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Pathophysiology
DUB is most common near the beginning and end of a woman's reproductive life, but may occur at any
time. In the first 1 months after menarche, the immature hypothalamin!pituitary a"is may fail to respond
to estrogen and progesterone, resulting in anovulation.#,$ In obese women, the non!ovarian endogenous
estrogen production may upset the normal menstrual cycle.% &s menopause approaches, decreases in
hormone levels or in responsiveness to hormones also may lead to anovulatory DUB. Potential causes of
vaginal bleeding are shown in 'able 1.

Table 1. Causes of dysfunctional uterine bleeding.
Endocrine
(ushing's disease
immature hypothalamin!pituitary
a"is
hyperprolacinemia
hypothyroidism
menopause
obesity
polycystic ovary disease
premature ovarian failure
Stuctural lesions
adenomyosis
coagulopathies
condyloma acuminata
dysplastic or malignant lesion of the
cervi" or vagina
endometiosis
endometrial cancer
uterine or cervical polyps
uterine leiomyomata
trauma
Infections
chlamydia
gonorrhea
PID
Medications
hormonal agents
low!dose oral contraceptive pills
)*(Ps+
nonprogestin!containing IUDs
nonsteroidal anti!inflammatory drugs
),-&ID-+
,orplant -ystem
progestin!only contraceptive )the .mini pill.+
tamo"ifen
warfarin
Pregnancy
ectopic pregnancy
incomplete abortion
pregnancy complications
/ost cases of DUB are caused by anovulatory cycles that result in high steady!state estrogen with no
progesterone.l,%,0 'he continuous estrogen stimulation causes continuous development of the functionalis
layer until estrogen feedbac1 produces a slow drop in 2-3. 4ventually, the blood supply is outgrown and
parts of the endometrium slough. 4strogen, however, promotes healing of the endometrium so some parts
are always healing as others slough, resulting in menometrorrhagia.#,$
& luteal phase deficiency also may result in DUB. It is characteri5ed by a shortened luteal phase from
insufficient progesterone production or effect.0,6 'he insufficient progesterone stimulation may be
coe"istent with high, low, or normal estrogen levels and often will result in similar problems in anovulatory
cycles. 'his problem, along with the loss of 73 surge, may be especially prominent in amenorrheic
athletes.0!
&nother mechanism of DUB, especially in patients who are 89 years old and older, is diminishing number
and :uality of ovarian follicles. 2ollicles continue to develop but do not produce enough estrogen in
response to 2-3 to trigger ovulation. 4strogen continues to be produced, which usually results in late cycle
estrogen brea1through bleeding.1,#
Improper balance of estrogen and progesterone may result in DUB. It may result in low estrogen states
from low!dose oral contraceptive pills )*(Ps+, resulting in insufficient build up of stable endometrial
lining, with resultant prolonged light bleeding.$!; DUB can also be caused by high progestin activity oral
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contraceptive pills.$ 'hese patients will often need a higher level of estrogen or a lower activity progestin.;
Bleeding irregularities are very common with the ,orplant -ystem, depo!medro"yprogesterone in<ection,
and the .mini pill,. which is often the reason these contraceptives are discontinued.19,11 ,onprogestin!
containing IUDs also may cause DUB.8 ,onsteroidal anti!inflammatory drugs ),-&ID-+ or supplemental
estrogen as described below may help with this side!effect.
4ndocrine disorders also may cause DUB. 3yperprolactinemia inhibits production and release of
gonadotropin!releasing hormone. Polycystic ovary disease often presents as anovulatory cycles resulting in
DUB.% 3ypothyroidism, hyperthyroidism, and (ushing's disease can be associated with DUB.8,1# 2inally,
premature ovarian failure may be a factor in patients who present with DUB.%
Postcoital bleeding usually indicates a structural lesion of the cervi" or vagina.1 Infectious etiologies such
as chlamydia and gonorrhea must be e"cluded or treated. Uterine or cervical polyps also may be a source of
bleeding.8 Dysplastic or malignant lesion of the cervical or vaginal epithelium may cause irregular or
postcoital bleeding.#,8
&n enlarged uterus may be caused by adenomyosis, uterine fibroids, endometriosis, or pregnancy.#,8,1$
-ubmucosal myomas and endometrial polyps are associated with DUB in both premenopausal and
postmenopausal women.1$ 4ctopic pregnancy and pregnancy complications also must be ruled out. & high
inde" of suspicion for the possibility of pregnancy must be maintained.#,8 4ndometrial cancer should be
e"cluded, especially in older and high!ris1 patients with this symptom.1,#,8
4ndometrial (ancer
*ne of the most important goals in wor1!up of DUB is to rule out endometrial cancer, especially in older
women. Development of endometrial cancer is related to estrogen stimulation and endometrial hyperplasia.
=is1 factors are shown in 'able #. -ymptoms include postmenopausal bleeding, which is usually
considered endometrial cancer until proven otherwise.18 Bleeding prevalence may be as high as 1>$ of
cases, and the presence of uterine myomas should ,*' delay appropriate wor1!up. *ther symptoms may
include metrorrhagia, lower abdominal pain or pressure, and )rarely+ bac1 pain or lower e"tremity edema
secondary to metastasis.
(linical findings most commonly are a normal e"am of vagina, uterus, and cervi", although advanced
disease may be associated with enlarged uterus or pelvic mass. (ervical and vaginal metastasis can cause
cervical stenosis, pyometra, or a mucosanguineous vaginal discharge. =egional metastasis may present as a
bladder or rectal mass.

