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Comprehensive Gynecology 12th Ed: Abnormal Uterine Bleeding One third of those who require transfusion

50% of those whose severe menorrhagia occurred at the time of the first
Abnormal Uterine Bleeding menstrual period
Take many forms Falcone and associates: Indicated that a coagulation disorder was found in only
1. Infrequent episodes 5% of adolescents hospitalized for heavy bleeding.
2. Excessive flow Both studies indicated that the likelihood of a blood disorder in adolescents with
3. Prolonged duration of menses heavy menses is sufficiently high that all adolescents should be evaluated to
4. Intermenstrual bleeding. determine whether a coagulopathy is present.
Alterations in the pattern or volume of blood flow of menses are among the most In the adult, abnormal bleeding may be encountered frequently in women
common health concerns of women. receiving anticoagulation for a variety of medical disorders
Infrequent uterine bleeding Pattern of bleeding is usually menorrhagia but abnormal intracycle
OLIGOMENORRHEA bleeding also occurs.
Intervals between bleeding episodes vary from 35 days to 6 months Any other chronic systemic diseases can result an abnormal bleeding
AMENORRHEA Include hepatitis, renal disease, and cardiac disease, as well as coronary
No menses for at least 6 months vascular disorders
Normal menstrual flow Mechanism is usually anovulation related to hypothalamic causes and/or
Mean interval between menses: 28 days (7 days) problems with estrogen metabolism.
Abnormal if bleeding occurs at intervals of 21 days or less Endocrine disorders may lead to abnormal bleeding
Mean duration of menstrual flow is 4 days Include disorders of hormones such as thyroid, prolactin (PRL), and
Bleeding for longer than 7 days is abnormally prolonged cortisol
(MENORRHAGIA)
It is useful to document the duration and frequency of menstrual flow with the REPRODUCTIVE TRACT DISEASE
use of Menstrual Diary Cards Most common causes of abnormal uterine bleeding in women of reproductive
It is difficult to determine the amount of menstrual blood loss (MBL) by age are accidents of pregnancy
subjective means. Such as Threatened, Incomplete, or Missed Abortion and Ectopic
Several studies have shown that there is poor correlation between Pregnancy.
subjective judgment and objective measurement of MBL. Trophoblastic Disease must be considered in the differential diagnosis of
Subjective methods are used in predicting blood loss abnormal bleeding in any woman who has had a recent pregnancy
1. Pictorial Bleeding Assessment Chart Sensitive b-Human Chorionic Gonadotropin (-hCG) assay should be performed
2. Alkaline Hematic Method as part of the diagnostic evaluation.
More accurate method Any malignancy of the genital tract, particularly Endometrial and Cervical
Measures Hematin Cancer, may present as abnormal bleeding.
Less commonly, Vaginal, Vulvar, and Fallopian Tube Cancer may produce
Average menstrual blood loss is 35 mL
abnormal bleeding
Total volume is twice this amount
Estrogen-producing Ovarian Tumors may become manifest by abnormal
Being made up of endometrial tissue exudate
uterine bleeding.
Amount of MBL increases with parity but not age in the absence of Granulosa Theca Cell Tumors may present with excessive uterine
disease bleeding.
MENORRHAGIA Infection of the upper genital tract, particularly Endometritis
MBL of 80 mL or greater May present as prolonged menses
Occurs in 9% to 14% of women Episodic intermenstrual spotting is a more common symptom.
Endometriosis
CAUSES
May also result in abnormal bleeding
Causes of abnormal bleeding can be divided into
Frequently presents as premenstrual spotting
1. Organic Causes
Relate to the location of the endometriosis implants.
2. Dysfunctional (or hormonally related)
Dysfunctional Uterine Bleeding (DUB) Anatomic uterine abnormalities such as Submucous Myomas, Endometrial
Further divided into Polyps, and Adenomyosis frequently produce symptoms of prolonged and
excessive regular uterine bleeding
a) Anovulatory Bleeding
Secondary to abnormal vasculature and blood flow, as well as increased
b) Ovulatory Bleeding
inflammatory changes.
ORGANIC CAUSES Cervical lesions such as Erosions, Polyps, and Cervicitis
Subdivided into May cause irregular bleeding, particularly postcoital spotting
a) Systemic Disease Usually be diagnosed by visualization of the cervix
b) Reproductive Tract Disease. Traumatic vaginal lesions, severe vaginal infections, and foreign bodies
have been associated with abnormal bleeding.
Systemic Disease Foreign bodies in the uterus, such as an Intrauterine Device (IUD), frequently
Particularly disorders of blood coagulation such as von Willebrand disease and produce abnormal uterine bleeding.
