SOGC GuidelinesManagement 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

Diagnosis

Abdomino pelvic exam necessary Pap smear and CBC TSH, 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

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

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, the endometrium should be sampled since appearance not sufficient to exclude hyperplasia or carcinoma (EvL2a)

Dilatation and curettage

No yield in 10 to 25% of women Morbidities: perforation in 0.6 to 1.3% 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

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

Medical management

Age Desire to preserve fertility Coexisting medical conditions Patients’ preference Provide risks and contraindications Satisfaction depends on efficacy,

expectations, cost, inconvenience, side effects

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)

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, leg cramps 500 mg every 6 hours for first 4 days of cycle

decreases bleeding in 40%

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%, with side effects in 20%

including weight gain of 2 to 6 lbs (60% of patients)

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 30g ethinyl estradiol

reduces blood loss of up to 43% from baseline

Provides contraception and relieves dysmenorrhea

Progestin intrauterine system

Levonorgestrel IUD releases 20g/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

Endometrial ablation

Effective for chronic menorrhagia unresponsive to medication

Low complication rates, 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

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

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, reviewed other alternatives, conservative management has failed

Take home points

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

Take home points

2. Women presenting with menorrhagia should have a current cervical cytology and a complete blood count. Further investigations are individualized. 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. (III 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)

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)

Take home points

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

Take home points

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

Take home points

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

Take home points

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

Thank you!