Table ". is# factors for endo$etrial cancer. 81!86 % & relati'e ris#(
&ge ! 6%? of cases occur after menopause
with pea1 incidence in the late 09s.
*besity ! especially upper body fat. 'his may
be secondary to increased estrogen production and
bioavailability.
Polycystic ovary disease.
Unopposed e"ogenous estrogen.
@hen progestins are added )oral contraceptives
== )age A 09 years+ B %.#

==B $ to 19


== B %.#
== B # to 18
==B 9.% to 1
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or with replacement therapy+, relative ris1 is less
than for the general population.
Diabetes )all types grouped+.
Personal or family history of ovarian or breast
cancer. @omen who are overweight and have
had breast cancer are at even greater ris1.
,ulliparity.
7ate menopause.
'amo"ifen therapy ! Use for greater than one
year is an independent ris1 factor.


== B # to #.




== B 1.$
== )entering menopause after age %#+ B #.%
== B 6.%
4valuation
4valuation of DUB emphasi5es establishing the cause and ruling out endometrial cancer. & typical
algorithm )2igure #+ begins with a thorough history. Important factors to document include patient's age,
last menstrual period, last normal menstrual period, amounts and duration of bleeding, postcoital bleeding,
medications )especially hormonal agents, ,-&ID-, or warfarin+, history of any endocrine abnormalities,
symptoms of pregnancy, symptoms of coagulopathies, contraceptive history, and history of trauma.
Ceneral physical e"amination should focus on symptoms of endocrinopathies, including polycystic ovary
disease )including obesity and hyperandrogenism+, hyperprolactinemia, and hypothyroidism.# Pelvic
e"amination is unnecessary in oligomenorrheic patients who are not se"ually active and are within 1
months of menarche.$ *therwise, gynecologic e"amination includes inspection of the vagina and cervi" for
physical lesions )polyps, leiomyomata, tears, malignancy, or incomplete abortion+ or infection. 'he si5e,
shape, position, and firmness of the uterus should be e"amined. ,ote any signs of e"cessive blood loss.
Basal temperature charting may assist in determining when and whether ovulation occurs, if the patient will
cooperate with testing. 'he patient may ta1e her temperature any time during the day as long as she is
consistent from day to day. & rise in basal temperature of 9.$
D
( to 9.0
D
( is indicative of ovulation. 'his
determination may also be made using serum progesterone determination in the luteal phase, with a level
greater than $ mg>m7 indicating ovulation has occurred.#


Table ). *aboratory tests to consider for +U,. Testing s-ould be indi'iduali.ed
based on eac- /atiet0s -istory and /-ysical findings.
Test Indication %to rule out(
urine pregnancy test
(B(
P'>P''
Pap smearE
2-3
liver function tests
'-3
prolactin level
pregnancy
anemia
coagulpathy )especially in adolescents
cervical cancer
A 89IU>7 suggests ovarian failure
liver disease
thyroid disease
pituitary adenoma )with breast discharge+
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D34&- polycystic ovary disease
E if there is no evidence of infection and it is indicated

Diagnostic 'ests
Endo$etrial bio/sy %EM,( is the most commonly used diagnostic test for DUB )pages 16 !1;+. It
provides an ade:uate sample for diagnosis of endometrial problems in ;9? to 199? of cases,1%,10 but may
fail to detect polyps and leiomyomas.16 It is indicated in all women with DUB who are $% years of age or
older, since their ris1 of developing malignancy is much higher.#,$ &ny woman with amenorrhea for one
year or longer who e"periences uterine bleeding also should have an 4/B.# 'he newer slim endometrial
suction currettes )Pipelle+ produce samples comparable to older, more traumatic methods but with less
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pain.1,$,1%,10,1 -ampling should be performed late in the cycle if possible, so it can be determined if ovulation
has ta1en place.$
Uterine ultrasound, especially trans'aginal ultrasonogra/-y )'F!U-+, can give information about
suspected structural problems including fibroid tumors.#,16,1; It is classically indicated when physical e"am
indicates anatomic gynecologic abnormalities, especially of the ovaries where other methods provide poor
information.1; 'he endometrial stripe assessment on 'F!U- can provide information about the ovulatory
stage of the endometrium that has a ;$? correlation with hystological diagnosis.1; &n endometrial
thic1ness measurement of less than 8 to 6 mm is rarely associated with cancer, and endometrial sampling
may not be necessary in such patients.16, #9, #1
+ilatation and curettage )DG(+ allows more e"tensive sampling of the uterine cavity and has the
advantage of being both diagnostic and therapeutic. It may be the treatment of choice when bleeding is
severe or necessitates blood transfusions. # It has a higher sensitivity than endometrial biopsy, especially
with smaller in!situ lesions. It is often used when 4/B is inade:uate, the cervical os is stenotic, or DUB
treatment fails. 1, $, 1 @hen DG( is combined with endometrial biopsy, the detection rate approaches
199?. 2ractional DG( is usually not used in teenagers, because they rarely have endometrial cancer and
the procedure may damage the cervi" or uterus. % It is currently re:uired for the staging of occult cancer. 18,
##
1ysterosco/y can be used in place of DG( for most indications, and allows for direct visuali5ation of the
endometrial cavity with directed biopsy. 3ysteroscopy is more sensitive than fractional DG(, especially at
diagnosing polyps and submucosal leiomyomas, but it may miss endometritis. #$, #8 @hen combined with
4/B, it has almost 199? accuracy in diagnosing endometrial dysplasia and cancer. #8 It may eventually
become re:uired for staging of occult cancer. 7i1e 4/B, it often can be performed in the office setting and
may be used for treatment of DUB )see below.+ #8
'reatment
'here are medical, surgical, and combined methods of treating DUB. 'he choice of approach depends on
the cause, severity of bleeding, patient's fertility status, need for contraception, and treatment options
available at the care site. & typical algorithm for the treatment of mild to moderate DUB is shown in 2igure
$.
(ases of acute, heavy, uncontrolled bleeding should be treated with intra'enous estrogen, #%mg every 8
hours, to a ma"imum of $ doses or until bleeding stops )'able 8.+ #% Oral con2ugated estrogen also may be
given in divided doses up to 19mg per day, although this regimen often causes nausea and vomiting. In
less severe cases, con<ugated estrogens at doses of #.% to %mg per day stops the bleeding over #8 to 8
hours. =egardless of which regimen is used, it should be followed by con<ugated estrogen at 1.#% to #.%mg
plus 19mg of medro"yprogesterone per day for about 19 days. @ithdrawal bleeding should then occur as
all drugs are withdrawn. $ In postmenopausal women, continuous estrogen therapy with con<ugated
estrogens )9.0#% ! 1.#%mg+ plus cyclic medro"yprogesterone )19 mg + for 19 ! 18 days of each month may
be continued. $ 'his regimen wor1s best in patients with atrophic epithelium. 1
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Table 3. Medical T-era/ies for +U,. 1,#,$,1#,#;
T-era/y Co$$ents
/edro"yprogesterone )Provera+ 19
mg
P*>day for 19 to 1# days
Depo!medro"yprogesterone 1%9 mg
I/ every $ months
Progesterone in oil 199 ! #99 mg I/
Progestine!only oral contraceptives
pills
*ral contraceptive pillls up to Hid for
% to 6 days or until bleeding stops

