SOGC Guidelines

Management 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 30g ethinyl estradiol
reduces blood loss of up to 43% from
baseline
 Provides contraception and relieves
dysmenorrhea
Progestin intrauterine system

 Levonorgestrel IUD releases 20g/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!