DYSFUNCTIONAL UTERINE BLEEDING

I unit OG,2k6 Batch

MMC,madurai
 DYSFUNCTIONAL
UTERINE BLEEDING
INTRODUCTION

M.NITHYA
I UNIT
INTRODUCTION
Dysfunctional
uterine bleeding is
one of the most
common and
significant
gynaecological
problem of women
attending OPD
Cyclic interplay
between hormones
and uterus leads to
visible loss of
endometrial tissue
and blood called
menstruation.
Purpose – to prepare endometrium for
implantation and growth of fertilised ovum

This cyclical bleeding has been quoted as,

“weeping of the disappointed uterus”
Acyclical or prolonged – Dysfunctional

THE CURRENT CONCEPT IS,

The disturbance in endometrial blood vessels
and capillaries ,coagulation of blood in and
around these vessels are probably due to
alteration in the ratio of endometrial prostanoids.
 Vaginal bleeding is considered abnormal when
menstrual periods are too heavy /too light/lasts
too long ,occurs too often are irregular .any vaginal
bleeding that occurs before puberty or after
menopause is abnormal until proven otherwise.

 Bleeding may be abnormal in frequency

,duration,amount or combination of any of these
as the diagnosis is based with the exclusion of
organic lesion’s ,so with care and facilities such an
organic lesion is excluded and DUB is diagnosed
 DEFINITION

Dysfunctional uterine bleeding is defined as

an excessive state of abnormal bleeding from the
genital tract without any clinically detectable
and palpable organic pelvic pathology [tumour ,
inflammation] ,systemic illness and iatrogenic
cause . It is a symptom ,not a disease.
INCIDENCE
10-15 %
PREVALENCE
Varies widely
AGE GROUP
It can ocurr at any age group ,quite
frequently in the middle reproductive age
group .
CRITERIA FOR NORMAL
MENSTRUATION

cycle length
duration of bleeding
amount of blood loss
CYCLE LENGTH
Interval between first day of one period and first day
of next .

NORMAL RANGE : 21-35 days

NORMAL MEAN:28 days

 Regularity of cycle length depends on HPO [hypothalamo

pituitary ovarian ]axis.
 Irregular cycles ocurrs in post menarche and
perimenopausal women.
DURATION OF BLEEDING
Normal range: 2-7 days

Normal mean:5 days

AMOUNT OF BLOOD LOSS

Normal range:50-80ml

Normal mean:around 40ml

 MENSTRUAL CYCLE
IRREGULARITIES
 AMENORRHEA
 OLIGOMENORRHEA
 POLYMENORRHEA
 HYPOMENORRHEA
 DYSMENORRHEA
 MENORRHAGIA
 METRORRHAGIA
 MENOMETRORRHAGIA
AMENORRHEA
Absence of mensturation
It is a symptom not a disease.
OLIGOMENORRHEA
infrequent,irregularly timed episodes
of bleeding occurs at intervals of more than 35
days.
POLYMENORRHEA
frequent episodes of menstruation
,occurs at intervals of 21 days or less.
MENORRHAGIA
Regularly timed episodes of
bleeding that are excessive in amount [>80
ml] and/or duration of flow [>5 days].
METRORRHAGIA
Irregularly timed episodes of
bleeding superimposed on normal cyclical
bleeding.

MENOMETRORRHAGIA
Excessive prolonged bleeding that
occurs at irregularly timed and frequent
intervals.
HYPOMENORRHEA
Regularly timed but scanty episodes of
bleeding.

DYSMENORRHEA
Painful cramping pain accompanying
menstruation.
NORMAL AND ABNORMAL
MENSTRUATION

MALINI
 HYPOTHALAMO-PITUITARY
OVARIAN AXIS
+
FSH ESTROGEN
-
GnRH
+
LH PROGESTRONE
-
(Hypothalamus) (pituitary) (ovary)
 PHASES OF MENSTRUATION
PHASES :

1. MENSTRUATION 1–4 DAYS

2. PROLIFERATIVE PHASE 5–13 DAYS
3. PHASE OF OVULATION 14th DAY
4. SECRETORY PHASE 15–28 DAYS
 PROLIFERATIVE PHASE
• This phase is due to estrogen
• Corresponds to proliferative phase or
estrogenic phase of ovarian cycle
• Starts when regeneration of endometrium is
complete lasts until the 14th day of 28 days
cycle
• At the end of menstruation the endometrium is
represented by basal layer and its thickness is
about 1mm
• The uterine glands are short,straight,simple tubular
glands.