Intravenous estrogen #% mg H8 hrs!!
ma"imum of $ doses or until bleeding
stops
*ral con<ugated estrogen )Premarin+
divided doses up to 19 mg>day

*ral con<ugated estrogen )Premarin+
#.% to % mg>day

(on<ugated estrogen 1.#% mg>day
(on<ugated estrogens 9.0#% to 1.#%
mg
H day plus cyclic
medro"yprogesterone 19 mg for 19 to
18 days each month
(lomiphene citrate )(lomid,
-erophene+
Progesterone!containing IUD
,-&ID- ,apro"en ),aprosyn+ %99
mg BiD, menfenamic acid )Ponstel+
%99 mg 'iD,
ethamsylate %99 mg HiD
Dana5ol )Danocrine+ #99 to 99
mg>day
@or1s well to correct midcycle spotting and when
the 4/B demonstrates proliferative endometrium.
&lso provides contraception.



&lso provides contraception.
2or acute moderately heavy bleeding. 'he rest of the pills may then
be ta1en H day until the pac1 is completed, followed by an additional
# months of *(Ps.
2or acute, heavy, uncontrolled bleeding.

2or acute, heavy, uncontrolled bleeding. *ften causes nausea and
vomiting. -hould be followed by con<ugated estrogen 1 .#% to #.% mg
plus 19 mg of medro"yprogesterone per day for about 19 days.
2or less severe bleeding. *ften causes nausea and vomiting. -hould
be followed by con<ugated estrogen 1.#% to #.% mg plus 19 mg of
medro"ygesterone per day for abouth 19 days.
Used for DUB and patients with low!dose *(Ps with midcycle
spotting.
Used in treatment of peri! or postmenopausal women.
/ainly used for chronic DUB. Cood for patients who desire
pregnancy.