Prothrombin Deficiency Iatrogenic causes include
Initially present as abnormal uterine bleeding Oral and injectable steroids such as those used for contraception and
Other disorders that produce platelet deficiency, such as Leukemia, Severe hormonal replacement or for the management of dysmenorrhea,
Sepsis, Idiopathic Thrombocytopenic Purpura, and Hypersplenism can also hirsutism, acne, or endometriosis.
cause excessive bleeding. Tranquilizers and other psychotropic drugs
Routine screening for coagulation defects is mainly indicated for the adolescent May interfere with the neurotransmitters responsible for releasing
who has prolonged heavy menses beginning at menarche, unless otherwise and inhibiting hypothalamic hormones, thus causing anovulation
indicated by clinical signs such as petechiae or ecchymosis. and abnormal bleeding.
Claessens and Cowell: Coagulation disorders are found in
Approximately 20% of adolescent girls who require hospitalization for DYSFUNCTIONAL CAUSES
abnormal uterine bleeding. After organic, systemic, and iatrogenic causes for the abnormal bleeding have
Present in approximately 25% of those whose hemoglobin levels fall been ruled out, the diagnosis of DUB can be made
below 10 g/100 mL Two types of DUB

By: Rem Alfelor Comprehensive Gynecology 12th Ed: Abnormal Uterine Bleeding Page 1 of 7
a) Anovulatory have excessive uterine production of prostacyclin, a vasodilatory
b) Ovulatory prostaglandin that opposes platelet adhesion and may also interfere
Predominant cause of DUB in the postmenarchal and premenopausal years is with uterine contractility
anovulation secondary to alterations in neuroendocrinologic function Deficiency of uterine PGF2 or excessive production of PGE (another
vasodilatory prostaglandin) may also explain ovulatory DUB
Ratio of PGF2a/PGE correlates inversely with menstrual blood loss
Other uterine factors affecting blood flow, such as the Endothelins and
Anovulatory DUB Vascular Endothelial Growth Factor, which controls blood vessel formation,
There is continuous estradiol production without corpus luteum may be abnormal in some women with ovulatory DUB.
formation and progesterone production
Steady state of estrogen stimulation leads to a continuously
DIAGNOSTIC APPROACH
proliferating endometrium, which may outgrow its blood supply or lose It is essential to take a thorough history of frequency, duration, and amount of
nutrients with varying degrees of necrosis bleeding
Uniform slough to the basalis layer does not occur which produces Inquire whether and when the menstrual pattern has changed
excessive uterine blood flow Extremely important for determining whether the menstrual abnormality is
Occurs most commonly during the extremes of reproductive life in the Polymenorrhea, Menorrhagia (Hypermenorrhea), Metorrhagia,
first few years after menarche and during perimenopause. Menometorrhagia, or Intermenstrual Bleeding.
Adolescent: Cause of the anovulation is an immaturity of the History and physical examination provide clues about the diagnosis of PCOS
hypothalamic-pituitary ovarian (HPO) axis and failure of positive and other disorders.
Providing the woman with a calendar to record her bleeding episodes is helpful
feedback of estradiol to cause a luteinizing hormone (LH) surge
way to characterize definitively the bleeding episodes
Perimenopausal: a lack of synchronization between the components of Objective criteria should be used to determine if menorrhagia (blood loss>80
the HPO axis occurs as the woman approaches ovarian failure. mL) is present.
Pattern of anovulatory bleeding may be oligomenorrhea, Direct measurement of MBL is not generally possible
menometrorrhagia, metrorrhagia, or menorrhagia Indirect assessment by measurement of hemoglobin concentration, serum
Different patterns of bleeding occur within a distinct entity of iron levels, and serum ferritin levels is useful
anovulatory DUB is related to variations in the integrity of the Serum Ferritin Level provides a valid indirect assessment of iron
endometrium and its support structure. stores in the bone marrow
Up to 20% of women reporting normal menses may also be anovulating Additional useful laboratory tests include
Sensitive -hCG level determination
Pattern of Ovulatory DUB is mainly that of menorrhagia.
Sensitive TSH assay
Causes of Anovulatory DUB PRL
Extremes of reproductive life If PCOS is suspected, Androgen Level measurements may be
Women in their reproductive years: considered, but are not necessary.
Frequently because of polycystic ovary syndrome (PCOS), For adolescent girls, as well as older women with systemic disease, a
Suggested by other symptoms and signs, such as Coagulation Profile should be obtained to rule out a coagulation defect.
If the woman has regular cycles, it is important to determine whether she is
acne, hirsutism, and increased body weight
ovulating
Hypothalamic dysfunction which could have no known Ovulatory DUB displays a pattern of repetition with heavy bleeding.
cause or be related to weight loss, severe exercise, stress, If bleeding is very irregular, it may be difficult to determine the phase of
or drug use. the cycle to document ovulatory function by means of serum progesterone
Abnormalities of other (nonreproductive) hormones can lead to anovulatory DUB level determination or other methods
Not considered to be DUB but are closely related Endometrial biopsy may be indicated
Lead to anovulatory bleeding If obtained at the onset of bleeding, will show secretory changes
Most common hormones involved are thyroid hormone, prolactin, and Transvaginal ultrasound can be helpful in ruling out pathology and helping to
cortisol. guide the need for endometrial biopsy.