• Uterine glands grow in length and about the 10 th day

the glands become slightly sinous and their columnar
epithelium becomes taller than before.

• Epithelial cells also increase in number by mitosis and

stromal blood vessels of the endometrium also grow
with increase in number of coils.

Before ovulation the endometrial thickness becomes

5-6mm.
 OVULATION
• Occurs at the 14th day.
• Due to action of LH,the graffian follicle
ruptures and ovulates forming CORPUS
LUTEUM.
 LUTEAL PHASE
• Due to the action of progesterone
• Begins on the 15th day until the onset of
menstruation
CHANGES :
1. Development of subnuclear vacuolation - Day 17
2. Uterine glands become tortuous (cock screw) and
glycogen appears in the glandular lumen
Endometrial thickness : 8-10mm Day 19
3. Stromal edema-Day 21.
• Perivascular cuffing – Day 23
• Coiled arteries becoming more closely
wound,lymphocyte infilteration occur –Day 25

MENSTRUAL PHASE

• Lasts for 3-5 days

• Superficial endometrium becomes ischemic
due to vasoconstriction and blood stasis
• Tissue sloughs off and blood vessels open up
• Perivascular cuffing – Day 23
• Coiled arteries becoming more closely
wound,lymphocyte infilteration occur –Day 25

MENSTRUAL PHASE

• Lasts for 3-5 days

• Superficial endometrium becomes ischemic
due to vasoconstriction and blood stasis
• Tissue sloughs off and blood vessels open up
 HEMOSTASIS
Achieved in a normal menstruation by 2
mechanisms:

Formation of platelet plug

Constriction of spiral arterioles

Vasoconstriction is brought about by means of

prostaglandins
 DEFICIENT HEMOSTASIS
DUE TO:
Disturbance in prostanoid metabolism
Increased fibrinolysis in endometrium

NORMAL:
• In proliferative phase the endometrium synthesizes equal
amount of PGE2 & PGF2α
• In luteal phase PGF2α increases due to estradiol &
progesterone
PGF2α : PGE2 =2:1
Endometrium – PGF2α, PGE2 & PGD2
Myometrium – PGE2 from arachidonic acid &
endoperoxidases.

Phospholipid

Free Arachidonic Acid

Endoperoxides

PGE2 PGF2 α

PGI2
1. First, PGF2 α produces vasoconstriction

2. Endoperoxides from endometrium are

deviated to the myometrium which
produces PGI2

3. This then diffuses back into endometrium

which causes vasodilation followed by
vasoconstriction of spiral arterioles
preceding menstruation
 WITHDRAWAL OF PROGESTERONE

BREAKDOWN OF LYSOSOMES

RELEASE OF PHOSPHOLIPASE A2

PROSTANOID CASCADE

PREDOMINATION OF VASOCONSTRICTOR PROSTANOIDS

ORDERLY BLEEDING
ABNORMAL HEMOSTASIS IN DUB

 Failure in vasoconstriction due to excessive

secretion of PGE2 & increase in PGE2 :PGF2α.

 Failure in formation of adequate thrombotic

plugs due to PGI2 excess.

 Increased fibrinolysis due to increase in the

tissue plasminogen activator.
 Increased endometrial lysosomal enzymes
with excessive prostanoid formation.

 Failure in vascular endothelial proliferation

due to relaxin.

 Delay in endometrial regeneration.