4ffective for long!term use. /uch e"perience with long!term use for
other problems. @atch for CI and renal side!effects.
&ndrogenic side!effects limit use. &cts as anti!estrogen and prevents
ovulation.
Primarily used to thin the endometrium prior to surgery. Used when
hormonal methods have failed or are containdicated. /ay cause
ospeporiis the chrnoic use, DUB will also recur in up 19 19Iof
women treants
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for $ to 0 months
Cn=3 agonists goserelin acetate
)Jolade"+, $.0 mg -H every # daysK
leuprolide
acetate )7upron+ or nafarelin acetate
)-yneral+
In cases of moderately heavy DUB, oral contrace/ti'e /ills %OCPs( may be given up to four times a day
for % to 6 days or until bleeding stops. #, $ 'he rest of the pills may then be ta1en once a day until the pac1
is finished and withdrawal bleeding occurs. In anovulatory patients, this is followed by an additional #
months of *(Ps as usually prescribed. 'his regimen will stabili5e the epithelium, slough e"cessive build!
up, and provide contraception. *(Ps may also be started initially at one pill every day in milder cases of
DUB. # ! 8, 6 If the patient is already on *(Ps and e"periencing DUB, a change to a higher estrogen activity
*P( is indicated. $
Medro4y/rogesterone %Pro'era( at 19mg P* per day for 19 to 1# days has traditionally been one of the
most common methods used to control DUB. 'his .medical curettage. wor1s well to correct midcycle
spotting and when the 4/B demonstrates proliferative endometruim. 1 ! $ Depo!medro"yprogesterone
)1%9mg+ or progesterone in oil )199 ! #99mg+ may be given intramuscularly to achieve similar effects. #, $
'he progestin!only contraceptive pills also wor1 well and, li1e depo!Provera, have the added benefit of
providing contraception. $ Breast tenderness and mood swings are possible side!effects of therapy. 'hese
regimens wor1 especially well with chronic or milder acute DUB. Progestin!containing IUDs, together
with oral or transdermal estrogen, may control DUB in postmenopausal patients. #0, #6
Nonsteroidal anti5infla$$atory drugs ),-&ID-+ can decrease DUB, probably through inihibition of
prostaglandin synthesis. #6 ,apro"en ),aprosyn+ %99mg twice daily, mefenamic acid )Ponstel+ %99mg
three times daily, or ethamsylate %99mg four times a day has been shown to decrease menstrual flow. # ! $9
*nce bleeding is controlled, ,-&ID- need only be used during menstruation. #6 'hese drugs are safe for
long!term usage, and the long!term effects are well studied. &spirin does not appear to be effective. 8
'he androgenic synthetic steroid dana.ol %+anocrine(, which is traditionally used to treat endometriosis,
can be used to treat DUB. -imilarly, the Cn=3 agonists goserelin acetate %6olade47( leu/rolide acetate
%*u/ron7( or nafarelin acetate %Syneral( induce a hypogonadotropic state which stops dysfunctional
bleeding. #6, #, $1 'hey all produce hypogonadism and induce ammenorrhea. Because of their side effects,
these drugs are used when hormonal methods have failed or are contraindicated. 'hese agents are primarily
used to thin the endometrium prior to surgical intervention. 8, 1#, $1 ! $8 =esearch involving estrogen and
progesterone .add bac1. therapy may provide a means of overcoming the long! and short!term side!effects.
#6, $1, $%, $0 DUB will recur in up to %9? of women treated.
+ilatation and curettage )DG(+ may ameliorate DUB, as well as diagnose potential dysplasia or
malignancy. It is sometimes avoided in adolescents because of concerns about possible infertility.
=epeated procedures may result in intrauterine adhesions. 1#
Neody$iu$8yttriu$5alu$inu$5garnet %Nd8Y!9( laser endo$etrial ablation is a newer method of
surgically treating the endometrium. It has a success rate of appro"imately %? and is more effective in
patents over the age of $% years. $6 &menorrhea may occur in #;? of patients. 'here is some concern that
cancers could be missed, since no tissue is available for pathologic study. $6 Possible ris1s include fluid
overload, endometritis, and uterine perforation. $6 7aser e:uipment is e"pensive and re:uires special
safety precautions. 8
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1ysterosco/ic transcer'ical resection of t-e endo$etriu$ %TCE( ma1es use of an electrocautery loop
or ball to remove or coagulate the endometrium to stop DUB. It may reduce the need for hysterectomy by
up to ;9?, #;, $, $; and has been shown to have a lower overall procedure cost )including retreatment costs
and eventual hysterectomies+ than immediate hysterectomy for more severe DUB. $$ 'he goal is to ablate
the endometrium and encourage endometrial adhesions resulting in hypo! or amenorrhea. 'he
hysteroscope is considerably less e"pensive to buy and maintain than the laser but carries the ris1s of fluid
overload, endometritis, and uterine perforation. #8, $8, #;, $ 'he potential fluid overload problem can be
alleviated by the use of carbon!dio"ide gas or De"tran 69 solution to distend the uterus. #8 3ysteroscopy is
most effective in women who are over the age of $%, and postmenopausal 3=' may be safely started or
continued in patients after endometrial ablation. #;, $; 'here have been $ reported cases of adenocarcinoma
diagnosed after endometrial ablation for DUB. 89, 81
'he enometrium may also be hysteroscopically ablated via the insertion of a t-er$al uterine balloon. 'he
system consists of a control system attached to a 10cm by %mm catheter with a late" balloon on the end that
houses a heating element. & sterile %?de"trose solution is instilled until the pressure reaches between 109
and 19mm3g. 'he solution is heated to 6 degrees (. for minutes and then the device is removed. 'he
treatment has been fount to be as efficatious as roller!ball ablation with less complications. 81a
1ysterecto$y remains the most absolutely curative treatment for DUB. 4lective hysterectomy has a
mortality rate of si" per 19,999 operations. *ne randomi5ed study found that hysterectomy was associated
with more morbidity and much longer healing times than endometrial ablation. 1# 2ortunately, a recent
study found that se"ual functioning improved overall after hysterectomy with an increase in se"ual activity
abd a decrease in problems with se"ual functioning. 8 It still remains a popular method of treating DUB,
especially in industriali5ed countries.
###
Treatment
DUB is usually painless and is generally not a problem unless the woman is upset by the bleeding or is
trying to conceive.
3ormone therapy typically involves oral contraceptives or progesterone therapy to regulate bleeding
patterns. 'reatment depends on the patient's age and the severity and timing of the bleeding.
e$o'al of t-e endo$etriu$
If hormone therapy is not effective, the endometrium may be removed. 4ndometrial ablation is usually the
method of choice, although some patients choose a hysterectomy or D G (.
Endo$etrial ablation
4ndometrial ablation is the removal or destruction of the entire endometrium as well as a superficial layer
of the underlying smooth muscle )myometrium+. 'he procedure may be done using a laser )e.g., ,dIL&C
