Dysfunctional uterine

bleeding (DUB)
Alex Brooks, Feb 24
Gynae Hx

 PC
 HPC
 Past Gynae and Obs Hx
 PMH
 Allergies
 Drugs !Don’t forget OTC or overseas sourced
 Smoking
 Social hx
 Family Hx
 Summary
Dysfunctional uterine bleeding

 DeKned as unexplained menorrhagia

 Heavy and/or irregular bleeding, may be ovulatory or anovulatory
 Cause of heavy menstrual bleeding in 40-60% of women with
menorrhagia
 One in 20 women aged 30–49 years consult their GP each year for
heavy menstruation
Let’s backtrack – what is
menorrhagia?
 Excessive (heavy) menstrual blood loss over several consecutive
cycles which interferes with a woman's physical, emotional, social, and
material quality of life

 In research, it is usually deKned as an objectively measured blood loss of

60–80 mL or more per menstruation (the average blood loss is 30–
40 mL, and 90% of women have losses less than 80 mL)

 However, objective measurements of menstrual blood loss are not

practical in the clinical setting, and they correlate poorly with a woman's
subjective assessment of blood loss and its impact on quality of life
IdentiKable causes of menorrhagia
 Uterine and ovarian pathologies
 Fibroids
 Endometriosis and adenomyosis
 Endometrial polyps, hyperplasia, carcinoma
 PCOS
 Pelvic infection
 Systemic diseases and disorders
 Coagulation disorders
 Hypothyroidism
 Renal or liver disease
 Iatrogenic
 Anticoagulants
 IUCD
 chemotherapy
Complications

 Negative eaect on quality of life

 Limits normal activities, work and social life
 Mood changes
 Low mood, self consciousness
 Negative eaect on sex life/relationships
 Iron-deKciency anaemia (aaects about 2/3 of women with menorrhagia)
 Menstrual history

 Age at menarche, details about menstrual cycle, length of cycle, the number of days of menstruation, for
how long she has considered her periods to be heavy, what her periods were like previously, and the impact
on quality of life

 Enquire about symptoms that suggest an underlying pathology, particularly 'red bag' symptoms (for example
persistent intermenstrual or postcoital bleeding)

 Consider the possibility of an underlying systemic disease, such as hypothyroidism or a coagulation disorder
(for example von Willebrand disease)

 Take a family history, and in particular ask about endometriosis and coagulation disorders that may have a
hereditary component

 Check smear status

 Ask about current contraceptive use, contraceptive plans, and future plans for a family
Underlying pathology?

 Symptoms that may indicate an underlying pathology include:

 Persistent postcoital bleeding.
 Persistent intermenstrual bleeding.
 Dyspareunia.
 Dysmenorrhoea.
 Pelvic pain and/or pressure symptoms.
 Vaginal discharge.
Examination

 Abdominal and pelvic examination in the following women:

 Women with symptoms suggestive of underlying abnormalities,
before further investigations are arranged.
 Those in whom initial treatment has proved ineaective.
 Those for whom the levonorgestrel-releasing intrauterine system is
being considered.
 A pelvic examination should include:
 Vulval examination for evidence of external bleeding and signs of
infection (for example vaginal discharge).
 Speculum examination of vagina and cervix. High vaginal,
endocervical, and chlamydia swabs should be obtained if infection is
suspected.
 Bimanual palpation to identify uterine or adnexal enlargement or
Investigations

 Bloods
 FBC (Fe deKciency anaemia)
 Clotting proKle if appropriate
 TFT if appropriate
 Smear if appropriate
 STI screening if appropriate
 Pelvic ultrasound
 If uterus palpable abdominally, pelvic mass on VE, symptoms suggestive of
underlying cause or previous Rx ineaective
 Secondary care – hysteroscopy /endometrial sampling
Rapidly stopping heavy bleeding

 Oral norethisterone, 5 mg three times daily for 10 days, usually stops

bleeding within one to three days. Inform the woman that a withdrawal bleed
will occur two to four days after stopping treatment.
 If bleeding is exceptionally heavy ('booding'), 10 mg three times daily (oa-
label dose) may provide better results (get informed consent). This should
then be tapered down to 5 mg three times daily for about a week once
bleeding has stopped.
Management

Medical (pharmaceutical) treatment Krst-line

 If no symptoms suggestive of underlying pathology (PCB, IMB,
dyspareunia, dysmenorrhoea, discharge, pelvic pain)
 While awaiting results of Ix
Medical management

 First choice
 Levonorgestrel-releasing IUS
 Second choice
 Tranexamic acid (antiKbrinolytic)
 NSAID (mefenamic acid, naproxen, ibuprofen; good if also dysmenorrhoea)
 COCP (regulates cycles, helps dysmenorrhoea, more readily reversible than IUS)
 Third choice
 Oral NET days 5-26 of cycle
 Depot progestogen
 (GnRH analogues only in secondary care)
Management – when initial treatment
ineaective
 Switch to an alternative pharmaceutical treatment. Oral norethisterone or
depot medroxyprogesterone are often suitable if initial treatment was
ineaective.
 Add on an additional drug. Typically, tranexamic acid can be combined with a
nonsteroidal anti-inbammatory drug (NSAID), or an NSAID can be combined
with the combined oral contraceptive.
 Consider IUS (Mirena) – 90% amenorrhoea after 1 year
Referral to secondary care

 Possible malignancy – 2WW referral

 Failed treatment in primary care
 Surgery requested
 Individual funding for each hysterectomy not related to malignancy

 Persistent anaemia
 Menorrhagia in the ED
 Pregnancy test (12 -55yrs)

 Assessment of bleeding – how much

 Look at pad. ?double protection

 Observations – compromise?

 Almost never admitted, care via GP

 Consider norethisterone 5mg tds 10/7

Surgical treatments

 Always second-line options

 Reserved for cases where medical Rx has failed or is contraindicated
 Endometrial ablation
 Hysterectomy
Endometrial ablation

 Destruction of endometrium and superKcial myometrium

 Not suitable if woman would like to have children in future or previous
multiple Caesareans
 First generation techniques use electrosurgical loop or heated rollerball
(now only recommended when hysteroscopic myomectomy needed, for
Kbroids <3cm)
 Newer techniques involve microwaves, radio waves, cryotherapy,
thermal balloons
Endometrial ablation
Rollerball ablation vs. Novasure

 https://youtu.be/tIG7jFhRbT8

 https://youtu.be/G3ie1mIUQ4U
Hysterectomy

 +/- salpingectomy,Bilateral Salpingo-oophorectomy

 Open (rare)/ Vaginal / Laparoscopic / Laparoscopic assisted
 https://www.youtube.com/watch?v=v7ZTrbHckIk

 Incredible surgery to remove over 100 Kbroids | Your Body Uncovered Wi

th Kate Garraway - BBC (youtube.com)
NICE Guidance NG88
(Heavy Menstrual Bleeding)
 https://wisdom.nhs.wales/all-wales-guidelines/all-wales-guidelines/hmb-s
hared-decision-making-aid-updated-version-mar-2020-pdf/

 Guidance at
Overview | Heavy menstrual bleeding: assessment and management | G
uidance | NICE