Hypothyroidism Endometrial biopsy
Elevated thyroid stimulating hormone (TSH) level can lead to Women who are older (>35 years) and/or have a long history of excessive
anovulatory bleeding. bleeding
Unexplained causes of ovulatory DUB (see later) may also be Endometrial lining > 8 mm has a greater sensitivity for picking up
explained by subtle hypothyroidism. endometrial pathology.
Hyperprolactinemia If bleeding has been prolonged and an ultrasound endometrial thickening
PRL level >20 ng/mL can also lead to anovulatory bleeding, as can is < 4 mm, there is little benefit for a biopsy in this setting
hypercortisolism Biopsy at the time of bleeding can also help determine whether the
Cushings syndrome is rare bleeding is caused by ovulatory function if it reveals a secretory
May be considered only if other signs are present endometrium.
e.g., obesity, moon facies, buffalo hump, striae, weakness It is often valuable to assay the SHG level in women with menorrhagia.
TSH and PRL assays should be part of the normal workup. To rule out an intracavity lesion before ascribing the diagnosis to ovulatory
DUB
Ovulatory Dysfunctional Uterine Bleeding Saline or sterile water (1015 mL) is usually introduced through the cervix
Women who present with menorrhagia without causes such as uterine lesions, with an insemination catheter, or with a special Hysterosalpingography
polyps, fibroids (HSG) catheter that has a balloon for inflation in the cervical canal,
It is important to understand how menstrual bleeding ceases each month to allowing continuous infusion. If this is not available, HSG may be ordered.
appreciate what can go wrong in ovulatory DUB. Hysteroscopy
Primary line of defense is a platelet plug Excellent diagnostic technique
Followed by uterine contractility Has the potential advantage of being able to treat the abnormality at the
Largely mediated by Prostaglandin F2 (PGF2) same time such as removal of a polyp
prolonged and heavy bleeding can occur with abnormalities of the It is not cost-effective as a diagnostic test if it cannot be carried out in an
platelet plug and/or inadequate uterine levels of PGF2a women office setting.

By: Rem Alfelor Comprehensive Gynecology 12th Ed: Abnormal Uterine Bleeding Page 2 of 7
Can be performed in the office, with or without local anesthesia May be continued for up to 6 months with the situation reevaluated
More accurate diagnostic procedure than a dilation and curettage (D&C) thereafter
D&C Oral Contraceptive (OC)
Blind technique May not be necessary and does not allow the HPO to mature on its
Does not always detect focal lesions own.
Apart from an SHG or similar technique to rule out lesions before a diagnosis of If the problem persists beyond 6 months, OCs may be an option in
ovulatory DUB is made in some women presenting with menorrhagia that the condition may be more chronic.
A subtle hypothyroidism can also be found. If this is found, it is strictly not In the perimenopausal woman who has dysregulation of the HPO axis, there is
ovulatory DUB. much variability and unpredictability of cycles because the HPO axis is in flux,
A third-generation ultrasensitive TSH assay should be performed moving toward ovarian failure
and elevations should be assessed further Most of the bleeding in this setting is caused by anovulation, occasional
Coagulation defects can also present in this setting ovulation can occur, with or without a normal luteal phase, which is highly
Studies have found a fairly high prevalence of coagulation disorders in variable and erratic
women presenting with menorrhagia. More efficient to use a Low-Dose (20-mg) OC pill (OCP) in a nonsmoking
Most abnormalities are platelet-related woman.
Single most common abnormality is a form of von Willebrand disease Progestogens used cyclically
Prevalence of von Willebrand disease is 13% in women with Preventing endometrial tissue from building up because of
menorrhagia. anovulation will help the endometrium but will not reliably
von Willebrand factor is responsible for proper platelet adhesion control bleeding because of the unpredictability of the
and protects against coagulant factor degradation. hormonal situation.
During reproductive life, chronic anovulatory DUB, after a careful workup
History is key before a comprehensive
Primarily caused by hypothalamic dysfunction leading to anovulation or
Hematologic workup is undertaken
PCOS.
History of menorrhagia
OCPs work well in this setting
Family history of bleeding
Alternative is Cyclic Progestogens
Epistaxis
Women may also wish to conceive, in which case ovulation induction is
Bruising
indicated.
Gum bleeding
Postpartum hemorrhage Ovulatory Dysfunctional Uterine Bleeding
Surgical bleeding For women with menorrhagia for whom there is no known cause and anatomic
In the absence of these clues, a comprehensive workup is probably lesions have been ruled out, the aim of therapy is to reduce the amount of
unnecessary at outset but should be considered in cases refractory excessive bleeding
to treatment Some women with ovulatory DUB have abnormal prostaglandin production and
Hematologist should be consulted. some have alterations of endometrial blood flow.
Treatment involves a variety of options, including: Options for treatment to reduce blood loss include
a) Oral contraceptives for milder cases a) More prolonged regimen of Progestogens (3 weeks each month)
Levonorgestrel Releasing Intrauterine System Shorter cyclic therapy does not work here
(Mirena IUS) Doses in excess of 10 mg daily of Medroxyprogesterone Acetate
Tranexamic Acid, 1 g every 6 hours during menses (MPA) have been used
Desmopressin (DDAVP) intranasally, one puff per Large doses can cause side effects and weight gain when
nostril for the first 3 days of menses used for several months and may not be necessary.
