D&C

Rarely indicated in <40yrs with regular heavy periods 3000 4000 D&C to detect 1 END Ca Only 50% of uterine cavity is samples 50% of endo Ca may be missed by D&C alone

ROLE OF USG

Uterine architecture Endometrial thickness Impt adjunct to sampling TVS better sensitivity 89% specificity 96% Endometrial thickness 5mm Exclude endo. Ca (Goldstein 1990) After menopause USG + endo biopsy when endo>5mm

Management
Medical Non-hormonal Hormonal Surgical Conservative Hysterectomy

Non-hormonal NSAIDs Inhibits cyclooxygenase,blocks PGE2 20-30%redn in bld loss ovulatory DUB Antifibrinolytics EACA,Tranexamic A Inhibits tpA 50% redn in bld loss IUCD related menorrhagia

Hormones Progestogens Norethisterone MPA Dydrogesterone IU Progestogens LNG IUS (Mirena) Progestasert

Hormones Combined O/P OCP HRT OTHERS Danazol Gestrinone GnRH analogues

Surgical therapy

Curettage E A /RESECTION HYSTERECTOMY

Management
Puberty and adolescent -<20 yrs Reproductive-20-40 yrs Perimenopausal->40 yrs

Pubertal
75%- Primary DUB Anovulatory (90%) 15% - Coaguln. defects 10% -condns like ovarian trs

Life style modificn, diet ,exercise ,wt. redn Mild-reassurance, iron and vitamin supplementation,menstrual calender,periodic reevaluation

Moderate PROGESTINS for 3-6 months

Progestogens reverses the effect of unopposed estrogens due to anovulation In married women-contraceptive action also

Severe-hospitalisation,exclude coagulative pathology rapidly ,blood transfusion,iron and vitamin supplementation, Trt CCF if present

Role of progestogens

NEA 10mg 1-1-1 * 3days till bleeding stops .taper over 3 days_ Withdrawal bleed _ Restart from 5th day of menstrual bleed

If progestogens fail

Can start on parenteral estrogens(premarin 25 mg 4th hrly,max 6 doses After achieving haemostasis give progestogens concurrently
D&C-very rarely indicated Helps to know hormonal status,and tissue diagnosis of tuberculous endometritis

Majorily return to normal pattern within 34 yrs of menarche If anovulation exceeds 4 yrs,increased risk of PCOD,infertility, Ca endometrium

REPRODUCTIVE AGE GROUP

80% OVULATORY 20% ANOVULATORY Take a careful h/o,detailed general and pelvic examination,r/o pregnancy complications,USS,r/o PID,irregular hormone intake/r/o malignancy,D&C

OPTIONS AVAILABLEmedical and surgical therapy

Prescribing practically

Progesterones-androgenic progesterones mainstay of treatment in anovulatory cycles. Produces MEDICAL CURETTAGE

Used to Arrest hge in endometrial hyperplasia Luteal phase trt in C L insufficiency d15-d25 Whole cycle trt in endometrial hyperplasia d5-d25 Give for 6 months and reevaluate.

Estrogen and Progesterone

Cyclical therapy COC

4 tab 6 12 hrly for 5 7 days withdrawal bleed Low dose pill from 5th day COC may be tapered (4 times, 3 times, 2 times) Over 3 6 days and 1 everyday
2

ESTROGENS - limited use to arrest acute haemorrhage uncontrolled by progesterones Acts as a stimulus to clotting at capillary level CONTRAINDICATIONS

Undiagnosed DUB H/o thromboembolism, thrombophlebitis Suspected pregnancy Breast Ca

DANAZOL 200mg/d decreases MBL Antiestro,antiprogesto,androgenic 800mg/d produces amenorrhoea Used in cases of recurrent bleed,awaiting hysterectomy

GESTRINONE-2,5 mg twice a week for 3 months CLOMEPHINE citrate-used in anovulatory DUB with infertility ,wanting pregnancy GnRH analogues-produces hypoestrogenic state and decreases MBL.These are indicated only in cases with adverse effects to sex steroid therapy,failure of sex steroid therapy,in haematologic disorders

PG SYNTHETASE INHIBITORS-decreases MBL by 20-30% Used in ovulatory DUB given during menses

ANTIFIBRINOLYTIC AGENTS-tranexamic acid used in IUCD induced menorrhagia and ovulatory DUB. CI in patients with h/o thrombosis

DESMOPRESSINincreases factor VIII levels used in DUB PATIENTS WITH COAGULOPATHY LNG IUD decreases MBL by 96% after 12 months of use

HPR
proliferative endometrium and pregnancy desired-CC proliferative endometrium and pregnancy not desired-prog 2nd half*12 days Secretory endometrium and pregnancy desired-PG synthetase inhibitors Secretory endometrium and pregnancy not desired-OCP* 6 mths Atrophic endometrium-est dominant OCP Hyperplastic endometrium-prog dominant OCP

Surgical treatment
Conservative
ABLATIVE

PROCEDURES-Thermal,roller ball RESECTION

Radical

vaginal hysterectomy TAH

Indications for endometrial ablation

Heavy menstrual loss Endometrial atypia excluded Uterus<12 weeks size No pelvic infection Completed family Fit for surgical procedure Willing for hysterectomy if reqd

Indications for hysterectomy

If conservative treatment fails Blood loss impairs health Younger age group with completed family and with symptoms uncontrolled on medical management

ROLE OF RADIOTHERAPY

External beam radiation to induce

menopause in patients with intractable DUB when hysterectomy is indicated but patient is unfit for surgery

Perimenopausal group
Cause- functional ageing of HPO axis Pituitary produces more FSH ,the ovaries become refractory to it-anovulatory cycles

Unopposed endogenous estrogens from fatendometrial hyperplasia---persistent hyperplasia---adenomatous hyperplasia--atypical hyperplasia---CIS

EVALUATION
Detailed history Clinical examination Diagnostic procedures Hormones-progestins tried for a few cycles may reverse dysplastic changes

h/o + examination
PAP SMEAR,COLPOSCOPY MALIGNANCY (APPROP TRT)

HYSTEROSCOPY----N ENDOMETRIUM (LOOK FOR MYOMA,POLYP) FC

Proliferative endometrium Simple hyperplasia

Adenomatous/atypical hyperplasia

progestins

hysterectomy

Follow up after 6 months Endometrial sampling Ablative therapy is indicated in carefully selected cases

Post menopausal
No place for hormones Rule out adnexal mass,malignancy,organic lesions by USG FRACTIONAL CURETTAGE is mandatory If bleeding stops-can wait If recurs-hysterectomy

Take home messages

Hysterectomy for DUB should be made a last resort. The liberal use of hysterectomy to treat DUB reflects failure in establishing a correct diagnosis When the diagnosis is correct , medical management or limited surgical management is a better option if facilities are available