 TYPES OF DYSFUNCTIONAL UTERINE
BLEEDING

• JAYAPRABHA
 DUB

ANOVULATORY OVULATORY
(80%) (20%)
• PUBERTY MENORRHAGIA OVULATORY POLYMENORRHOEA
• REPRODUCTIVE AGE OVULATORY OLIOMENORRHOEA
GROUP MENORRHAGIA
• METROPATHIA HEMORRHAGICA OVULATORY MENORRHAGIA
 ANOVULATORY

 PUBERTY MENORRHAGIA :-

Few cycles following menarche are anovulatory

Immature hypothalamo – pituitary – ovarian axis

Underactivity of ovarian function

Immature follicles & no ovulation

Only oestrogen secretion

Oestrogen level reaches critical threshold level

Hormone withdrawal

Shedding of endometrium (Breakthrough bleeding)

• REPRODUCTIVE AGE GROUP MENORRHAGIA :-

Following pregnancy & abortion

Disturbed hypothalamo – pituitary – ovarian axis

Hormonal imbalance

Bleeding
 METROPATHIA HAEMORRHAGICA :-

 Exact cause is not known

 Disturbance in Hypothalamus or Anterier pituitary

FSH is continuously secreted without LH surge

Mature follicle

Increased level of oestrogen

Short period of amenorrhoea

Withdrawal of oestrogen

Continues bleeding
BLEEDING IN METROPATHIA
HAEMORRHAGICA
• MICROSCOPIC FEATURES :-

 Cystic glandular hyperplasia (Swiss cheese pattern)

 Absence of secretory hypertrophy

 Areas of necrosis are scattered over superficial layers of endometrium

 OVARY :-

 Cysts are present

 Corpus luteum absent

 Diffuse polyp in the endometrium

Pic. 1 in MH
Pic. 2 in MH
Pic. 3 in MH
 OVULATORY

 OVULATORY OLIGOMENORRHOEA :-

 Prolonged proliferative phase with normal secretory phase

 Infrequent cycles are present

 Occurs in adolescence & preceding menopause

 Endometrium normal
• OVULATORY POLYMENORRHOEA:-

Ovary is normally functioning but matures quickly affecting follicular phase than
luteal phase

Short proliferative phase

Menstrual bleeding occurs every 2-3 weeks

 Normal Endometrium

 Occurs in few cycles following menarche, abortion & delivery

 CORPUS LUTEAL ABNORMALITY :-

D/T Irregular Ripening,

Deficient corpus luteum

Decreased progesterone secretion

Endometrial support of progesterone is inadequate

Breakthrough bleeding before actual date of menstruation

(Spotting / brownish discharge premenstrually)

 ENDOMETRIUM:-

 Contains both proliferative & secretory phases

 Changes are seen in superficial zone of endometrium

 IRREGULAR SHEDDING:- (HALBAN’S DISEASE)

Persistent corpus luteum even after menstruation

Menstruation comes on time but prolonged

 ENDOMETRIUM:-

 Curettage on 2nd / 3rd day of menstruation shows secretory edomentrium

DIAGNOSIS AND INVESTIGATIONS

MONICA
Diagnosis of DUB depends on the process of
exclusion of organic causes for menorrhagia.

It is based on

1. History

2. Examination

3. Investigations
 HISTORY
1. Age, parity and fertility of the patient

2. Uterine bleeding –
onset,duration,amount,pattern,character,cyclical features.

MENSTRUAL CALENDAR can be maintained.

 It is a day to day record of amount of blood loss for 2-3
months
 Useful when pattern and amount of
blood loss are uncertain.
3. Antecedent cause – IUCD, recent
delivery/abortion, drug intake, sterilisation
operation.
4. Any symptoms suggestive of bleeding disorders or
hypothyroidism.

CLINICAL EXAMINATION

1.Degree of anaemia
2.Associated thyroid problems
3.Abdomen and bimanual pelvic examination
 INVESTIGATIONS
1. Assessment of amount of menstrual blood loss by
• Direct method - weighing napkins before and after
use
• Indirect method - amount of clot passage
degree of anaemia
2. Complete haemogram
Hb%, coagulation profile, blood grouping and typing.
3. Thyroid profile
4. Hormonal profile
 5. ULTRASOUND
• Transvaginal US preferred over
transabdominal.
USE:
 Exclude organic causes of abnormal bleeding
 Endometrial thickness and texture accurately measured.
thickness>12mm – risk of disease and is an indication for biopsy
thickness<5mm – biopsy unnecessary.