TREATMENT OCPs will reduce the blood loss by 50% in women with ovulatory
In the absence of an organic cause for excessive uterine bleeding, it is DUB.
preferable to use medical instead of surgical treatment, especially if the b) Use of the Levonorgestrel IUS
woman desires to retain her uterus for future childbearing or will be Menorrhagia can be substantially reduced
undergoing natural menopause within a short time. It should be noted that in ovulatory DUB, although all obvious lesions have been
Includes: ruled out, some anatomic abnormalities cannot be easily diagnosed.
These include endometriosis and Adenomyosis, although this might be
a) Estrogens
improved with imaging.
b) Progestogen (Systemic Or Local) Thus, other options also have to be considered for reducing blood loss.
c) Nonsteroidal Anti-Inflammatory Drugs (Nsaids)
Local progestogen exposure
d) Anti-Fibrinolytic Agents
e) Danazol Progesterone-Releasing IUD
f) Gonadotropin-Releasing Hormone (Gnrh) Agonists Effective for the treatment of women with ovulatory DUB
Type of treatment depends on whether it is used to stop an acute heavy This device needs to be reinserted annually because of the rapid
bleeding episode or is given to reduce the amount of MBL in subsequent diffusion of progesterone through polysiloxane
menstrual cycles. No longer available
Before instituting long-term treatment, definitive diagnosis is required and should Levonorgestrel-Releasing Intrauterine System (LNG-IUS)
be made on the basis of hysteroscopy, sonohysterography, or directed Effective duration of action of more than 5 years
endometrial biopsies, if indicated, with definitive treatment determined by the At the end of 3 months, it caused an average 80% reduction in
diagnosis. MBL, which increased to 100% at the end of 1 year
Reduction in MBL is significantly greater than that achieved with an
Anovulatory Dysfunctional Uterine Bleeding antifibrinolytic agent or a prostaglandin synthetase inhibitor
In adolescents, after ruling out coagulation disorders, the main direction of
Effective in increasing hemoglobin levels, decreasing
therapy is to temporize because with time and maturity of the HPO axis, the
dysmenorrhea, and reducing blood loss caused by fibroids and
problem will be corrected
Adenomyosis.
Cyclic progestogen: Medroxyprogesterone Acetate
10 mg for 10 days each month for a few months Nonsteroidal Anti-inflammatory Drugs
All that is needed to produce reliable and controlled menstrual Prostaglandin synthetase inhibitors that inhibit the biosynthesis of the cyclic
cycles. endoperoxides, which convert arachidonic acid to prostaglandins

By: Rem Alfelor Comprehensive Gynecology 12th Ed: Abnormal Uterine Bleeding Page 3 of 7
These agents block the action of prostaglandins by interfering directly at their As with NSAIDS, they are best combined with another agent, such as oral
receptor sites. contraceptives, for a greater effect on MBL reduction.
To decrease bleeding of the endometrium, it would be ideal to block selectively
the synthesis of prostacyclin alone, without decreasing thromboxane formation, Androgenic Steroids (Danazol)
because the latter increases platelet aggregation DANAZOL
All NSAIDs are cyclooxygenase inhibitors and thus block the formation of both Has been used by several investigators for the treatment of menorrhagia.
thromboxane and the prostacyclin pathway Doses of 200 and 400 mg daily given over 12 weeks after careful pretreatment
Have been shown to reduce MBL, primarily in women who ovulate observation and evaluation.
Administered during menses to groups of women with menorrhagia and MBL was markedly reduced in these studies from more than 200 to less than 25
ovulatory DUB and have been found to reduce the mean MBL by approximately mL
20% to 50% There was an increased interval between bleeding episodes
Mefenamic Acid (500 mg, three times daily) Most common side effects are weight gain and acne.
Ibuprofen (400 mg, three times daily) Reduction of dosage from 400 to 200 mg daily decreased the side effects
Meclofenamate Sodium (100 mg, three times daily) but did not alter the reduction in blood loss
Naproxen Sodium (275 mg, every 6 hours after a loading dose of 550 Some women may ovulate when receiving this dose of Danazol
mg) Further reduction to 100 mg daily did not effectively reduce MBL in most women.
Usually given for the first 3 days of menses or throughout the bleeding episode. Although Danazol is effective, it is also expensive and has moderate side
Have similar levels of effectiveness. effects.
