How best to manage dysfunctional uterine bleeding

The Journal of Family Practice. 2010 August;59(8):449-458

August 1, 2010|The Journal of Family Practice

Avinash Reddy, MD;David L. Maness, DO, MSS;Carolyn L. Harraway-Smith, MD

Irregular or unusually heavy periods are a common complaint. Most often, the condition is benign and can by managed conservatively.

TABLE 2
Medical treatment for dysfunctional uterine bleeding

Mild (bleeding is minimal and symptoms limited)
NSAIDs, mefenamic acid 500 mg TID for 3-5 days^28,29,31 Medroxyprogesterone acetate 10 mg/d for 7-10 days each month^28,29,31 Monophasic OCPs 35 mcg each day of the month, including inactive pills^28,29,31 Levonorgestrel IUD^28,29,31 Danazol 200-400 mg/d^32-35
Moderate (moderate amounts of bleeding, mild anemia, and mild orthostatic symptoms or fatigue)
Medroxyprogesterone acetate 10 mg/d for 7-10 days each month²⁸ OCPs BID for 5-7 days (flow should decrease in 24-48 hours), followed by 1 pill/d for the rest of the cycle for the next 3-6 months. Warn patients that flow will be heavy after the first pill pack, will decrease by 60% toward end of treatment period. Use an antiemetic with increased OCP dose²⁸ Levonorgestrel IUD¹ Danazol^32-35 Antifibrinolytic agents (tranexamic acid, 1-1.5 g 3 to 4 times per day)^32-34,36
Severe (heavy bleeding, moderate to severe anemia, significant orthostatic symptoms)
OCPs as for moderate bleeding, with antiemetic for increased dose²⁸ IV estrogen, 25 mg IV q 4 to 6 hours until bleeding stops or for 24 hours, followed by OCPs. Use with antiemetic medication² Levonorgestrel IUD¹ Danazol^32-35 Antifibrinolytic agents (tranexamic acid 1-1.5 g 3 to 4 times per day)^32-34,36
IUD, intrauterine device; NSAIDs, nonsteroidal anti-inflammatory drugs; OCPs, oral contraceptive pills.

Lessons learned

Patients like Casey, Sarah, and Joan can be successfully managed by the family physician. A thorough history, physical examination, and basic laboratory tests will usually suffice to rule out anatomic, systemic, or iatrogenic explanations. Pregnancy, the most common explanation for abnormal uterine bleeding, can be ruled out with a urine pregnancy test. Patients like Sarah and Joan, who have some of the risk factors for endometrial cancer, require an evaluation of the endometrium to rule out that possibility. When none of these etiologies is the culprit, your working diagnosis is DUB, and medical treatment for it is well within your competence.

CORRESPONDENCE David L. Maness, DO, MSS, Department of Family Medicine, University of Tennessee Health Science Center, College of Medicine, 1301 Primacy Parkway, Memphis, TN 38119; dmaness@uthsc.edu

References

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