Dysfunctional Uterine Bleeding (DUB)

Question 1

Define

Answer 1

Abnormal uterine bleeding in the absence of organic pathology (affects ~10% of women)

Hormonal influences in anovulatory and ovulatory cycles

AKA: Ovulatory/Endometrial Dysfunction

AKA: Heavy menstrual bleeding

• Risk Factors: extremes of reproductive age, obesity

Types:

• Anovulatory (90%) = failure of follicular development -> no increase in progesterone -> cystic hyperplasia of endometrial glands with hypertrophy of columnar epithelium due to unopposed oestrogen stimulation
• Shedding of this may be prolonged or long-term

Ovulatory (10%) = prolonged progesterone secretion -> irregular shedding

• Menorrhagia is defined as what the individual woman believes is menorrhagia – there is no need to quantify it

Question 2

Signs and symptoms

Answer 2

(diagnosis of exclusion):

o Bleeding (menorrhagia, IMB, dysmenorrhoea)

o Anaemia signs/symptoms

o S/S of the cause:

§ Relation to the menstrual cycle

§ Fertility issues

§ Compression symptoms

§ Cervical screening history

§ DHx, FHx, sexual history (fevers, previous STIs, sexual contacts)

§ Coagulopathy disorders (von Williebrand disease)

Question 3

Investigations

Answer 3

Examination à speculum (i.e. ectropion), bimanual (i.e. bulky, fibroids)

§ If menorrhagia without other related symptoms (i.e. persistent IMB, pelvic pain, pressure symptoms), consider starting management without any physical examination (unless LNG-IUS) [NICE, 2018]

o 1st line:

§ FBC (anaemia)

§ TFTs (hypothyroid)

§ Clotting screen (if primary menorrhagia or FHx)

o 2nd line à TVUSS (PCOS, fibroids, malignancy)

o 3rd line à OPD hysteroscopy / laparoscopy ± biopsy (endometriosis)

Question 4

Management

Answer 4

If no identified pathology, fibroids <3cm, suspected/diagnosed adenomyosis:

1st line (contraception required; hormonal): LNG-IUS (may not be possible in large fibroids distorting uterus)

2nd line (fertility required; 1st line declined/unsuitable):

• BLEED à Tranexamic acid, 1g TDS (contraindications: renal impairment, thrombotic disease)
• PAIN -> Mefenamic acid (NSAIDs; contraindications: IBD)

2nd line (contraception required; 1st line declined/unsuitable):

• 1st à COCP
• 2nd à cyclical oral progestogens
  
  • · Norethisterone 5 mg TDS for 10 days can be used to arrest bleeding acutely
  • · When you stop taking this, it causes a heavy bleed

o Surgical:

• § Endometrial ablation (will need continued contraception)
• § Hysterectomy

o If fibroids >3cm à see fibroids management