Not all women treated with these agents have reduction in blood flow, but those Dockeray and associates: Women with DUB
without a decrease usually had only a mildly increased amount of MBL Danazol was more effective in reducing MBL, 60% compared with 20% for
Greatest amount of MBL reduction occurs in women with the greatest Mefenamic Acid
pretreatment blood loss Adverse side effects were more severe with Danazol and occurred in 75%
Fraser and coworkers: treatment of menorrhagia with Mefenamic Acid in for of patients, compared with side effects in only 30% of patients treated with
longer than 1 year results in a significantly sustained reduction in amounts of Mefenamic Acid
MBL and a significant increase in serum ferritin levels
Can be used for long-term treatment because side effects, mainly
gastrointestinal (GI), are mild with this intermittent therapy. Cochrane review:
Can also be given in combination with OCs or Progestins approach, Danazol appears to be more effective than placebo, oral progestogens,
Reduction in MBL can be achieved more effectively than with the use of oral contraceptives, and NSAIDs. However, compared with NSAIDs, the
any of these agents alone. side effects of weight gain and skin problems were sevenfold and fourfold
greater when compared with Progestogens.
Anti-fibrinolytic Agents
a) -Aminocaproic Acid (EACA) Gonadotropin-Releasing Hormone Agonists
b) Tranexamic Acid (AMCA) Inhibit ovarian steroid production
c) Para-Aminomethyl Benzoic Acid (PAMBA) Daily administration of a GnRH agonist for 3 months markedly reduced MBL
Potent inhibitors of fibrinolysis and have therefore been used in the of various from 100 to 200 mL per cycle to 0 to 30 mL per cycle.
hemorrhagic conditions Unfortunately, after therapy was discontinued, blood loss returned to
Nilsson and Rybo: Compared the effect on blood loss of EACA, AMCA, and oral pretreatment levels
contraceptives in women with Because of the expense and side effects of these agents, their use for
EACA 18 g/day for 3 days and then 12, 9, 6, and 3 g daily on successive menorrhagia caused by ovulatory DUB is limited to women with severe MBL
days who fail to respond to other methods of medical management and wish to retain
total dose was always at least 48 g their childbearing capacity.
AMCA 6 g/day for 3 days followed by 4, 3, 2, and 1 g/day on successive Use of an Estrogen and/or Progestin (add-back therapy) together with the
days agonist will help prevent bone loss.
total dose of at least 22 g
Significant reduction in blood loss after treatment with EACA, AMCA, and MANAGEMENT OF ACUTE BLEEDING
In women who are bleeding very heavily and are hemodynamically unstable, the
OCs
Use of each of these agents resulted in approximately a 50% \ reduction quickest way to stop acute bleeding is with a Curettage
Should also be the preferred approach for older women and those with
in MBL
The greatest reduction in blood loss with anti-fibrinolytic therapy occurred medical risk factors for whom high-dose hormonal therapy might pose a
great risk.
in women who exhibited the greatest MBL.
Preston and colleagues: Compared the effects of 4 g of AMCA daily for 4 days
each cycle with 10 mg of norethindrone for 7 days each cycle in a group of
women with ovulatory menorrhagia with a mean MBL of 175 mL.
AMCA reduced MBL by 45%
20% increase with Norethindrone
Side effects of this class of drugs, in decreasing order of frequency, are
nausea, dizziness, diarrhea, headaches, abdominal pain, and allergic
manifestations.
Much more common with EACA than with AMCA. Other
investigators have compared the use of AMCA with placebo in
double-blind studies PHARMACOLOGIC AGENTS
Found no significant differences in the occurrence of side effects. To stop acute bleeding that does not require curettage; the most effective
Renal failure and pregnancy are contraindications to the use of Anti-fibrinolytic regimen involves High-Dose Estrogen.
agents. This treatment, aimed at stopping acute bleeding, is diagnosis-independent and
Clearly produce a reduction in blood loss is merely a temporary measure.
May be used as therapy for women with menorrhagia who ovulate. Use is Estrogens
somewhat limited by side effects Rationale for treatment of DUB is based on the fact that estrogen in
Mainly GI side effects and can be minimized by reducing the dose and limiting pharmacologic doses causes rapid growth of the endometrium.
therapy to the first 3 days of bleeding This is for the acute management of abnormal bleeding

By: Rem Alfelor Comprehensive Gynecology 12th Ed: Abnormal Uterine Bleeding Page 4 of 7
Bleeding those results from most causes of DUB will respond to this therapy Options are therapy with Progestogen Alone given continuously or
because a rapid growth of endometrial tissue occurs over the denuded and raw intermittently
epithelial surfaces Invasive Curettage
Effect is independent of the cause of abnormal bleeding. Remains the fastest way to stop acute bleeding
To control an acute bleeding episode: Use of oral conjugated Equine Estrogen Should be used in women who are volume-depleted and severely anemic
(CEE) 10 mg/day, in four divided doses, is a therapeutic regimen that has been (hemodynamically unstable).
