Dysfunctional Uterine Bleeding

General Gynecology

Clinicals - History

Fact Explanation
Heavy menstrual bleeding (with passage of clots and flooding) This is the commonest presenting symptom in most women. Heavy menstrual bleeding is defined as a menstrual blood loss greater than 80 mL. A crude measure can be made by asking how many blood soaked sanitary napkins are used during a day, whether there is passage of clots, whether there is flooding of blood etc. Heavy menstrual bleeding (with passage of clots and flooding)
This is the commonest presenting symptom in most women. Heavy menstrual bleeding is defined as a menstrual blood loss greater than 80 mL. A crude measure can be made by asking how many blood soaked sanitary napkins are used during a day, whether there is passage of clots, whether there is flooding of blood etc.
Irregular menstrual bleeding Occur in women at extremes of reproductive life i.e. postmenarche and perimenopausal Irregular menstrual bleeding
Occur in women at extremes of reproductive life i.e. postmenarche and perimenopausal
Dysmenorrhoea May be an associated symptom Dysmenorrhoea
May be an associated symptom
Prolonged menstrual bleeding Can be a associated with heavy menstrual bleeding Prolonged menstrual bleeding
Can be a associated with heavy menstrual bleeding

Clinicals - Examination

Fact Explanation
Pallor Pallor may be seen in women with anemia due to heavy menstrual bleeding. Pallor
Pallor may be seen in women with anemia due to heavy menstrual bleeding.
Abdominal palpation is normal DUB is a diagnosis of exclusion. There will be abnormalities such as the presence of a mass will lead to a different diagnosis such as an ovarian tumor, uterine fibroid etc. Abdominal palpation is normal
DUB is a diagnosis of exclusion. There will be abnormalities such as the presence of a mass will lead to a different diagnosis such as an ovarian tumor, uterine fibroid etc.
The cervix will appear normal in vaginal speculum examination DUB is diagnosed when all other possible pathologies are excluded. If cervix appears normal cervical causes for bleeding can be clinically excluded The cervix will appear normal in vaginal speculum examination
DUB is diagnosed when all other possible pathologies are excluded. If cervix appears normal cervical causes for bleeding can be clinically excluded
Bimanual examination of uterus and adnexiae is normal This excludes the possibility of a uterine or ovarian mass etc. leading to heavy menstrual bleeding. Bimanual examination of uterus and adnexiae is normal
This excludes the possibility of a uterine or ovarian mass etc. leading to heavy menstrual bleeding.

Investigations - Diagnosis

Fact Explanation
Urine Beta-hCG Done to exclude pregnancy Urine Beta-hCG
Done to exclude pregnancy
Clotting screen (APTT , PT/INR, Clotting time, Bleeding time) Done if a clotting disorder is clinically suspected Clotting screen (APTT , PT/INR, Clotting time, Bleeding time)
Done if a clotting disorder is clinically suspected
Serum TSH and T4 Done to detect hypothyroidism, if it is clinically suspected Serum TSH and T4
Done to detect hypothyroidism, if it is clinically suspected
Cervical smear Done to detect cervical pathology. But need not be done routinely if smear history is normal Cervical smear
Done to detect cervical pathology. But need not be done routinely if smear history is normal
Trans-vaginal ultra sound scan (TVS) Done to detect fibroids, polyps and to determine endometrial thickness particularly in women over the age of 40 yearsThis is the first line investigation to detect structural abnormalities Trans-vaginal ultra sound scan (TVS)
Done to detect fibroids, polyps and to determine endometrial thickness particularly in women over the age of 40 yearsThis is the first line investigation to detect structural abnormalities
Endometrial biopsy Done if the endometrial thickness is increased as seen by TVS Endometrial biopsy
Done if the endometrial thickness is increased as seen by TVS
Hysteroscopy and biopsy Done if there is suspicion of endometrial hyperplasia or cancer and when TVS is inconclusive Hysteroscopy and biopsy
Done if there is suspicion of endometrial hyperplasia or cancer and when TVS is inconclusive

Investigations - Management

Fact Explanation
Complete blood count test(CBC) Done to detect presence of anemia as women with heavy menstrual bleeding are at risk to develop anemia. Complete blood count test(CBC)
Done to detect presence of anemia as women with heavy menstrual bleeding are at risk to develop anemia.
Serum ferritin Done to detect iron deficiency,if only indicated by CBC Serum ferritin
Done to detect iron deficiency,if only indicated by CBC

Management - Supportive

Fact Explanation
Iron tablets (Ferrous sulphate) Oral iron replacement therapy is given when iron deficiency anemia is present Iron tablets (Ferrous sulphate)
Oral iron replacement therapy is given when iron deficiency anemia is present

Management - Specific

Fact Explanation
Nonsteroidal anti-inflammatory drugs Mefenamic acid is given to reduce menstrual blood loss in patients with heavy menstrual bleeding and it also reduces dysmenorrhoea Nonsteroidal anti-inflammatory drugs
Mefenamic acid is given to reduce menstrual blood loss in patients with heavy menstrual bleeding and it also reduces dysmenorrhoea
Antifibrinolytics Tranexamic acid is prescribed to reduce the menstrual blood loss in heavy menstrual bleeders Antifibrinolytics
Tranexamic acid is prescribed to reduce the menstrual blood loss in heavy menstrual bleeders
Levonorgestrel ­releasing intrauterine system (LNG­-IUS) This treatment method reduces the menstrual blood loss significantly. Can be used in both ovulatory and anovulatory DUB. Provides contraception. Levonorgestrel ­releasing intrauterine system (LNG­-IUS)
This treatment method reduces the menstrual blood loss significantly. Can be used in both ovulatory and anovulatory DUB. Provides contraception.
Combined oral contraceptives (COCs) COCP pills reduce menstrual blood loss and improves dysmenorrhoea and also provides contraception Combined oral contraceptives (COCs)
COCP pills reduce menstrual blood loss and improves dysmenorrhoea and also provides contraception
Oral progestogen (norethisterone) Cyclical treatment with noresthisterone or medroxyprogesterone acetate regulates menstrual cycles. It can also be given for emergency suppression of heavy menstrual bleeding. Oral progestogen (norethisterone)
Cyclical treatment with noresthisterone or medroxyprogesterone acetate regulates menstrual cycles. It can also be given for emergency suppression of heavy menstrual bleeding.
Gonadotrophin ­releasing hormone analogue (GnRH­-a) This treatment is given when first line medical treatment has failed and there are are contraindications to surgery. GnRH analogues induce medical menopause and cause bone demineralisation.Therefore this treatment is limited to 6 months. Gonadotrophin ­releasing hormone analogue (GnRH­-a)
This treatment is given when first line medical treatment has failed and there are are contraindications to surgery. GnRH analogues induce medical menopause and cause bone demineralisation.Therefore this treatment is limited to 6 months.
Endometrial ablation Done if the patients fails to respond to medical management and only if she has completed her family. Radiofrequency ablation, thermal balloon endometrial ablation(TBEA), microwave endometrial ablation (MEA) are methods currently used for endometrial ablation. Endometrial ablation
Done if the patients fails to respond to medical management and only if she has completed her family. Radiofrequency ablation, thermal balloon endometrial ablation(TBEA), microwave endometrial ablation (MEA) are methods currently used for endometrial ablation.
Hysterectomy This is the only definitive cure for DUB. But has higher complications and morbidity. Therefore is done as the last option when all other treatment fails in a woman who has no future fertility wishes. Hysterectomy
This is the only definitive cure for DUB. But has higher complications and morbidity. Therefore is done as the last option when all other treatment fails in a woman who has no future fertility wishes.

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