42 Gynaecff Diagnosis of DUB and management-M

Diagnosis & management of DUB:

Diagnosis & management of DUB Dr Manjula M Senior lecturer in O&G SAT Hospital

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Definition Normal menstruation Pathology Types of DUB Evaluation and diagnosis Management

DEFINITION:

DEFINITION abnormal uterine bleeding without any clinically detectable organic pelvic pathology Novak-bleeding of uterine origin in the absence of pregnancy,tumour or inflammation

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DUB is a diagnosis of exclusion An incorrect and improper diagnosis leads to failure of medical management and unnecessary surgical interventions

Normal menstruation:

Normal menstruation 21-35 days cycle,3-8 days flow,30-60ml Normal HPO axis Decreased O&P- decre. BF to endometrium- endo. necrosis

Pathophysiology of DUB:

Pathophysiology of DUB ↑ PGE2, PGF2 ratio ↑tpA - endometrial fibrinolysis Abn. vascularity of endometrium Delayed regn. of endometrium ↑ endo. tissue necrosis ↑Prostacycline,TxA2 ratio

DUB-Diag of exclusion.:

DUB-Diag of exclusion. Organic disease of the genital tract Pregnancy and its related complications Organ failure Genital injury, FB Pathology of outflow tract

TERMS:

TERMS Menorrhagia Metrorrhagia Polymenorrhea Oligomenorrhea Amenorrhea

Classification:

Classification Aetiological Primary Secondary Iatrogenic Types Anovulatory Ovulatory

HISTORY :

HISTORY Full menstrual history,medical history Asso. mens. symptoms,h/o PID Symptoms of endocrine / organic diseases /bleeding disorder Stress,psych abn. Drugs,IUCD Family history Future preg , contraception

Examination :

Examination Built Pallor,icterus,hirsuitism Petechial rashes,LNE Thyroid,breast,abdomen L/E- lesions ,FB,injury,anomalies P/V-uterus ,adnexa P/R- unmarried

Investigations:

Investigations Hb, CBC,BT ,CT ,PS LFT,RFT PT,APTT TFT UPT PAP smear USG-TAS,TVS Prolactin

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RBS R/O CAH ,Cushing synd. F C ,D/C,endom. biopsy Lap, hysteroscopy, sonohysterography

Endometrial Assessment:

Endometrial Assessment Array of methods Dilatation and curettage Hysteroscopy and endometrial Endometrial sampling Ultrasonography

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CURETTAGE-primarily diagnostic,rarely therapeutic In adolescents-deferred until severe bleeding In reproductive –postponed till 3 months Perimenopausal-done immediately Postmenopausal-mandatory

Timing of curettage:

Timing of curettage Cyclic menorrhagia-5-6 days prior to onset of pds Irregular shedding-5-6 days after pds start Irregular ripening-soon after pds start Acyclic-soon after pds start Continuous-anytime

D&C :

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:

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 :

Management Medical Non-hormonal Hormonal Surgical Conservative Hysterectomy

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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

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

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

Surgical therapy:

Surgical therapy Curettage E A /RESECTION HYSTERECTOMY

Management:

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

Pubertal :

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

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

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Moderate PROGESTINS for 3-6 months Progestogens reverses the effect of unopposed estrogens due to anovulation In married women-contraceptive action also

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

Role of progestogens:

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

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If progestogens fail Can start on parenteral estrogens(premarin 25 mg 4 th 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

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Majorily return to normal pattern within 3-4 yrs of menarche If anovulation exceeds 4 yrs,increased risk of PCOD,infertility, Ca endometrium

REPRODUCTIVE AGE GROUP:

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

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OPTIONS AVAILABLE—medical and surgical therapy

Prescribing practically:

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:

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

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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

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

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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

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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

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

HPR:

HPR proliferative endometrium and pregnancy desired-CC proliferative endometrium and pregnancy not desired-prog 2 nd 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:

Surgical treatment Conservative ABLATIVE PROCEDURES-Thermal,roller ball RESECTION Radical vaginal hysterectomy TAH

Indications for endometrial ablation:

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:

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:

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:

Perimenopausal group Cause- functional ageing of HPO axis Pituitary produces more FSH ,the ovaries become refractory to it-anovulatory cycles Unopposed endogenous estrogens from fat—endometrial hyperplasia---persistent hyperplasia---adenomatous hyperplasia---atypical hyperplasia---CIS

EVALUATION:

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

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PAP SMEAR,COLPOSCOPY MALIGNANCY (APPROP TRT) HYSTEROSCOPY----N ENDOMETRIUM (LOOK FOR MYOMA,POLYP) FC Proliferative endometrium Simple hyperplasia progestins Follow up after 6 months Endometrial sampling Adenomatous/atypical hyperplasia hysterectomy Ablative therapy is indicated in carefully selected cases h/o + examination

Post menopausal:

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:

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

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thank you