How best to manage dysfunctional uterine bleeding
Irregular or unusually heavy periods are a common complaint. Most often, the condition is benign and can by managed conservatively.
For patients with DUB, hormonal (medroxyprogesterone acetate, oral contraceptive pills [OCPs], levonorgestrel intrauterine device [IUD]) and nonhormonal treatment (nonsteroidal anti-inflammatory drugs, tranexamic acid, danazol) decisions are based on the age of the patient, severity of bleeding and symptoms, and the patient’s hematocrit.19 Patients with persistent bleeding despite medical treatment require a complete reevaluation and referral to a gynecologist if an explanation is not found or if surgical treatment is required.
CASE 1: Casey
Where does Casey fit in this typology? She is in the perimenarchal stage of her reproductive life cycle, when anovulatory bleeding is common. For the first 18 to 24 months after menarche, the immature hypothalamic-pituitary-ovarian axis may fail to respond to estrogen and progesterone stimulation, resulting in anovulation and irregular, often heavy bleeding. Her urine test rules out pregnancy. Blood tests confirm the anemia her pallor and fatigue suggest. Her initial, empiric treatment would be iron supplementation for anemia and cyclic medroxyprogesterone acetate or OCPs (TABLE 2) to regulate her periods. If these conservative measures are not sufficient, further evaluation would be indicated.
Blood dyscrasias (5%-20% incidence in teenagers) and systemic disorders, including Von Willebrand’s disease, idiopathic thrombocytopenic purpura, and leukemia, are the major diseases to consider.20-23 An endometrial biopsy is not indicated, because the incidence of endometrial cancer in Casey’s age group is less than 1 in 100,000. 24
CASE 2: Sarah
How can you explain Sarah’s irregular periods? A negative urine test rules out pregnancy, and her responses to questions about diet, exercise, and stress rule out hypothalamic suppression. She doesn’t complain of headaches, visual field changes, or galactorrhea, which would exclude a pituitary microadenoma. She does not exhibit symptoms of a thyroid disorder and her TSH is normal. Complaints of frequent urination, thirst, or weight loss could be indications of diabetes mellitus, but Sarah does not present with these symptoms. Her facial hair and acne suggest androgen excess originating from the adrenal glands or ovaries.
Sarah’s history of infrequent and heavy menses, as well as an absence of breast tenderness, bloating, or mittelschmerz, indicate she is not ovulating. The most likely explanation for her failure to ovulate is polycystic ovarian syndrome (PCOS), and you can initiate treatment immediately. The major treatment options for this disorder are observation, medroxyprogesterone acetate, and OCPs (TABLE 2).
If Sarah does not respond to hormonal therapy, a thorough reevaluation is indicated, including additional laboratory tests and a pelvic sonogram to evaluate the uterus and ovaries. Other tests to consider include prolactin, fasting blood sugar, early morning 17-hydroxy-progesterone, dehydroepiandrosterone (DHEA) and dehydroepiandrosterone sulfate (DHEA-S), testosterone, and cortisol. For an extensive review of PCOS and its relationship with endocrine, metabolic, and reproductive disorders, as well as cardiovascular disease and obstructive sleep apnea, see the excellent review by Ehrmann.25 If hormonal therapy is unsuccessful, a hysteroscopy with endometrial ablation could then be offered. In refractory cases, a hysterectomy can be performed.
Although Sarah is only 35, her prolonged exposure to unopposed estrogen (>3 years, according to her history) warrants an endometrial biopsy. The presence of other endometrial cancer risk factors (obesity, chronic anovulation, nulliparity) supports this decision. The incidence of endometrial cancer is 2.3 cases per 100,000 patients in 30- to 34-year-old women, 6.1 cases per 100,000 patients in 35- to 39-year-old women, increasing to 36.5 cases per 100,000 in women ages 40 to 49 years. 24
If Sarah is troubled by her infertility, consider referring her to a specialist. Treatment options for her infertility would include weight loss, insulin-lowering medications, and clomiphene citrate to induce ovulation.
CASE 3: Joan
Uterine bleeding in a postmenopausal patient like Joan is always abnormal. In 5% to 10% of cases, such bleeding indicates endometrial cancer. 26,27 An endometrial biopsy to rule out cancer is the first order of business. If the biopsy is nondiagnostic or reveals endometrial polyps or submucosal fibroids, the next step would be a diagnostic hysteroscopy. Alternatively, Joan’s endometrium could first be evaluated with a TVUS. If the sonogram showed an endometrium 5 mm in thickness or more, an endometrial biopsy could be performed then.26-29
If these tests rule out a cancer diagnosis, your next step would be to try low-dose cyclic OCPs or medroxyprogesterone acetate (TABLE 2) to control the bleeding. If hormonal therapy is not effective or Joan doesn’t want to try it, an endometrial ablation in conjunction with a hysteroscopy performed by a gynecologist is another option. But if Joan’s bleeding is light, it may be due simply to her postmenopausal hypoestrogenic state, and can be left untreated as long as Joan is comfortable with this option.