ADVANTAGE:
 Safe
 painless
 convenient
 non-invasive procedure
 avoids unnecessary biopsy

DISADVANTAGE:
 Variation of endometrial thickness with menstrual cycle hence less useful
in pre-menopausal women.
6. DILATATION OF CERVIX
AND CURETTAGE
Consider the age group
Peri-menopausal – mandatory without delay
Reproductive – abnormal USG and biopsy
- failed medical therapy
Pubertal – LAST RESORT
- severe persistent bleeding
- non-responsive to medical therapy

CONTRAINDICATION:
• Any infection
USE:

Esentially DIAGNOSTIC but also THERAPEUTIC

only 60% diagnosed 30-40% cured

 Excludes intrauterine - removes intrauterine path

-removes structurally
diseased fragile endometrium
 Functional state of
endometrium det. Restores normal
haemostasis
 HISTOPATHOLOGICAL PICTURE OF
ENDOMETRIUM
Normal endometrium - 54%
Endometrial hyperplasia - 31%
Irregular shedding - 6%
Irregular ripening - 3%
Atrophic endometrium - 3%

COMPLICATIONS:
• Haemorrhage
• Infection
• Uterine perforation
DILATATION AND CURETTAGE
7. HYSTEROSCOPY
Endoscopic technique of directly
visualizing interior of uterine cavity.
USES AND ADVANTAGE:

Identification of intrauterine pathology even small lesions

identified.
Identification of endometrial atrophy and bleeding from
ruptured venules.
HYSTEROSCOPY GUIDED BIOPSY – Gold standard
investigation of choice.

DISADVANTAGE:

Expensive
Needs skill and experience
 8. UTERINE ASPIRATION
CYTOLOGY

Vibra aspirator, Gravlee’s jet washer, Isaac’s

aspirator & Pipelle aspirator.

ADVANTAGE:
Very simple OP procedure
Avoids anaesthesia

DISADVANTAGE:
Less diagnostic
Not curative
 9. SONOHYSTEROGRAPHY

• Involves transvaginal ultrasound

• Injection of sterile saline improves
visualization.
10. MRI

11. PELVIC ANGIOGRAPHY AND

VENOGRAPHY; COLOUR DOPPLER
Medical Management of DUB :
Objective :
To retrieve the natural controlling influence
that are missing in the endometrium.
Management : depends up on
 age of the patient
 her fertility
 her desire for children
 degree of anaemia
 Medical Management

Harmonal Non harmonal

Progesterone NSAIDS
Estrogen Antifibrinolytics
Contraceptive pills Miscellenous
Danazol Ethamsylates
GnRH analogue
Androgens
Hormonal therapy :
Aim :
 To stop bleeding
 To control the cycle
 To improve the quality of period
PROGESTERONE :
In puberty DUB
 anovulotory
 endometrium - proliferative stage
 No progesterone to start the secretory phase.
Mode of action :
 Causes secretory changes in the endometrium
 Decrease the ER in the endometrium
 Estradiol - estrone sulphate
 Enhancement of stromal matrix
 Heals superficial breaks

It is available as
a) Oral pills – nor ethisterone, MPA
b) Depot formulation – MPA
c) Progesterone containing IUD
a)ORAL PILLS
Dose and Administration :
 5 mg tds, until bleeding stops,
 Dose tapered to 5 mg bd for next 2
weeks
 5 mg od for 1 week
 Withdrawal bleeding occurs in 48 hours
Then for the next 3-6 cycles patient is put on

Whole cycle Rx Luteal phase Rx

Whole Cycle Treatment :
 5mg / day from day 5 to day 25
 withdrawal bleeding follows after the
stoppage of drug
Luteal phase Treatment :
 5mg / day from day 15 – day 25 of the cycle.
 mainly used in ovulatory bleeding
Medical curettage :
Proliferative endometrium  secretory
endometrium  normal shedding
Advantage :
Decrease in 80% of blood loss

Side effects :
 GIT symptoms - nausea, vomiting
 Symptoms of pseudopregnancy state
 Weight gain and depression
 Increased LDL – atherosclerosis
b) DEPOT FORMULATIONS :
Depot MPA : 50 mg i.m at 3 months
interval
Norethindrone : 200 mg i.m at 2 months
interval

