Dysfunctional Uterine Bleeding

Question 1

Definition of Dysfunctional Uterine Bleeding

Answer 1

• Excessive bleeding (Heavy, frequent, or prolonged) of uterine origin, which is not due to pelvic pathology/systemic disease
• Over several consecutive cycles
• Affects 1 in 3 women in reproductive age
• ‘Heavy Menstrual Bleeding’

Question 2

6 Hormonal Treatments of DUB

Answer 2

1. Combined Oral Contraceptive Pill
2. Levonorgestrel-Releasing Intrauterine Device (LNG-IUD)
3. Oral Progesterones
4. Injected/Depot Progestogens
5. Gonadotropin-Releasing Hormone Analogues (GnRH Analogues)
6. Selective Progesterone Receptor Modulators (SPRMs)

Question 3

Combined Oral Contraceptive Pill

Answer 3

• Generally effective in the management of Heavy Menstrual Bleeding (HMB)
• Reduces bleeding by about 50%
• Reduces dysmenorrhoea
• Adverse effects: Risk of breast cancer, Thromboembolic and Cardiovascular disease, and Migraine

Question 4

Levonorgestrel-Releasing Intrauterine Device (LNG-IUD)

Answer 4

• An alternative to surgery for women who also seek reliable long-acting reversible contraception
• Reduces menstrual bleeding and less anaemia
• Requires change every 3-5 years depending on the licence of the preparation inserted
• Unscheduled spotting/bleeding during the initial month of use

Question 5

Oral Progestogens

Answer 5

• Women at the extremes of reproductive life
• Ovulatory HMB: Norethisterone Acetate (5mg 3x daily) cyclically for 21 days
• Anovulatory HMB (e.g. Polycystic Ovarian Syndrome) and risk of endometrial hyperplasia, short course of oral progestogens (14 days) for women

Question 6

Injected/Depot Progestogens

Answer 6

• Used for Contraception
• Unscheduled bleeding in proportion of women

Question 7

Gonadotrophin-releasing Hormone Analogues (GnRH Analogues)

Answer 7

• Indication: If all other options fail
• Down regulate the hypothalamic-pituitary-ovarian axis
• Induce ovarian suppression ‘
• Leading to Amenorrhoea
• Effects do not continue after stopping the treatment
• Adverse Effects on Bone Density

Question 8

Selective Progesterone Receptor Modulators (SPRMs)

Answer 8

• Synthetic Steroids
• Reversible morphological change in the endometrium
• Reduce menstrual bleeding
• Reduce the fibroid volume

Question 9

Non-hormonal Treatment of DUB

Answer 9

• Indications: Women wishing to conceive, hormonal treatments and most surgical interventions are unacceptable
• Antifibronolytics and Prostaglandin Synthase Inhibitors

Question 10

Antifibrinolytics

Answer 10

• Reduce blood loss by up to 50% by inhibiting endometrial fibrinolysis (e.g. Tranexemic Acid)
• Adverse Effects: Gi Symptoms
• Contraindicated for women with a history of Thromboembolism

Question 11

Prostagladin Synthase Inhibitors

Answer 11

• Non-steroidal anti-inflammatory drugs
• Inhibit endometrial prostaglandin production and reduce menstrual blood loss
• Mefenamic Acid: Most frequently used drug, reduces blood loss by approximately 25%, taken during menstruation, additional analgesic effect, GI side effect

Question 12

Surgical Treatments

Answer 12

Indication: Women with completed family (with the exception of polypectomy and myomectomy where fertility may be retained

1. Polypectomy (Avulsion of Endometrial Polyps)
2. Endometrial Ablation (Targeted destruction of endometrium and some underlying myometrium)
3. Myomectomy (The surgical removal of fibrous from the uterine with conservation of the uterus)
4. Uterine Artery Embolisation (Use of embolic agents to block both uterine arteries)
5. Hysterectomy (Removal of the Uterus)