Dysfunctional uterine bleeding

Condition

• Dysfunctional uterine bleeding

Definition

• Dysfunctional uterine bleeding is excessively heavy, prolonged or frequent bleeding of uterine origin which is not due to pelvic or systemic disease, or pregnancy
• It can only be diagnosed after other uterine and systemic causes have been excluded by history, examination and investigations

History

• Dysfunctional uterine bleeding is common in women aged 30-50 years of age
• Ovulatory dysfunctional bleeding, where cycles are regular, accounts for about 80% of cases and is most common in women who are in their 30s
• Excessive menstrual loss in women in their late 30s and early 40s is usually ovulatory and a result of fibroids, in particular sub mucous fibroids
• Irregular bleeding is associated with an increased incidence of underlying pathology, esp. in women > 40s, as the risk of endometrial carcinoma starts to rise at this stage.

Examination 

• Pelvic examination if 
• features in the history suggesting underlying pathology  (e.g. risk factors for endometrial hyperplasia or carcinoma)
• the patient has decided to go ahead with a levonorgestrel intrauterine device - a pelvic examination is performed to assess the uterus for suitability for the device 
• the patient is to be referred for further investigations such as ultrasound or biopsy

Investigation

• FBE
• TSH
• Serrum ferrtin (should not routinely be carried out on women with heavy menstrual bleeding)
• Female hormone testing should not be carried out on women with heavy menstrual bleeding
• Transvaginal ultrasound 

Management options

• Levonorgestrel intrauterine device
• Oral progesterone (days 5-25)
• Tranexamic acid
• Nonsteroid anti inflammatory drugs
• combined oral contraceptive pill 
• Danazol 
• Oral progesterone  (days 12-26)