Disadvantage :
 Bleeding - heavy
 Systemic side effects more.
c) IUD :
Progesterone IUD include
Progestasert :
 38 mg of progesterone releasing 65 ug of daily
 should be replaced every year.
Mirena :
 52 mg of levonorgestrol releasing 20
ug / day
 Can be left in place for 5 years
Disadvantage of mirena :
 Ectopic pregnancy
 Amenorrhoea

LNG – IUD monthly used, menstrual blood

loss decreases by 21-44% after first 2
months and by 82-96% after 3-12 months
after insertion.
2. OCP
Contains both estrogen and progesterone

Mode of action
 Suppresses FSH & LH
 Atrophic changes in the endometrium
Dose :
 2 tablets od until bleeding stops
 20 – 30 ug ofethinyl estradiol + 0.5 mg of
norgestrol
Benefits
 Contraception
 Reduces the incidence of benign breast
neoplasia, ovarian cyst, uterine malignancy,
PID, ectopic pregnancy.

Advantage :
50% reduction in menstrual blood loss
Contraindications :
 coronary, cerebral vascular disease
 Thrombo embolism
 Genital carcinoma
 Liver disease
 DM, HT, Smokers
Adverse effects :
 Gall stones
 Hepatoma
 Genital Carcinoma
 Thromboembolic disorder
3. ORMELOXIFENE

Mode of action :
ER - Uterus

suppress endometrial proliferation

Dose :
60 mg twice weekly for 3 months - 60 mg
weekly for another 3 months
Side effects :
 Nausea, headache
 Fluid retension
 Weight gain
 Increased BP

4. GnRH ANALOGUE :
 Last drug when others fail
 Depot injection 3.6 mg monthly for 3 months
 Therapeutic dose – amenorrhoea.
Mode of action :
GnRH agonist
Down regulation of pituitary
Decrease FSH, LH
Ovarian function depressed
Hypoestrogenism
Regression of endometrial tissue
Side effects :
 Hot flushes,
 Vaginal dryness,
 Osteporosis,
 menopausal symptoms

Prior to endometrial ablation - reduces

the thickening of endometrium, pseudo
decidual reaction.
5. CLOMIPHENE CITRATE :
SERM
Anovulatory cycles with infertility

6.DANAZOL
Synthetic androgen

Indications :
 When OCP are contraindicated
 When progestrogens produce side effects
Mode of action :

Binds to androgen receptor

Androgen specific MRNA production

Suppression of Gn secretion

Inhibition of ovarian function

Dose :
200 mg daily for 4-6 months
Side effects :
 Complete amenorrhoea
 acne, hirsutism, breast atrophy,
deepening of voice
 Weight gain

Main use of danazol – preop adjunct

7. ESTROGEN THERAPY :
Used in atropic endometrium

Mode of action :
 Increase the threshold level in serum
 Build up the basal endometrium
Drugs :
Estradiol valerate 4 mg / day
Ethinyl estradiol 0.05 mg / day
Premarin 25 mg IV
Disadvantages :
 CVS risk,
 Malignancy of breast and endometrium
8. NEWER DRUGS :

GESTRINONE :
 A derivative of 19-nortestosterone
 Dose : 2.5 mg orally twice weekly or
5 mg vaginal tablet thrice weekly for 6 months

SEASONALE
 Combined estrogen and progestogen
 Daily for 84 days and a gap of 6 days is given in
a 3 monthly treatment.
 SUMMARY
Endometrial Treatment
Histology
Proliferative Acute : High dose progestrogen
Chronic : progestogens
Normal Acute : Antifibrinolytics
Chronic : Low dose oc and or
NSAIDs
Atrophic Emergency : Premarin 25 mg
Acute : unopposed estrogen 21
days, then OC
Chronic : Estrogen dominant OC
NON-STEROIDAL ANTI
INFLAMMATORY DRUGS
ANTI-FIBRINOLYTICS
TREATMENT OF ANEMIA
 NSAID
• MECHANISM OF ACTION:
• Inhibits Cyclo-oxygenase pathway, imparing the
production of vaso dialator PGE2, PGI2.
• Inhibits binding of PGE2 to its specific receptor in
Uterine Myometrium.
• Improve Platelet aggregation, degranulation & vaso
constriction.
• DOSE:
• Mefenamic acid 500mg TDS
• Flurbiprofen 100mg TDS
• Naproxen 500mg BD
• Indomethacin 25mg QID
 Taken during Menstruation
 USE

