PG Classroom - CME: Diagnosis and Management of Dysfunctional Uterine Bleeding

Introduction Abnormal uterine bleeding (AUB) affects up to one-third of women of reproductive age, and can be physically and socially debilitating. AUB is defined as any bleeding that differs in regularity, frequency, duration or volume from a patient’s usual menstrual flow. Although it is a common complaint in the family medicine office setting, AUB can sometimes be a deceptively challenging condition.

The etiology of AUB encompasses a wide range of disorders, including anovulation, pregnancy-related conditions, trauma, and anatomic abnormalities of the genital tract, infection, endocrinal disorders, malignancies and systemic illness.

Dysfunctional uterine bleeding (DUB), which is associated with, functional abnormalities of the hypothalamic-pituitary axis, is the diagnosis usually given when no clear systemic, anatomic or infectious etiology is identified

DUB is a diagnosis of exclusion that can only be established once structural and pregnancy-related causes have been ruled out. Anovulatory DUB is usually characterized by bleeding that is irregular in timing and quantity

Rarely, DUB can occur in women who are ovulating. In these cases, periods are usually heavy or prolonged but occur at regular intervals (i.e., menorrhagia). Anovulatory DUB accounts for more than 70% of cases of dysfunctional uterine bleeding and results from unopposed estrogen stimulation in the endometrium. In anovulation, estrogen is continually secreted but progesterone, which normally counteracts uterine lining proliferation, is not produced.

A deficient luteal phase, shortened by insufficient progesterone production, may coexist with high, low or normal estrogen levels, leading to a disruption of the hypothalamic-pituitary-ovarian functioning and resulting in AUB. With ovulatory cycles, menorrhagia, polymenorrhea or oligomenorrhea may occur.

Differential Diagnosis
In order to establish a diagnosis of DUB, it is important to rule out pregnancy, systemic diseases and pelvic pathology. Effective management of AUB is highly dependent on its etiology; therefore, a detailed history and careful evaluation of the patient are useful in determining the cause of bleeding and the most appropriate treatment options.

As unopposed estrogen stimulation resulting from anovulatory menstrual cycles represents an increased risk for endometrial cancer, a menstrual history is important to distinguish between prolonged and irregular menses.
Obesity, acne and hirsutism may be signs of Polycystic Ovary Syndrome (PCOS). If galactorrhea is detected in the physical examination, a serum prolactin level is recommended to detect hyperprolactinemia, which can cause anovulation and irregular bleeding

Pelvic examination and palpation of the vagina’re also helpful in the detection of anatomic bleeding sites and signs of infection, polyps, leiomyomata, tears or malignancy.

Other endocrinopathies such as thyroid disorders should be considered and a thyroid-stimulating hormone (TSH) test may be appropriate in patients who report unexplained excessive weight gain, fatigue, constipation, hair loss or edema.

Other Diagnostic Tools
Dilatation and curettage (D&C) is a diagnostic procedure generally used for stabilization in acute episodes of uterine bleeding. When performed in conjunction with hysteroscopy, which allows for direct visualization of the uterine cavity, the accuracy of D&C may be improved.

Endometrial biopsy is an accurate and commonly used diagnostic test, with an endometrial cancer detection rate of 91 percent and a 2 % false-positive rate in premenopausal women.

Management of DUB
Severe bleeding:
Conjugated equine estrogen therapy is very effective in the management of severe, acute bleeding. Once the acute bleeding episode has been stabilized, a regimen of one monophasic oral contraceptive pill (OCP) twice daily for 5-7days must be administered until bleeding stops.

Pharmacologic Treatments for Nonemergent Menstrual Bleeding:
Treating AUB medically with OCPs is the preferred treatment. OCPs induce endometrial atrophy & regulate the menstrual cycle, helping to prevent the risks associated with prolonged unopposed estrogen stimulation. Progestogens reduce menstrual blood loss by suppressing endometrial growth and maturing the existing functionalis layer of the endometrium.

Nonpharmacologic Treatments
Surgical treatment of AUB is generally reserved for cases in which the patient no longer desires to conceive, does not tolerate or respond to pharmacologic therapy, when pharmacologic therapy is contraindicated.

Hysterectomy is the definitive treatment for ovulatory and anovulatory DUB. The surgery can be performed vaginally, abdominally and laparoscopically, with vaginal hysterectomy being associated with fewer complications and shorter recovery time.

Compared with hysterectomy, endometrial ablation is a less invasive, uterus-sparing alternative that is cost-effective. The need for general anesthetic is reduced, postoperative complications are fewer and recovery time is shorter.

Ref: Gaunt A M et al; Diagnosis and Management of Dysfunctional Uterine Bleeding CME Bulletin-The American Academy of Family Physicians 2007;6 (6)



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