found to be clinically useful When ultrasound is available
In addition to the rapid growth mechanism of action, these large doses of It is more logical to use Estrogen therapy if there is prolonged heavy
CEE may alter platelet activity, thus promoting platelet adhesiveness. bleeding in the setting of a thin endometrium (<5-mm stripe)
Livio and coworkers: Reported that 6 hours after infusion of an average dose of If the endometrium is thick (>10 to 12 mm), or if an anatomic finding is
30 mg of CEE to individuals with a prolonged bleeding time caused by renal suspected, Curettage should be considered
failure, the bleeding time was significantly shortened Unless bleeding is extremely heavy (where Estrogen Therapy is
Measurements of various clotting factors were unchanged after CEE preferred), Progestogens may be used initially and will help by organizing
infusion. the endometrium
Acute bleeding from most causes is usually controlled, but if bleeding does not In the setting of a thickened irregular endometrium, if curettage is not
decrease within the first 24 hours, consideration must be given to an organic performed, an endometrial biopsy should be obtained.
cause, e.g., accident of pregnancy should be considered, and curettage be
considered. Progestogens
IV administration of Estrogen is also effective in the acute treatment of Progestogens
menorrhagia. Not only stop endometrial growth but also support and organize the
DeVore and associates: endometrium so that an organized slough occurs after their withdrawal.
Significantly greater percentage of women had cessation of bleeding 2 In the absence of progesterone, erratic unorganized breakdown of the
hours after the second of two 25-mg doses of CEE was administered IV, 3 endometrium occurs.
hours apart. With progestogen treatment, an organized slough to the basalis layer allows a
No significant difference in cessation of bleeding between women rapid cessation of bleeding
administered Estrogen and those given a placebo 3 hours after the first Stimulate Arachidonic Acid formation in the endometrium, increasing the
infusion PGF2a/PGE ratio.
At least several hours are required to induce mitotic activity and growth of There is no evidence that progestogen will stop acute bleeding.
the endometrium, whether the Estrogen is administered orally or After stabilization of the endometrium occurs (2 to 3 days), bleeding slows down
parenterally and eventually stops
IV Estrogen therapy accompanied by its rapid metabolic clearance does As initial therapy, a regimen of progestogen only may be appropriate, but
not appear to offer a significant advantage compared with the same dose only for those with less significant acute bleeding who do not require
of Estrogen given orally immediate cessation of bleeding
If IV therapy is chosen, it usually requires that women remain in the office or Administered actively, do not stop bleeding but may slow it down as organization
clinical setting for 4 to 6 hours to receive at least a second dose. of the tissue occurs.
Estrogen therapy reduces the amount of uterine bleeding within the first Higher doses of Norethindrone, however, which have been suggested to stop
24 hours after treatment is initiated. bleeding more acutely, may be efficacious on the basis of some conversion to
Because most women with an acute heavy bleeding episode bleed Ethinyl Estradiol
because of anovulation, Progestin treatment is also required Mimicking the use of a low-dose OCP
After bleeding has ceased, oral Estrogen therapy is continued at the same Mainstay of progestogen therapy is opposing the effects of estrogen in
dosage and a Progestin, usually MPA, 10 mg once daily, is added. anovulatory women.
Both hormones are administered for another 7-10 days, after which For women with a history of bothersome Menometorrhagia, it is advisable to use
treatment is stopped to allow withdrawal bleeding, which may have an intermittent Progestogens for several months or an OC.
increased amount of flow but is rarely prolonged. MPA, 10 mg/day for 10 days each month, is a successful therapeutic regimen
After the withdrawal bleeding episode, one of several other treatment modalities that produces regular withdrawal bleeding in women with adequate amounts of
should be used. endogenous Estrogen to cause endometrial growth.
Before instituting long-term treatment, a definitive diagnosis should be 19-Norprogestogens, such as Norethindrone or Norethindrone
made after reviewing the endometrial histology. Acetate (2.5 to 5 mg) may be used in the same regimen
Definitive treatment should be based on these findings. More androgenic progestogens are less favorable for metabolic
OCs are usually the best long-term treatment. parameters
More convenient method to stop acute bleeding than the sequential high- High-Density Lipoprotein [HDL]
dose Estrogen-Progestin regimen is the use of a combination oral Cholesterol
contraceptive containing both estrogen and progestin. Carbohydrate Tolerance
Four tablets of an Oral Contraceptive containing 50 mg of Estrogen
Short term cyclic therapy is considered to be safe.
taken every 24 hours in divided doses will usually provide sufficient
Estrogen to stop acute bleeding and simultaneously provide Progestin.
SURGICAL THERAPY
Treatment is continued for at least 1 week after the bleeding stops.
Dilation and Curettage
This is successful and convenient, and is thus the preferred method of Performance can be diagnostic and is therapeutic for the immediate
some clinicians. management of severe bleeding.
