Download Dysfunctional uterine bleeding

Max Brinsmead MB BS PhD
May 2015
The common causes are…

Pregnancy-related
○ Miscarriage – threatened, inevitable or incomplete
○ Ectopic

Cervical Bleeding
 Benign
 Ectropion, Cervicitis or Polyp
 Cancer of the cervix
 Rare in patients who have regular Pap smears)

Bleeding from the uterine cavity
 Benign
 Fibroids and Polyps
 Cancer
 Dysfunctional uterine bleeding
 A diagnosis made after excluding other causes
But also keep in mind…

Hormones that have been given
○ Depoprovera (or DMP or DMPA)
○ Oral contraceptives (COC)
○ Other (some OTC drugs affect cycles)

Bleeding disorders
○ Rare
○ Usually associated with other bleeding or
bruising
When a patient complains about abnormal
vaginal bleeding...
 First determine if she has:
○ Regular but heavy or prolonged periods
 This is called menorrhagia
 It is a common manifestation of fibroids
 Rarely due to a bleeding disorder
○ Regular periods with bleeding at other times
 If the bleeding is postcoital it should be regarded as
cancer of the cervix until proven otherwise
○ Irregular bleeding
 This may be dysfunctional uterine bleeding but this
diagnosis is can only made when other causes are
excluded

And always exclude pregnancy
 Best done by pregnancy test
Consider your patient’s age…

If the patient is young (<40 years)
○ Endometrial cancer is uncommon
○ But Ca cervix always needs to be ruled out

If the patient is very young & never
sexually active
○ Pregnancy, STD and Ca cervix never occurs
○ But dysfunctional uterine bleeding is not
uncommon

If the patient is >45 years
○ Cancer from within the uterine cavity can only
be excluded by endometrial biopsy or curette
○ Check also for Ca cervix
○ But dysfunctional bleeding is not uncommon
You must always examine…
Look for signs of anaemia
 Examine the abdomen to see if there is a
uterus or other mass arising out of the
pelvis
 Pass a speculum and decide if the bleeding
is coming from or through the cervix
 Look carefully at the cervix
 Examine the pelvis bimanually to see if the
uterus is enlarged

○ (And if the cervix feels normal even if it looked
abnormal)
Tests you should perform
FBC to check HB & platelet count
 Pap smear if not recently performed

 But this is not a test for cervical cancer!
Cervical or 1st voided urine for Chlamydia if
the patient is at risk of STD
 Ultrasound of the uterus has a limited role

 But should be performed if the uterus is enlarged
 It is NOT a substitute for clinical examination
Dysfunctional Uterine Bleeding (DUB)
There is often a history of missed periods
or irregular cycles
 May be associated with obesity and
hirsutism (PCO Disorder)
 Bleeding is usually painless

 Unless there is clot colic
Bleeding can be very heavy or quite
prolonged
 There is a normal cervix and the uterus is
not enlarged

Management of Abnormal Vaginal Bleeding


Antibiotics are indicated only for proven STI
Bleeding from an abnormal cervix is rarely a
life-threatening emergency
 But it generally requires referral for further testing
and treatment



Transfusion should be reserved for those with
severe anaemia and in whom you cannot
immediately control the bleeding
Uterine bleeding after the age of 45 requires
referral for D&C or biopsy
Dysfunctional uterine bleeding can be treated
with oral hormone therapy (Progestin or COC)
Management of Dysfunctional Uterine Bleeding

Bleeding can be controlled with Norethisterone

Give 2x 5m tablets every 2 – 3 hours until
the bleeding slows or stops
Then 5 mg BD for 10 – 14 days
The patient can then expect a “normal
period” a few days after stopping the pills
Give COC in the next cycle
or Norethisterone 5 mg BD from day 10 –
25 of each cycle for 4 – 6 months
Give oral iron ± folate to treat anaemia





Emergency treatment of any Endometrial
Bleeding
When the blood is coming through the
cervix
 Even if the patient is >45 years
 Or if the uterus is enlarged by
adenomyosis or fibroids
 Or the patient has a bleeding disorder
 You can try Norethisterone 10 mg every 2
– 3 hours
 But refer also for further Ix and Rx

Management of Hormone-related PV
bleeding
Irregular PV bleeding with Depoprovera or
COC is secondary to their effect on the
endometrium
 But make sure that the cervix is normal
 Then try Norethisterone as per DUB
regimen

 Or give Premarin 1.25 mg 8 hourly
 Or any COC one tablet 6 hourly
 Or just give another injection of Depot Provera
 An episode of bleeding can be shortened with
Mefanamic acid 500 mg BD for 5 days
Please leave a note on the Welcome Page to this
website