laser+, a thermal balloon, a hysteroscope, or a resectoscope.
4ndometrial ablation is about 9? successful in reducing heavy periods and may eliminate menstruation
altogether. &dvantages of the procedure over hysterectomy includeI
it is safer, less invasive, and does not require a surgical incision
it is less expensive
it requires a shorter hospital stay
women can resume normal activity within days, compared to 4 to 6 weeks
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T-er$al balloon
'he thermal balloon procedure involves inserting a balloon into the uterine cavity, filling the balloon with
fluid, and heating the fluid to destroy endometrial tissue.
1ysterosco/y
& hysteroscope is a thin, telescopic instrument that is inserted through the cervi" into the uterus. 'he
instrument has a camera and a light attached so the inside of the uterus can be viewed on a screen. @hen an
endoscope is used to view the inside of the uterus, the procedure is called a diagnostic hysteroscopy. &n
operative hysteroscopy involves using a hysteroscope with surgical instruments attached to cut and remove
tissue.
esectosco/y
=esectoscopy involves using hysteroscope with a wire loop attached. 'he wire carries an electric current to
cut and coagulate )solidify+ the endometrial tissue. 'his procedure is also 1nown as electrocoagulation.
1ysterecto$y
3ysterectomy involves removing the uterus. 3ysterectomies include subtotal hysterectomy )removal of the
uterus, but not the cervi"+ and total hysterectomy )removal of the uterus and the cervi"+. 'he procedure can
be performed through the vagina, through an incision in the abdomen, or laparoscopically )through a small
incision in the abdomen+.
+ : C
D G ( )dilation and curettage+ involves dilating the cervi" and inserting an instrument called a curette into
the uterus through the vagina. 'he curette is used to scrape the uterine wall and collect tissue. 'he long!
term benefits of this procedure are unclear, and it is often performed in con<unction with hysteroscopy.
The patient selection criteria for endometrial ablation includes: blood loss >80 ml per cycle; bleeding for
longer than 8 days; blood loss sufficient to cause anemia; or blood loss or symptoms that interfere with
normal activities; drug treatment failed, was contraindicated, was refused; uterine size <! wee"s gestation,
and uterine cavity <! cm in length; all other causes of e#cessive menstrual bleeding have been e#cluded
including cancer, precancer, and uterine lesions; and childbearing is complete$
%everal endometrial ablation techni&ues have been developed$ Transcervical resection of the endometrium
'T()*+, involves the destruction of the endometrium with a resectoscope, a telescopic instrument with a
wire loop or a rollerball at its tip$ ,n electrical current delivered to the tip of the instrument cuts or
coagulates the endometrium$ -uring endometrial laser ablation '*.,+, thermal energy produced by a
neodymium/yttrium/aluminum/garnet '0d:1,2+ laser destroys the endometrium$ T()* and *., are
guided by hysteroscopy$ , newer alternative for endometrial ablation is thermal balloon ablation of the
endometrium 'T3*,+, a procedure that does not re&uire the use of a hysteroscope$ , late# balloon is
inserted through the vagina into the cervi# and is filled with heated fluid that coagulates the endometrium$
,n advantage of endometrial ablation is that it does not involve the removal of the uterus and thus, the
operative and recovery times are shorter, and the complication rates are lower than for hysterectomy$ 4n this
evaluation the ma5ority of studies reviewed compared one or more endometrial ablation techni&ues with
hysterectomy, the surgical removal of the uterus$
Endometrial ablation is a quick outpatient treatment for heavy
bleeding.
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Endometrial ablation is the removal or destruction of the endometrium
(lining of the uterus). It does not require hospitalization, and most women
return to normal activities in a day or two. Ablation is an alternative to
hysterectomy for many women with heavy uterine bleeding who are wish to
avoid maor surgery. After a successful endometrial ablation, most
women will have little or no menstrual bleeding. !atient selection and
physician e"perience is essential to a good outcome.
How is endometrial ablation done?
Endometrial ablation has traditionally been done using a hysteroscope. #he procedure was
developed by $r. %oldrath in &'(' using a )d*+A% laser. I did the first endometrial ablation in
)orthern ,alifornia in &'-. using the laser. /y results using the laser were e"cellent, but
because of research done by myself and others, I switched to an instrument called a
resectoscope. #he resectoscope is a special type of telescope that allows me to see inside the
uterus. It has a built in wire loop that uses high0frequency electrical energy to cut or coagulate
tissue.
#he resectoscope has the advantage of being able to remove polyps and some fibroids at the
time of ablation. In results reported to the 1$A where resectoscopic endometrial ablation was
done by e"perts, the success rate was appro"imately '.2, with 342 of women having no
bleeding whatsoever in & year. In my own patients treated with the resectoscope as part of those
trials, .-2 of women had no bleeding at all after & year. It takes etensive eperience and skill
to be able to safely use the resectoscope, and obtain this degree of success.
!hat is a "balloon ablation?" !hat about other devices?
&lthough the resectoscope provides e"cellent results in e"perienced hands, the technique is
difficult to master. 5ther methods of ablation have been investigated. #he first to obtain 1$A
approval was the #hermachoice$ balloon. #his uses a balloon placed in the uterine cavity
through the cervi". 6ot water is circulated inside the balloon to destroy the endometrium. 7ome
e"perts are concerned about the balloon8s ability to reach the cornual areas (the 9top corners9) of
the uterus. Although the balloon8s 9success9 rate in 1$A studies was reasonable, the it had a
much lower rate of amenorrhea the other currently available device : only &;2. I see no
advantages and many disadvantages to it8s use, so do not recommend this device.
#he H#A Hydrothermablator
%
also uses hot water, but allows it to circulate freely in the
endometrial cavity. It is done under direct vision through a hysteroscope. 5nce the proper
temperature is reached, the hot water circulates for &4 minutes. 5nce of the original concerns
was about the possibility of fluid lea<ing out the fallopian tubes and burning intestines. Although
this did not happen in clinical studies, a case of an intestinal burn is being reviewed by the 1$A.
#here are other devices available in this country and other countries, but I thin< that their
disadvantages outweigh their advantages.
#he &ovasure 'ystem
Another new device, the &ovasure 'ystem$ , is now available, and has a number
of advantages over other systems. It only ta<es a few minutes and has an e"cellent
safety record.