Found not to be as effective as of high doses of CEE. For women with markedly excessive uterine bleeding who may be hypovolemic,
Combined use of estrogen and progestin does not cause as rapid D&C is the quickest way to stop acute bleeding.
endometrial growth as estrogen alone, because the progestin Treatment of choice in women who suffer from hypovolemia.
decreases the synthesis of estrogen receptors and increases May be preferred as an approach to stop an acute bleeding episode in women
estradiol dehydrogenase in the endometrial cell, thus inhibiting the older than 35 when the incidence of pathologic findings increases.
growth-promoting action of estrogen. Use of D&C for the treatment of DUB has been reported to be curative only
High-dose estrogen, even for a short course, may be contraindicated for some
rarely.
women Temporary cure of the problem may occur in some women with chronic
Those with prior thrombosis
anovulation, because the curettage removes much of the hyperplastic
Certain rheumatologic diseases endometrium
Estrogen responsive cancer The underlying pathophysiologic cause is unchanged

By: Rem Alfelor Comprehensive Gynecology 12th Ed: Abnormal Uterine Bleeding Page 5 of 7
Not proved useful for the treatment of women who ovulate and have Controller unit heats the fluid and monitors the pressure and treatment
menorrhagia. time.
Nilsson and Rybo: Shown that more than 1 month after the D&C, there was no Destruction of the endometrium is carried out in approximately 8 mins.
difference or an increase in MBL in women with menorrhagia who ovulate. Prior to any EA techniques, Endometrial Sampling is required as part of the
D&C is only indicated for women with acute bleeding resulting in workup evaluation of the woman with abnormal bleeding
hypovolemia and for older women who are at higher risk of having Uterine cavity should be evaluated for size and presence of pathology that
endometrial neoplasia. may limit come of the techniques.
All other women, after having an endometrial biopsy, sonohysteroscopy, With the possible exception of the use of the NovaSure system, a review by
or diagnostic hysteroscopy to rule out organic disease, are best treated Sowter has confirmed the benefit of pretreatment with Danazol or a GnRH
with medical therapy without D&C. Agonist before an ablation
More successful when a thin endometrial lining is present.
Endometrial Ablation Most systems typically treat to a depth of 4-6 mm.
Abnormal bleeding may be treated by endometrial ablation (EA) if medical In the evaluation, it is important to note that there is no thinning of the
therapy is not effective. myometrium from some other cause, such as prior surgery, particularly with the
Exceptions are women who have very large uteri caused by fibroids or microwave method
abnormal pathology, such as endometrial hyperplasia or cancer. Myometrium should be no less than 10 mm anywhere in the uterus.
Alternative to hysterectomy or to the use of the Levonorgestrel IUS, which is Most methods of EA, with the exception of the Her option, may be beneficial in
also highly effective treating submucous fibroids up to 3 cm in size, with the strongest data coming
Laser-based approaches were largely replaced with Resectoscopic from the use of the Microwave and Thermachoice Systems
Techniques to resect, vaporize, or electrodessicate the endometrium Complications are infrequent with EA if adherence occurs to the manufacturers
Most commonly nonresectoscopic devices have been approved by the U.S. guidelines.
Food and Drug Administration (FDA) for this type of treatment. Cervical lacerations and perforations occur more commonly with
Resectoscopic EA endometrial resection.
Usually carried out with a loop electrode, roller ball, or grooved or spiked Lower genital tract burns may occur, as well as endometritis (1%)
electrode to vaporize the endometrium. Syndrome of tubal pain post-EA caused by trapping of endometria at the
Hysteroscopic Surgical Techniques cornual recesses.
Have the advantage of dealing definitively with associated pathology (e.g., Less likely in women with a tubal ligation.
polyps, submucous fibroids) If pregnancy occurs unexpectedly, there is a high incidence of poor
Require greater surgical skill outcomes, including prematurity and placenta accreta.
Have longer procedure times compared with nonresectoscopic methods. Most procedures can now be safely performed in an office setting with
Various nonresectoscopic methods are given in Table 37-2 which lists the paracervical block and conscious sedation.
success rates and limitations based on anatomy. Although amenorrhea may not always occur (only up to 55% of the time),
bleeding is significantly improved for most women.
Hysterectomy is thus avoided in 86% of women
Success is slightly worse in women with a retroverted uterus.

Hysterectomy
The decision to remove the uterus should be made on an individual basis and
should usually be reserved for the woman with other indications for
Most systems, except the Hydro Therm Ablator are carried out without hysterectomy, such as leiomyoma or uterine prolapse.
Should only be used to treat persistent ovulatory DUB after all medical therapy
hysteroscopic monitoring.
Cryotherapy may be performed in approximately 10 minutes using a 4.5-mm has failed and the amount of MBL has been documented to be excessive by
direct measurement or abnormally low serum ferritin levels.
disposable cryoprobe (HER option) which is moved from one uterine cornual
With increasing use of EA to treat this problem, the use of hysterectomy as
recess to the other.
Hydro Therm Ablator therapy for ovulatory DUB should decrease.
As many as 50% of women older than 40 years with menorrhagia without
Uses heated normal saline delivered through a 7.8-mm sheath
uterine lesions have been treated by hysterectomy
Uterus is distended and causes a closed circuit process, heating the
20% of all hysterectomies in women of reproductive age are performed for
saline to 90C and maintaining this temperature for 10 minutes, followed
excessive uterine bleeding.
by a 1min cooling process
Benefits of the LNG-IUS when hysterectomy or ablation is being considered.
