The patient has abnormal uterine bleeding without any identifiable cause, i. e. Dysfunctional uterine bleeding. She should be offered the non-surgical treatment option which are the first line treatment for dysfunctional uterine bleeding. She should be offered information about various treatment options, which include NSAIDS like Mefenamic acid, Antifibrinolytics such as Tranexamic acid which are the non-hormonal medications. The hormonal treatment options include combined oral contraceptive pills, progestogens which include oral as well as Injectable progestogens , Mirena – levonorgestrel intrauterine system and GnRh analogues.
NSAIDS (Mefenamic acid) & Tranexamic acid are time line treatment. They reduce the menstrual blood loss & generally well treated. Tranexamic acid decreases by 50%
Combined oral contraceptives are first line hormonal therapy, but have increased risk of VTE associated with obesity. They reduce menstrual blood loss by 50%. Progesterone cyclical (leuteal phase) were given previously are not recommended now. They are associated with irregular bleeding.
Mirena coil is very effective in treatment of DUB, it reduces HBL by 90-95%. It is associated with minimal systemic side effects. It may be associated with irregular bleeding for initial 3-6 months, which then settles down.
GnRh analogues can be used in patients while waiting for surgery for correction of anemia or weight loss, but are not a preferred option.
Patient should be offered evidence based information about the treatment options & allowed to make an informed decision.
As the patient wishes to undergo a hysterectomy, she should be offered information about the risk associated with surgery such as risks of anaesthesia, increased risk of hemorrhage, infection, morbidity & wound dehiscence . She is at a greater risk of VTE due to her obesity.
Anesthesia risk is more due to difficult intubation, difficulty in regional anesthesia due to obesity.
Pre-operative preparation has to be done & she is advised to stop smoking. If patient is taking OC pills they had to be stopped. Pre-operative weight loss & correction of anemia is advisable.
Route of surgery should be decided depending on the expertise & equipments available. Vaginal route may be preferred as it is associated with less post operative morbidity but inspection of adnexa can be difficult . It requires surgical expertise in a case with no descent.
Laparoscopic surgery is now a days preferred in obese patients with appropriate expertise as it is associated with less post operative pain, morbidity & early mobilization. Entry into the peritoneum can be difficult, can be overcome by inserting Verre's needle perpendicular to the abdominal wall. Visiports can be used
Abdominal hysterectomy is less preferred as it has increased risk of wound dehiscence. Prophylactic antibiotics should be given.
Pelvic surgery in obese patients have increased risk of VTE. Graduated elastic compression stockings should be recommended during surgery & post operative. LMWH Prophylaxis should be started. Maintenance of hydration & early mobilization & physiotherapy are encouraged.
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