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(ecovery from endometrial ablation
/ost women are able to go home within an hour after the an endometrial ablation. #here may be
mild cramping, which can usually be relieved by ibuprofen. 5ccasionally stronger medicine may
be needed. It is normal to be tired for a few days, but most women are able to return to most
normal activities in a day or two. Intercourse and very strenuous activity is usually restricted for =
wee<s. It is normal to have a increased discharge for = to 3 wee<s afterward, as the lining is
shedding. I normally do the first chec<0up 3 wee<s afterwards.
!ho should consider endometrial ablation?
!omen who have menstrual bleeding that is impacting their life, and do not have other
problems that require a hysterectomy should consider endometrial ablation.
)ou limit your activity because of your periods.
*leeding is causing you to be anemic and tired
*leeding limits your intimate time with your partner?
)ou do not desire to retain fertility
(isks of endometrial ablation
As with any surgical procedure, there are ris<s, which should be compared to the ris<s of things
we do in every day life. A number of things can be done to reduce these ris<s. 7ome of the ris<s
of endometrial ablation procedures are perforation of the uterus, absorbing e"cess fluid, bleeding,
infection, inury to organs within the abdomen and pelvis, and accumulation of blood within the
uterus due to scarring. Another rare, but important, concern after any endometrial ablation
procedure is that it might decrease your doctor8s ability to ma<e an early diagnosis of cancer of
the endometrium. Abnormal bleeding should be evaluated whether or not you have had an
ablation.
A small percentage of properly selected women having an ablation will still eventually need a
hysterectomy, but the vast maority will not. 6aving done endometrial ablation since &'-., I can
often identify women who will have a successful ablation and those who would be better off with
other treatment.
!ho shouldn+t have an endometrial ablation?
7ince an endometrial ablation destroys the lining of the uterus, endometrial ablation is not for
anyone who desires to keep her fertility. >omen who have a malignancy or pre0malignant
condition of the uterus are not candidates for ablation. >omen who have severe pelvic pain,
unless the pain is coming from an intracavitary myoma, may be better served by alternative
treatments. Although pregnancy is unli<ely after ablation, serious complications could arise. It is
essential for to use reliable contraception after an endometrial ablation.
!ho can help me decide if an endometrial ablation is for me?
It is helpful to see a gynecologist who is familiar with, and who is able to provide all of the
alternatives for the treatment of your problem. A physician who does not do endometrial
ablation on a regular basis is unlikely to have the eperience to help you make the best
decision. #he physician should be e"pert at vaginal0probe ultrasound and at diagnostic
hysteroscopy, and should consider non0surgical treatments, as well as discussing the advantages
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and disadvantages of all the options available. >hile the physician can provide you with
information, the decision is ultimately yours.
Earlier, hysterectomy seemed to be the solution to dysfunctional uterine bleeding in
pre-menopausal women, who had completed their families. Now, things are a
changing with a new method called thermal ablation with a uterine balloon.
Menorrohagia, or excessive menstrual bleeding, is defined as more than 8o cc of blood loss
during a menstrual cycle. ecause actual blood loss is not usually measured, physicians
typically identify a patient with menorrhagia as one who bleeds for more than seven days, or a
women who routinely uses more than !" pads a day during her period. #enorrhagia affects
approximately $$% of healthy women. &n the 'nited (tates, approximately ).6 million pre*
menopausal women aged between +" and ,, perceive their menstrual bleeding to be
excessive. -xcessive menstrual bleeding does not discriminate by age. &t may begin as early
as a women.s first menstrual /ycle. &t can be chronic condition. 0hile drug therapy is the first
line of treatment, most women resort to surgery if drugs fail to control the bleeding.
1here are two general types of excessive menstrual bleeding2 structural and dysfunctional.
1he structural causes of excessive menstrual bleeding are physical abnormalities, which can
be seen, in diagnostic tests.
1hese abnormalities include fibroids, polyps, or other anatomical or systemic disorders 3e.g.
4epatic or renal disease, thyroid dysfunction5.
Dysfunctional bleeding, the focus of this article, is primarily caused by a hormone
imbalance. 1he uterus has no observable abnormalities. 6ysfunctional bleeding is the
diagnosis in approximately ),%of patients with abnormal menstrual bleeding. 6ysfunctional
bleeding is most commonly seen in patients at the extremes of their reproductive life. 0omen
over 4, years old account to ,"% of patients with dysfunctional uterine bleeding.
&n treating menorrhagia, success is usually defined as a reduction in menstrual flow to normal
bleeding levels or less. 1reatment options include drug therapy, dilatation and curettage
367/5, hysterectomy, or the destruction of the endometrial lining using a laser or
electrosurgical probe.
8ecently, 9ynecare received '( approval to market a new device to treat this condition. 1his
new system uses a uterine balloon to thermally ablate the endometrium. &t can be performed
under local or general anaesthesia in the physician.s office or in the :8.
Drug Therapy
1he typical treatment regimen for women with menorrahagia begins with drug therapy, which
may reduce, but not eliminate, menstrual bleeding. 1his treatment does not compromise a
woman.s ability to become pregnant once therapy is discontinued. 6rug therapy is the first
line of treatment prescribed by approximately three*quarters of physicians.
(election of the appropriate therapy for each individual, and appropriate timing for the therapy
remains a challenge. /urrent medical therapy consists of hormones 3progestins or any of the
currently available combination oral contraceptives5 or prostaglandin synthestase inhibitors
3nonsteroidal anti*inflammatory drugs such as mefenamic acid, ibuprofen and naproxen5.
:ral contraceptives and non*steroidal anti*inflammatory medications are often used in women
who want to retain fertility. 1he effectiveness of this therapy depends on the continued use of
the drug. 1hese medications may need to be taken until menopause symptoms may return if
treatment is topped. &n addition, women may experience side effects typically associated with
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oral contraceptive drugs, 3eg. headaches5 or nonsteroidal anti*inflammatory drugs 3eg.
gastrointestinal reactions5.
; :ral contraceptives work by suppressing pituitary gonadotropin release, which inhibits
ovulation and results in a more stable endometrial lining. <s a result, menstrual blood loss
decreases.
; =onsteroidal anti*inflammatory drugs have been shown to be effective in reducing blood loss,
particularly when used concomitantly with oral contraceptive therapy.
; <ntifibrinolytic agents 3e.g. <minocaproic acid5 have also been shown to reduce blood loss in
patients with menorrhagia. 4owever their use is associated with frequent side of nausea,
di>>iness, diarrhoea, headache, abdominal pain and allergic manifestations. 0hile these drugs
are widely used in (candinavia, their use in the 'nited (tates is limited due to these side
effects.
Dilatation and Currettage
&f drug therapy is unsuccessful, dilatation and currettage is usually recommended. &n this
procedure, the cervical canal of the uterus is expanded 3dilatation5 to allow the surgeon to
scrape the surface lining of the uterine wall 3curettage5. 67/ is used both for diagnostic and
therapeutic purposes. 0hile this therapy has been used for many years , its efficacy in
reducing menstrual flow is generally limited to the first few menstrual cycles after the
procedure. ?requently a women under treatment for excessive menstrual bleeding will have
multiple 6s7/s.
Hysterectomy
<pproximately !.8 million hysterectomies are performed each year throught the world. &t is
the second most frequently performed female surgical procedure in the 'nited states,
surpassed only by ceasarean section. &n the 'nited states, approximately 6"","""
hysterectomies are performed each year, more than +"% of which are for excessive menstrual
bleeding. <nnual hospital costs for this procedure are estimated to exceed @, billion.
4ysterectomy is considered to be an appropriate treatment for women who experience
menorrhagia, who have not been successfully treated with drug therapy and who have
completed their families. 4owever, hysterectomy is associated with a range of no*potential
surgical and psychological risks and typically requires a four*day hospital stay and a three to
six week recovery period.
Endometrial ablation with laser or electrosurgical probe
&n the past decade, endometrial ablation has emerged as an effective treatment for excessive
menstrual bleeding. 0ith this procedure, the lining of the uterus is examined with a
hysteroscope and then destroyed with laser or electrosurgical techniques. 1he cost associated
with endometrial ablation is lower than those of hysterectomy. Aatients are not hospitalised,