1.Ovulatory DUB
2.IUCD DUB
 SIDE EFFECTS

• GIT Symtoms.
• Bleeding Time is increased.
• Pruritus, Rashes , Edema.
• Abnormal Renal funtion tests, increased Liver
Enzymes.
 CONTRA INDICATIONS
• Hypersensitivity, Bleeding disorders.
• Compromised Renal function.
• Active Ulceration.
• Chronic inflammation of GIT.
 ADVANTAGE & DISADVANTAGE
• ADVANTAGE:
• Beneficial effects on Dysmenorrhea.
• Low cost.
DISADVANTAGE:
• Limited Efficacy.
• Failure to cure DUB.
• Side effects.
• Poor Acceptability for long term use.
 ANTI-FIBRINOLYTICS
• MECHANISM OF ACTION:
• Prevents Plasminogen activation & Fibrinolysis
& Dissolution of Clot.
 DOSE
• Tranexamic Acid 1-1.5g orally 3-4 times a day
for three to four days.
• SIDE EFFECTS:
• GI symptoms.
• Thrombotic events.
CONTRAINDICATION:
• Renal failure
 MISCELLANEOUS-ETHAMSYLATE

• MECHANISM OF ACTION:
• Inhibits capillary fragility.
DOSE:
• 500mg QID From 5th day prior to anticipated
start of menses to 10 days after.
 It has very less side effects.
 TREATMENT OF ANEMIA
• Blood Transfusion.
• Iron Supplementation.
MINIMAL INVASIVE

PROCEDURE
A.KAVITHA
• Hystrectomy-100% success rate
• Disadvantages
the diseased organ is only
endometrium

• Long term complications – urinary

dysfunction, cvs problems
• So better choice is MIS
 MIS

• An alternative to hysterectomy when medical

management fail
• The idea for this procedures evolved from
pathology that happens in Ashermann
syndrome leading to amenorrhea
• The basic principle is ablation of endometrium
INDICATIONS CONTRAINDICAIONS

•Intractable uterine •Uterine size>12wks

bleeding •Any pathology in uterus
•Coagulopathies-risk •Pregnancy
for hysterectomy •Acute pelvic
•Age >40yrs inflammation
(completed family) •Scarred uterus
•Not willing for
hysterectomy
PREREQUISITE
• preoperative thinning of endometrium –
danazol 200 mg tds -6 wks,
Gnrh analogues 3 months
• Immediate Post menstrual period – endometrial thickness < 3 cm

PRE OPERATIVE PREPARATION:

• Evaluate completely and rule out CI

INTRA OPERATIVE:
• Anaesthesia – GA or regional
• Position – dorsal lithotomy
 • Under
HYSTEROSCOPE
• Distension medium-
1stGeneration irrigate

OBJECIVE of Ablation is to cause thermal

damage to the basalis layer of endmetrium
 ABLATION BY Nd-YAG LASER
• Distension-saline
• 5mm destroyed
• SUCCESS RATE-95%
• ADVANTAGE
– More precise
– Lesser complication
 ELECTROSURGERY

TCRE
•‘U’ shaped loop
•3-5mm myometrium resected
•SUCCESS RATE
50%Amenorrhoea
96%Hypomenorrhea
• ADVANTAGE

