This document summarizes guidelines for evaluating and managing dysfunctional uterine bleeding (DUB), also known as heavy menstrual bleeding. It describes taking a medical history, performing an examination, ordering investigations, and providing initial medical management. If initial treatment is ineffective, options include switching or combining pharmaceutical treatments. For failed primary care management, referral for procedures like endometrial ablation or hysterectomy is recommended. The document outlines treatment goals, options, guidelines, and provides examples of surgical procedures for heavy menstrual bleeding.
This document summarizes guidelines for evaluating and managing dysfunctional uterine bleeding (DUB), also known as heavy menstrual bleeding. It describes taking a medical history, performing an examination, ordering investigations, and providing initial medical management. If initial treatment is ineffective, options include switching or combining pharmaceutical treatments. For failed primary care management, referral for procedures like endometrial ablation or hysterectomy is recommended. The document outlines treatment goals, options, guidelines, and provides examples of surgical procedures for heavy menstrual bleeding.
This document summarizes guidelines for evaluating and managing dysfunctional uterine bleeding (DUB), also known as heavy menstrual bleeding. It describes taking a medical history, performing an examination, ordering investigations, and providing initial medical management. If initial treatment is ineffective, options include switching or combining pharmaceutical treatments. For failed primary care management, referral for procedures like endometrial ablation or hysterectomy is recommended. The document outlines treatment goals, options, guidelines, and provides examples of surgical procedures for heavy menstrual bleeding.
This document summarizes guidelines for evaluating and managing dysfunctional uterine bleeding (DUB), also known as heavy menstrual bleeding. It describes taking a medical history, performing an examination, ordering investigations, and providing initial medical management. If initial treatment is ineffective, options include switching or combining pharmaceutical treatments. For failed primary care management, referral for procedures like endometrial ablation or hysterectomy is recommended. The document outlines treatment goals, options, guidelines, and provides examples of surgical procedures for heavy menstrual bleeding.
PC HPC Past Gynae and Obs Hx PMH Allergies Drugs !Don’t forget OTC or overseas sourced Smoking Social hx Family Hx Summary Dysfunctional uterine bleeding
DeKned as unexplained menorrhagia
Heavy and/or irregular bleeding, may be ovulatory or anovulatory Cause of heavy menstrual bleeding in 40-60% of women with menorrhagia One in 20 women aged 30–49 years consult their GP each year for heavy menstruation Let’s backtrack – what is menorrhagia? Excessive (heavy) menstrual blood loss over several consecutive cycles which interferes with a woman's physical, emotional, social, and material quality of life
In research, it is usually deKned as an objectively measured blood loss of
60–80 mL or more per menstruation (the average blood loss is 30– 40 mL, and 90% of women have losses less than 80 mL)
However, objective measurements of menstrual blood loss are not
practical in the clinical setting, and they correlate poorly with a woman's subjective assessment of blood loss and its impact on quality of life IdentiKable causes of menorrhagia Uterine and ovarian pathologies Fibroids Endometriosis and adenomyosis Endometrial polyps, hyperplasia, carcinoma PCOS Pelvic infection Systemic diseases and disorders Coagulation disorders Hypothyroidism Renal or liver disease Iatrogenic Anticoagulants IUCD chemotherapy Complications
Negative eaect on quality of life
Limits normal activities, work and social life Mood changes Low mood, self consciousness Negative eaect on sex life/relationships Iron-deKciency anaemia (aaects about 2/3 of women with menorrhagia) Menstrual history
Age at menarche, details about menstrual cycle, length of cycle, the number of days of menstruation, for how long she has considered her periods to be heavy, what her periods were like previously, and the impact on quality of life
Enquire about symptoms that suggest an underlying pathology, particularly 'red bag' symptoms (for example persistent intermenstrual or postcoital bleeding)
Consider the possibility of an underlying systemic disease, such as hypothyroidism or a coagulation disorder (for example von Willebrand disease)
Take a family history, and in particular ask about endometriosis and coagulation disorders that may have a hereditary component
Check smear status
Ask about current contraceptive use, contraceptive plans, and future plans for a family Underlying pathology?
Symptoms that may indicate an underlying pathology include:
Abdominal and pelvic examination in the following women:
Women with symptoms suggestive of underlying abnormalities, before further investigations are arranged. Those in whom initial treatment has proved ineaective. Those for whom the levonorgestrel-releasing intrauterine system is being considered. A pelvic examination should include: Vulval examination for evidence of external bleeding and signs of infection (for example vaginal discharge). Speculum examination of vagina and cervix. High vaginal, endocervical, and chlamydia swabs should be obtained if infection is suspected. Bimanual palpation to identify uterine or adnexal enlargement or Investigations
Bloods FBC (Fe deKciency anaemia) Clotting proKle if appropriate TFT if appropriate Smear if appropriate STI screening if appropriate Pelvic ultrasound If uterus palpable abdominally, pelvic mass on VE, symptoms suggestive of underlying cause or previous Rx ineaective Secondary care – hysteroscopy /endometrial sampling Rapidly stopping heavy bleeding
Oral norethisterone, 5 mg three times daily for 10 days, usually stops
bleeding within one to three days. Inform the woman that a withdrawal bleed will occur two to four days after stopping treatment. If bleeding is exceptionally heavy ('booding'), 10 mg three times daily (oa- label dose) may provide better results (get informed consent). This should then be tapered down to 5 mg three times daily for about a week once bleeding has stopped. Management
Medical (pharmaceutical) treatment Krst-line
If no symptoms suggestive of underlying pathology (PCB, IMB, dyspareunia, dysmenorrhoea, discharge, pelvic pain) While awaiting results of Ix Medical management
First choice Levonorgestrel-releasing IUS Second choice Tranexamic acid (antiKbrinolytic) NSAID (mefenamic acid, naproxen, ibuprofen; good if also dysmenorrhoea) COCP (regulates cycles, helps dysmenorrhoea, more readily reversible than IUS) Third choice Oral NET days 5-26 of cycle Depot progestogen (GnRH analogues only in secondary care) Management – when initial treatment ineaective Switch to an alternative pharmaceutical treatment. Oral norethisterone or depot medroxyprogesterone are often suitable if initial treatment was ineaective. Add on an additional drug. Typically, tranexamic acid can be combined with a nonsteroidal anti-inbammatory drug (NSAID), or an NSAID can be combined with the combined oral contraceptive. Consider IUS (Mirena) – 90% amenorrhoea after 1 year Referral to secondary care
Possible malignancy – 2WW referral
Failed treatment in primary care Surgery requested Individual funding for each hysterectomy not related to malignancy
Persistent anaemia Menorrhagia in the ED Pregnancy test (12 -55yrs)
Assessment of bleeding – how much
Look at pad. ?double protection
Observations – compromise?
Almost never admitted, care via GP
Consider norethisterone 5mg tds 10/7
Surgical treatments
Always second-line options
Reserved for cases where medical Rx has failed or is contraindicated Endometrial ablation Hysterectomy Endometrial ablation
Destruction of endometrium and superKcial myometrium
Not suitable if woman would like to have children in future or previous multiple Caesareans First generation techniques use electrosurgical loop or heated rollerball (now only recommended when hysteroscopic myomectomy needed, for Kbroids <3cm) Newer techniques involve microwaves, radio waves, cryotherapy, thermal balloons Endometrial ablation Rollerball ablation vs. Novasure