and recovery time is short * approximately three to five days. < relatively small numbers
endometrial 3$","""5 are performed in the 'nited (tates because of the surgical skill required.
1his procedure is performed in the :8 with a physician trained in endometrial ablation and a
scrub person. 1he patient is given a light, general anaesthesia. Aatients who cannot tolerate
general anaesthesia are sedated and a local anaesthetic is administered.
< neodymium2 B<9 laser or high*powered electrical CrollerballC is used to burn off the
endometrial glands a $mm to +mm of myometrium. Aatients usually receive antiestrogenic or
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antigonadotophic drugs to shrink the uterus. 0hile either laser rollerball electro coagulation
may be used, most procedures are performed using the rollerball because it is more available,
and considered safer and easier to use.
1he most serious risk of endometrial ablation is fluid overload from the fluid that is used to
distend the uterus. :ther risks include hyponatremia, perforation of the uterus or adDacent
organs, uterine rupture, infection or haemorrhage. :verall, endometrial ablation has a
morbidity rate of +%.
ecause this procedure destroys the endometrial lining that must be intact to bring normal
pregnancy to term, it generally renders the patients sterile. -ndometrial ablation laser or
electrosurgical probe takes between !, and +" minutes. Aatients are discharged two or three
hours after the procedure. ?ollowing endometrial ablation, patients should be counselled to
avoid exercise, heavy lifting and sexual intercourse for one week. <s the uterus heals in the
first six weeks after the procedure, the patient notices a blood*tinged or yellow discharge. 1he
patient should be reassured that this discharge is normal.
Endometrial ablation using a thermal balloon
9ynecare has received '( approval to market a new device for the treatment of excessive
menstrual bleeding. 1hermal ablation uses heat to remove the lining of the uterus. 1he system
consists of two components * a balloon catheter containing heating and sensing elements, and
a controller connected to the catheter that monitors and controls pressure, time and
temperature during treatment. <fter local anaesthesia is administered, a balloon catheter is
inserted vaginally, through the cervix and into the uterus. < heating element inside the balloon
raises the temperature to approximately 8) degrees /elsius, which is maintained for eight
minutes.
1he controller continuously monitors and displays catheter pressure, and regulates
temperature and time throughout the procedure. <fter the treatment cycle has been
completed, the balloon is deflated and balloon catheter is withdrawn and discarded. 1hermal
ablation of the uterine lining results from the contact of the endometrium with the heated
balloon.
1he procedure is performed under either local or general anaesthesia depending on the
patient.s preference. 1he system was designed as an outpatient procedure using local
anaesthesia and intravenous sedation. 1he procedure is easy to perform2 some surgeons
equate it to inserting an intrauterine device 3&'65.
(ome women, when treated under local anaesthesia, may experience a pressure or cramping
sensation similar to that experienced during their menstrual cycles. 1his mild or moderate
cramping can be managed effectively with a nonsteroidal anti*inflammatory drug 3=(<&65
suppository administered 4, minutes prior to the procedure. #ost patients do not feel a strong
sensation of heat during the procedure. Aatients rest under supervision in an outpatient
recovery area for two to four hours following the procedure. 8est at home is recommended for
the remainder of the day. 1hey may experience mild to moderate cramping during the first
day, which can be alleviated with anti*inflammatory pain relievers. <fter resting at home, most
patients can resume normal activities the next day. Aatients should be counselled that they
might experience vaginal discharge or spotting, which normally changes to a watery
discharge, that can last between !" and +" days. 1his discharge is normal. <s with laser or
rollerball electro coagulation ablation, this procedure is intended for use by women who have
already completed their families. <s there is a chance that pregnancy may still occur after
endometrial ablation, contraception must be provided for as long as the patient is childbearing
age.
1o; successful is 1T at /re'enting $eno/ausal bleeding<
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(ontinuous combined hormone replacement such as that provided by &ctivellaM, (ombipatchM,
24/3='M 1>%, *rtho!PrefestM, or PremProM usually results in amenorrhea after about $ months of use
but intermittent bleeding during the first $ months is common. By 0 months, about #>$'s of women will not
have bleeding and at 1 year 9!%? will be without bleeding. Increasing the estrogen dose as well as the
progestin dose may help stop some of the bleeding.
'hus hormonal replacement therapy is not always successful at stopping all uterine bleeding. It is
especially unsuccessful if there is an anatomical cause of bleeding inside the uterus. In your case following
the recent DG(, it is difficult to say if the bleeding will subside over time or whether it will continue.
1o; successful is endo$etrial ablation at sto//ing uterine bleeding /roble$s<
'here are different techni:ues for performing endometrial ablation. *riginally physicians used a cautery
.roller ball. techni:ue or a Lag laser to burn the lining of the endometrium so it would not grow and slough
each month. =ecently a thermal balloon techni:ue is the most popular because it seems to have less
complications )1+. In this techni:ue a balloon in introduced into the endometrial cavity after hysteroscopy
is performed and water is then in<ected into the balloon. 'he water is then heated and the lining of the
endometrium is .scalded. so it does not 1eep growing under hormonal control.
'he various techni:ues used for endometrial ablation may have slightly different outcomes but in general
about 1>$ to 1># of women are completely without any bleeding afterwards )amenorrheic+ while about 1%!
#9? still have bleeding problems severe enough to warrant further surgery )#, $+. 'he overall satisfaction
rate of endometrial ablation is about 0%? )8+.
Is -ysterecto$y a better treat$ent t-an endo$etrial ablation for bleeding /roble$s<
'he two procedures are somewhat difficult to compare. *ne involves an outpatient surgery with recovery
in less than a wee1 and the other involves a 0 wee1 recovery and somewhat higher ris1 )about $!8?+ of
serious complications. *ne randomi5ed clinical trial has been conducted comparing hysterectomy with
endometrial ablation )%+. 2urther surgical treatment was re:uired during the follow!up period of 8 years by
$0? of the women having endometrial ablation and #8? of the women having hysterectomy. -atisfaction
rates were high for both groups being 9? in the ablation group and ;? in the hysterectomy group. 'he
difference in satisfaction was due to the different need for retreatment. Premenstrual symptoms improved
more in the hysterectomy group. & review or several trials comparing ablation and hysterectomy also came
to this same conclusion )0+. 'hus you can loo1 at this one of two waysI
1. 4ndometrial ablation allows about 6%? of women to avoid hysterectomy
#. 3ysterectomy was more successful in the long run in treating the bleeding problems as well as
premenstrual symptoms
&nother study following women for 0.% years found that #9? of women undergoing laser endometrial
ablation need a hysterectomy at a later time )6+. & study with a shorter follow!up felt endometrial ablation
was successful almost ;9? of the time )+. In spite of the success of endometrial ablation, it does not seem
to be replacing hysterectomy as a treatment for bleeding on the national or international level );+.
3ysterectomy performance continues at the same per capita rate and ablation is an additional procedure
available. 'he reason for this may perhaps lie in other associated problems for which hysterectomy ma1es
more sense in the long run.
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6ysfunctional uterine bleeding 36'5 occurs in women of childbearing age and is diagnosed
when the bleeding is unrelated to demonstrable congenital or acquired anomalies of the
reproductive tract. =o incidence or prevalence data are available, although it has been
estimated that up to $"% of women in their reproductive years experience excessive uterine
bleeding.
!
0omen with 6' are treated with a variety of approaches, including expectant
management, iron replacement, medical therapy, and surgery. (urgery is typically undertaken
only when appropriate medical therapy fails or is not tolerated by the patient. 1he (urgical
1reatments :utcomes AroDect for 6ysfunctional 'terine leeding 3(1:A*6'5 will compare two
surgical approaches, endometrial ablation versus hysterectomy, for 6'.
1he most common surgery for 6' is some form of hysterectomy. <bdominal hysterectomy is
generally associated with greater direct costs and side effects than vaginal hysterectomy.
Eaginal hysterectomy may be associated with complications such as infection, bleeding, organ
trauma, and, uncommonly, death. 8ecently, laparoscopic hysterectomy has been used,
although evidence for the efficacy of this approach has yet to be determined.
$