Closed system is automated to shut down if there is 10 mL or more
Uterine artery embolization is not particularly effective unless fibroids are the
leakage of fluid via the cervix or fallopian tubes.
Microwave Endometrial Ablation cause of excessive bleeding.
If hysterectomy is chosen, many different options are available, including
Carried out with an 8- mm reusable or disposable probe.
Vaginal Hysterectomy
Once the port is inserted into the fundus, transmission of endometrial
Laparoscopic-Assisted Vaginal Hysterectomy (LAVH)
tissue temperature is available, and the microwave system is activated
when the tissue temperature is 30 C. Laparoscopic or Supracervical Hysterectomy
Movement within the uterus of the microwave probe allows endometrial Laparoscopic Total Hysterectomy
destruct to occur within 2-4 mins. Abdominal Supracervical Hysterectomy
Novasure Radiofrequency Electricity System
Uses a 7.2-mm probe with a bipolar gold mesh electrode that opens to SUMMARY OF APPROACHES TO TREATMENT
conform to the shape of the uterus An important perspective is to approach the woman according to her acute and
Fixed volume of CO2 is injected and monitored to confirm the integrity of chronic needs or short-term and long-term therapy.
the endometrial cavity. Acute bleeding
Suction is carried out during the application of radiofrequency energy to Necessitates immediate cessation of bleeding
remove debris stream. Requires the use of pharmacologic doses of Estrogen or Curettage; the
Vaporization and desiccation is carried out over 80 to 90 secs. latter is used more liberally in older women with risk factors or in those
Thermachoice System who are hemodynamically compromised.
Uses a balloon-tipped catheter (5.5 mm) through which heated 5% This approach is not dependent on whether the woman is
dextrose in water is injected up to a pressure of 160-HD 160-1BO mm Hg anovulatory or ovulatory.

By: Rem Alfelor Comprehensive Gynecology 12th Ed: Abnormal Uterine Bleeding Page 6 of 7
Although estrogen will be temporarily helpful, even if there are abnormal Mean amount of menstrual blood loss in one cycle in normal women was
anatomic findings, such as fibroids, it is preferable to perform Curettage if previously reported to be approximately 35 ml but may be as much as 60 ml
pathology is suspected. Average loss of 13 mg of iron
For less significant bleeding that warrants treatment, but not necessitating Menorrhagia occurs in 9% -14% of healthy women, and most have a normal
the immediate cessation of blood loss duration of menses.
High doses of Progestogen alone may be used. DUB can be caused by anovulation but also occurs in women who ovulate.
It is imperative to know whether the woman is bleeding from an anovulatory or Diagnostic tests in women with menorrhagia include
ovulatory dysfunctional state. Measurement of hemoglobin
Most women fall into the anovulatory category. Serum Iron
In the adolescent, 10 mg of MPA, 10 days each month for at least 3 Serum Ferritin
months, should be prescribed and observed carefully thereafter. -hCG
Additional diagnostic studies should be performed to detect possible defects in TSH
the coagulation process, particularly if bleeding is severe. PRL levels
For the woman of reproductive age, long-term therapy depends on whether she Endometrial Biopsy
requires contraception, induction of ovulation, or treatment of DUB alone. Hysteroscopy
In the latter case, oral OCs or MPA can be administered monthly for at Sonohysterography
least 6 months Hysterosalpingography
OCs and Clomiphene Citrate are used for the other indications.
High doses of oral or IV Estrogen will usually stop acute bleeding episodes in
For the perimenopausal woman who characteristically has fluctuating amounts
most cases of abnormal bleeding.
of circulating estrogen Anovulatory DUB can be treated by cyclic use of Progestins or Oral
Use of Cyclic Progestogen alone is frequently not curative
Contraceptives.
Best treated by low-dose OCs. Patients with ovulatory DUB are best treated with oral contraceptives, NSAIDs
Most difficult type of DUB to treat is chronic treatment of ovulatory women with (Antiprostaglandins), Danazol, or Progestins during the luteal phase or
menorrhagia. Progesterone or Progestins released locally from an IUD.
If anatomic abnormalities are absent, long-term treatment is necessary to NSAIDs administered during menses reduce MBL by 20-50% in women with
reduce MBL ovulatory DUB.
NSAIDs, Progestins, Oral Contraceptives, Danazol, and GnRH D&C should be used to stop the acute bleeding episode in patients with
analogues are all useful therapeutic modalities hypovolemia or those older than 35 years
Combination of two or more of these agents is often required to D&C only treats the acute episode of excess uterine bleeding, not subsequent
obviate the need for endometrial ablation or hysterectomy. episodes.
LNG-IUS has become one of the most successful options. Various endometrial ablation techniques achieve a 22-55% amenorrhea success
rate at 1 year but an 86-99% satisfaction rate.
KEY POINTS Within 4 years after endometrial ablation, approximately 25% of women so
treated will have a hysterectomy.

By: Rem Alfelor Comprehensive Gynecology 12th Ed: Abnormal Uterine Bleeding Page 7 of 7

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