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
– Heavy blood loss, Regular Cycles, PMS
• ? Pathology
– Pelvic Pain, Post-coital Bleeding, Irregular Bleeding
• Family History
– Coagulopathy
Diagnosis
• Physical Exam
• Abdominal Exam
• Pelvic Exam
• Pap Test
• Lab Tests
• CBC +/- Ferritin
• Other
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TSH
Prolactin – day 21-23 to verify ovulatory status
FSH/LH - ?menopause
Coagulation Profile
Investigations
• Sample endometrium in all patients at risk for
endometrial cancer.
• Risk Factors
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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.
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
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
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
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
Surgery
• D&C
• Endometrial Ablation
• Hysterectomy
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.