1o reduce the morbidity and cost of surgery, endometrial ablation was introduced in the !F8"s
as an alternative to hysterectomy. 'sing hysteroscopic guidance, it uses a number of
techniques to remove the endometrium including =eodymium2 Bttrium*<luminum*9arnet
3=d2B<95 lasers
+
, electrosurgical resection
4
, and electrosurgical ablation
,
. =on*hysteroscopic
endometrial ablation 3=4-<5 was first approved for use in the '.(. in 6ecember, !FF)
31herma/hoiceG -thicon, &nc, (ommerville =H5, in which ablation is achieved by thermal
means, whereby a balloon inserted into the uterine cavity is heated with fluid to 8)I / for 8
minutes.
-ach of the above procedures incurs costs directly related to the performance of the procedure
3e.g., institutional, surgeon and anesthesiology fees and the cost of complications5, as well as
those related indirectly to the procedure 3e.g., loss of work hours, cost of child care5. 0hile
endometrial ablation appears to be initially less expensive than hysterectomy, continued
symptoms result in the need for repeat medical and surgical care sometimes.
1here is no consensus regarding the efficacy of endometrial ablation compared to
hysterectomy for 6', in terms of relevant clinical, cost, and quality of life outcomes.
:bservational studies have reported that endometrial ablation results in decreased direct and
indirect cost of care
6,)
, however, it is not possible to draw firm conclusions regarding costs
from observational data. oth observational studies
8*!!
and randomi>ed trials
!$*!,
have found a
relatively high degree of patient satisfaction 3,"*8"%5 with both types of surgery.
Study Design
1he overall obDective of (1:A*6' is to assess the effectiveness of hysterectomy versus
endometrial ablation in women with 6'. 1he study comprises two parts2 3!5 a clinical trial
comparing patients randomi>ed to either hysterectomy or to endometrial ablation, and 3$5 an
observational study of all women who are not eligible 3based on CprovisionalC criteria5 or who
elect not to participate in the trial. CArovisionalC eligibility criteria included certain eligibility
criteria that could change over time 3e.g., less than three months of medical management5.
Aatients fulfilling all eligibility criteria for the trial had equal probability of being randomi>ed to
hysterectomy or endometrial ablation. 1he manner in which surgery was performed was left to
each investigator, but the investigator was able to specify prior to randomi>ation the type of
hysterectomy 3e.g., abdominal vs laparoscopic5 or endometrial ablation 34-< vs =4-<5 that
would be employed for a particular woman if she were assigned to that arm of the trial.
1he primary outcomes of the trial are2 3!5 resolution of the primary problem J as specified by
each woman at the aseline Eisit J that led a woman to seek treatment, 3$5 bleeding, 3+5
pain, and 345 fatigue. :ther problems 3outcomes5 to be examined are those ranked as
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CsecondaryC to the primary problem at baseline, and include patient.s quality of life such as
restriction of normal activities, sexual functioning, and urinary incontinence. <nother
important secondary outcome is the evaluation of cost and cost*effectiveness of hysterectomy
compared to endometrial ablation.
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