Cheap,sampling,low failure
rate
 ROLLER BALL
ENDOMETRIAL
ABLATION
ROLLER BALL
••2-4MM
2-4MM
ball/barrel/ovoid
ball/barrel/ovoid
••Uniform
Uniformvapourisation
vapourisation
••FAILURE
FAILURERATERATE5-10%
5-10%
••ADVANTAGE
ADVANTAGE
Low
Lowrate
rateof
of
perforation
perforation
Short
Shorttime
time
 COMPLICATION
• Perforation
• Haemorrhage
• Gas embolism
• Infection
• Damage to vessels,bowels,urinary bladder
• Fliud absorbtion-lead to
HT,Hyponatremia,neurological symptoms,haemolysis
and even death
Hence,fluid input/output should be monitored
 •No hysteroscope
•No distention media
•Risk of 1st generation tech
2ndGeneration minimised
THERMOCHOICE OR CAVARERM BALLOON
THERAPHY
• Central computer system with disposable silicon
balloon catheter 5mm
• Insert
• Inflate balloon- 5%dextrose+water
circulate
• Heat-87deg for 8min and deflate
• ADVANTAGE
– Low complications
– No special skill
– Effective and safe 85% success rate
 NOVASURE/Impedense controled
electrocoagulation
• Disposable 3D fan shaped fabric like
expandable with metallic skeleton is used
• Outer sheath removed
• With high frequency electro generator
electrocoagulation is done
NOVASURE
 No HYSTROSCOPE
Even no distention
media
Only probe is used

3rdGeneration
MICROWAVE ENDOMETRIAL ABLATION

• Magnetic energy-9.2GHz
• 8mm applicator
• Temp 80 deg -3min
• 6mm destroyed
• ADVANTAGE
– No bleed,no fluid load
 OTHER PROCEDURES

• CRYOABLATION
• RADIOFREQUENCY INDUCED
THERMAL ABLATION
• HYDROTHERMAL
• ELITT-Endmetrial LASER Intrauterine
Thermotherapy
 POST OPERATIVELY

• Rapid recovery
• Normal diet
• May be bleeding slighty-serosanguinus
discharge-profuse watery discharge
SURGICAL MANAGEMENT OF
DYSFUNCTIONAL UTERINE
BLEEDING

K.KABILAN
SURGICAL MANAGEMENT OF DUB
• DUB is usually controlled by medical line of
management
• The need for surgical management arises
when there is a failure in medical line of
management
 An overview of Management of Menorrhagia
Menorrhagia

Young women Older women

Rule out uterine pathology and cancer

Pregnancy desired Pregnancy not desired
•Progestogens •COC Normal uterus Uterine pathology
•Ethamsylate •Progestogens (DUB)
•NSAID •Mirena
•GnRH 3-4 months •Medical theraphy
•COC contraindicated
over 40 years

Effective Fails No response

•MIS
Continue for 6-9
•Hysterectomy Hysterectomy with
months and oopherectomy after
follow up with conservation Surgery
of ovaries 50 years (No MIS)
 SURGICAL MODALITY
Hysterectomy
Abdominal
Vaginal
Laproscopic
Laproscopic assisted vaginal hysterectomy
Ovaries must be preserved in patients age
below 50yrs
 Indications
• Failure of medical line of management and
MIS.
• Family history of uterine malignancy.
• Premalignant endometrial pathologies.
 ABDOMINAL HYSTERACTOMY
Abdominal hysterectomy is preferred when
extensive adhesions are anticipated
Advantages:
• Good access and better visualisation.
• Technically easy.
• Less time consuming.
• No need of advanced instrumentation as in
laproscopic procedure
• P.Op bleeding and bladder injury are less in
compare to vaginal hysterectomy
• Anatomical relations not altered.
Disadvantages:
• Patient recovery prolonged.
• Prolonged hospitalisation.
• Incisional pain.
• P.Op wound infection.
• Uretral injury.
• Risk of developing hernia.
 VAGINAL HYSTERECTOMY
“ Gynaecologist route”

This approach preffered when

extensive adhesions are not
anticipated.
Pre-requesties:
• Uterus size <12 cms.
• Mobile uterus without
adhesions;vallsellum traction test
positive.
• No adnexal tumour or pathology
Advantages:
• Faster recovery
• Reduced hospital stay
• No risk of developing hernia
• Peritoneum minimally opened, no bowel
handling hence less post operative illness
• Bowel function returns soon
• Quick ambulation
• Less post-operative infection
• Least invasive route
Disadvantages:
• Pelvic infection
• Vesical injury, fistula
• Vaginal shortening and stenosis
• Recurrent cystocele, rectocele, entrocele
• Vault prolapse
• P.Op bleeding Haemorrhagic shock
LAPROSCOPIC HYSTERECTOMY
&
LAVH
Advantages:
• Faster patient recovery
• Reduced hospital stay
• Less post operative pain
• Less wound infection
• Provides better visualization and access to
abdomen and pelvis
Disadvantages:
• Time consuming
• Expensive
• Require better surgical skills
DYSFUNCTIONAL UTERINE BLEEDING

