An Approach to DUB

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An Approach to DUB

• Cynthia Phelan PGY 1
• 2003 / 08 / 05

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Dysfunctional Uterine Bleeding

• Normal Menstrual Cycle
• 28 /- 7 days
• 4 /- 2 days
• Blood loss 40 /- 20ml

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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

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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

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Investigations

• Sample endometrium in all patients at risk for
  endometrial cancer.
• Risk Factors
• Age gt45
• Obesity gt90kg
• Family History
• Nullpartiy / Infertility
• PCO
• Tamoxifen
• New Onset Heavy Irregular Bleeding
• Test all women with no symptomatic improvement
  after three months of therapy.

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Endometrial Sampling

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

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Ultrasound

• Used to assess endometrial thickness
• Thickness most useful in postmenopausal women
• gt5mm suggestive of endometrial disease
• Endometrial thickness much less useful in
  perimenopausal women and women of reproductive
  age
• Localization of polyps and myomata

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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

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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

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Surgery

• DC
• Endometrial Ablation
• Hysterectomy

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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.