exclude endometrial disease and carcinoma with a sensitivity of 92% and 96% respectively Not helpful if thickness is between 5 to 12 mm No correlations established in premenopausal patients .

Saline infusion sonography  Introduction of 15 ml saline through catheter or pediatric feeding tube improves the diagnosis of endometrial masses during TVS .

inconvenience. side effects . expectations.Medical management       Age Desire to preserve fertility Coexisting medical conditions Patients¶ preference Provide risks and contraindications Satisfaction depends on efficacy. cost.

Medical managements       NSAIDs Antifibrinolytics Danazol Combined oral contraceptives Progestin intrauterine system GnRH agonists .

NSAIDs     Inhibit cyclo-oxygenase and reduce endometrial prostaglandin levels Decrease menstrual blood loss by 20-25% Improve dysmenorrhea in up to 70% Initiated on first day of menses and continued for five days or until cessation of menstruation (EvL1a) .

leg cramps 500 mg every 6 hours for first 4 days of cycle decreases bleeding in 40% .Antifibrinolytics     Tranexamic acid (derivative of amino acid lysine) provides reversible blockade of plasminogen No effect on blood coagulation parameters nor dysmenorrhea Side effects in 1/3 of women: nausea.

with side effects in 20% including weight gain of 2 to 6 lbs (60% of patients) .Danazol      Synthetic steroid with mild androgenic properties inhibit steroidogenis in ovary and with profound effect in endometrial tissue Reduces blood loss by up to 80% 100 to 200 mg daily for up to 6 months Amenorrhea in 20% and oligomenorrhea in 70% No side effects in 50%.

Progestins    Ineffective in controlling heavy menstrual bleeding compared with NSAIDs or tranexamic acid Useful in women with anovulatory cycles given 12 to 14 days each month Medroxyprogesterone acetate produces amenorrhea in 80% but with irregular bleeding in 50% .

Combined oral contraceptives    Produces endometrial atrophy Intake of COC with 30Qg ethinyl estradiol reduces blood loss of up to 43% from baseline Provides contraception and relieves dysmenorrhea .

Progestin intrauterine system  Levonorgestrel IUD releases 20Qg/24 hours .

GnRH agonists    Produces reversible hypoestrogenic state and reduces uterine volume by 40 to 60% Myomas and uterine volume expand to pretreatment levels within months of cessation of treatment Effective but limited by side effects like hot flashes and reduction in bone density .

Surgical management    Dilatation and curettage Endometrial destruction Hysterectomy .

Dilatation and curettage   Temporary reduction in blood loss Useful in aiding diagnosis .

Endometrial ablation      85% satisfied patients in life table analysis of 6.5 years 10% will eventually have hysterectomy 10% will have repeat procedure after 5 years Women above 40 have better outcome Preoperative therapy improve ease of surgery and short term amenorrhea rates .

Endometrial ablation    Hysterocopically guided Photo or electrocoagulation Rollerball or loop resection .

high satisfaction rates on long term follow up Compares favorably with hysterectomy but need cost benefit analysis on long term if with repeat procedures necessary .Endometrial ablation    Effective for chronic menorrhagia unresponsive to medication Low complication rates.

Global endometrial ablation     Uses heat or cold to destroy endometrium Requires less operator skills Efficacy and cost-effectiveness not thoroughly evaluated Requires pre and post op visualization of endometrium by hysteroscopy .

reviewed other alternatives. conservative management has failed .Hysterectomy     Risk of major surgery weighed against alternatives Permanent solution for menorrhagia High levels of patient satisfaction in properly selected patients For women who have completed childbearing.

Take home points 1. Women with irregular menstrual bleeding should be investigated for endometrial polyps and/or submucous fibroids. (II-2 B) .

Further investigations are individualized.Take home points 2. Women presenting with menorrhagia should have a current cervical cytology and a complete blood count. (III B) . It is useful to delineate if the bleeding results from ovulatory or anovulatory causes. both in terms of tailoring the investigations and in choosing a treatment.

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.Take home points 3. Clinicians should perform endometrial sampling based on the methods available to them. (II B) .

Take home points 3. 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. (II B) .

(II B) .Take home points 4. Women with persistent symptoms but negative tests should be reevaluated. 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.

(I A) .Take home points 5. Progestogens given in the luteal phase of the ovulatory menstrual cycles are not effective in reducing regular heavy menstrual bleeding .

Take home points 6. it is not effective therapy for women with heavy menstrual bleeding. (II B) . While dilatation and curettage (D&C) may have a diagnostic role.

This should be reserved for the woman who has finished her childbearing and is aware of the risk of recurrent bleeding. The endometrium can be destroyed by several different techniques but reoperation rate at five years may be up to 40 percent with rollerball ablation.Take home points 7. (I A) .

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