Management at Pubertal Age Group

K NAVANEETHARAN
I UNIT OG
 ETIOLOGY

• MAJOR

Immature hypothalamo-pituitary axis

• excess/unopposed estrogen
• absent progesterone in
anovulatory cycles

MINOR

o coagulation disorders
o blood dyscrasias
o hypothyroidism
FACTORS DETERMINING THE CHOICE OF TREATMENT

◦ Age

◦ Parity

◦ Histopathological changes in Endometrium

◦ Need for contraception

◦ Availability of treatment option

TREATMENTOB
JECTIVES

3
Prevention of
2 recurrence
Normalizing cyclical rhythms
1
Early control of excessive bleeding
 Management
Assessment
• ASSESS THE SEVERITY
- Hb %, hematocrit
-Menstrual history (last menstrual period, frequency,
duration, flow, pain)

 CATEGORIZED AS

• MILD (Hb >10g%)

• MODERATE (Hb = 8 to 10g%)

• SEVERE (Hb < 5g%)

MILD PUBERTAL MENORRHAGIA

◦Reassurance

◦Maintenance of menstrual calendar, pictorial bleeding

assessment chart & assessment of menstrual blood loss
◦Iron & Vitamin Supplementation

◦Periodic re-evaluation
MILD (..contd)
• No Specific treatment required
• Normal menstrual pattern occurs spontaneously
within 1 or 2 years
 MODERATE PUBERTAL MENORRHAGIA

oHigh dose progestogen

o Norethisterone acetate
o 1st 48hrs 5-10mg tds
o Next 2 weeks 5-10mg bd
o Next 1 week 5-10mg od
o Then stop the drug

 Progestogen – Cyclical / Luteal Phase

 Administered for 3-6 months
 10mg/day for 10 days/month
 Re-evaluation after stopping the drug
 SEVERE PUBERTAL MENORRHAGIA

o ADMISSION OF THE PATIENT

o Blood Transfusion
o RULE OUT

Hypothyroidism-thyroid profile

Bleeding diathesis - FBC, platelet count, bleeding time, PTT,vwf antigen

oTo Achieve Hemostasis
oHigh dose progestogen
o Norethisterone acetate
o 1st 48hrs 5-10mg tds
o Next 2 weeks 5-10mg bd
o Next 1 week 5-10mg od
o Then stop the drug

oTo Regularise Menstrual Cycles

oCyclical progestogen for 6 months or longer

oRe-evaluation upto 12 months or longer if necessary

 OTHER DRUGS

OCP-20-30 microgram tabs

tranexemic acid 500-1000 mg 8 hourly

mefenemic acid 500 mg tds for 6 days

GnRH-leuprolide -3.75 mg im monthly for 6 months

• DILATATION AND CURETTAGE (D&C)

– Last resort

– To rule out Tuberculous Endometritis (4% of

cases)
MANAGEMENT

OF
DUB
IN
REPRODUCTIVE
&
PERI

MENOPAUSAL
 Reprodutive age group ( 20-39 years)

 Exclude pregnancy disturbances and

conditions like Fibroid uterus,
Endometriosis,PID,Functioning ovarian
tumour

 Dilatation & Curettage- 60% therapeutic

 Medical treatment
- Oral contraceptive pills
- NSAIDS-Mephenamic acid
-Anti-Fibrinolytics
-Hormones
Progestogens: Oral/Parenteral/

Intra-uterine devices
Danazol
DUB associated with infertility
1. Clomiphene
2. GnRH agonists
 OCP ANTI-FIBRINOLYTIC

PROGESTOGEN GnRH analogues

 Surgical Management
-Conservative:
MIS techniques like
Hysteroscopic endometrial ablation,
Non-hysteroscopic endometrial ablation
- Definitive:
Hysterectomy
 PERIMENOPAUSAL AGE GROUP
( > 40 YEARS)
 Exclude Malignancy
 Fractional curretage – Mandatory
 Hysterectomy- Treatment of choice