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Essay 2001 - DUB

Posted by Zaharuddin R.
Dysfunctional uterine bleeding(DUB) could be managed conservatively either with medications or surgery. Hysterectomy offer a definitive cure and management for DUB. However options for conservative management could be discussed first with the patient especially while optimizing patient\'s condition or before hysterectomy.

Medical management including mefenamic acid will offer 20-30% reduction of blood loss with less dysmenorrhoea. But side effect such as epigastric pain and peptic ulcer disease limit its use. Antifibrinolytic agent such as tranxenamic acid may reduce up to 30-40% blood loss and 40-50% reduction if combined use with mefenamic acid. Risk of central thrombosis should be warned especially longer usage.

Combined oral contraceptive pill (COCP) will reduce up to 50% of blood loss and it also offer contraception with less dysmenorrhoea.

Cyclical progestogen such as norethisterone or provera will regulate menses and reduce blood loss but no contraception. Side effect such as weight gain and acne should be explained.

Androgenic drug like danazol reduce blood loss but its usage limited by acne and hirsuitism. GnRh analog drugs cause pseudomenopausal state and amenorrhoea. Risk of 6% bone loss if use more than 6 months continuously.

Hysterectomy was previously the next step if failed medical treatment. However surgical treatment with uterine conservation is an alternative option with satisfactory result in current practise.

Levonogestrol-intrauterine system such as Mirena offer up to 98% reduction in blood loss after 12 months usage with marked less dysmenorrhoea. It is also contraceptive and the patient could avoid hysterectomy.

Endometrial ablation techniques such transcervical resection of endometrium either with loop wire or roller ball cause amenorrhoea with significant less blood loss post procedure. Satisfaction post procedure after 12 months up to 90%. However risk of uterine perforation and excessive bleeding during procedure may require hysterectomy. Risk of recurrent menorrhagia after 3-5 years should be discussed.

Risk of perforation could be reduced and satisfaction rate post procedure could be increased with new generation of endometrial ablation such as thermal balloon ablation or microwave endometrial ablation. However the machine is very costly. Ablation technique should be offered to women who completed family.

Options of management of the patient with DUB should be explained clearly for the patient to make an informed choice. Hysterectomy is still a definitive management of DUB in current practise especially for the patient who had failed conservative treatment.
Posted by Srivas  P.
Hysterectomy is the most common major gynecological operation in UK and though the newer more conservative procedures like medical therapies, endometrial ablation techniques and Mirena IUS have found good success for DUB treatment, hysterectomy by itself has its own place, advantages and definite indications.

Hysterectomy rates the highest in patient satisfaction, has minimal psychological symptoms and better perceived quality of life compared to conservative modes of therapy because it is efficacious and is definitive cure for DUB.

Medical therapies may not produce long lasting relief, has side effects and the woman may still need hysterectomy. Endometrial ablation is a short procedure with quicker recovery, involving shorter hospital stay, fewer post operative complications and is cost effective on short term but 20% patients may still need hysterectomy over long term. She would also need an on going contraception. LNG IUS is very efficacious but may not completely relieve excess bleeding but on a long term comparison, hysterectomy scores better on patient satisfaction because she may still require hysterectomy and she is not psychologically rid of the problem.

In DUB patients with atypical endometrial hyperplasia with no need to preserve fertility, hysterectomy is a first line indication because of 25-30 % risk of later developing endometrial carcinoma. In woman with DUB co existing with premenstrual syndrome or chronic pelvic pain hysterectomy can be combined with BSO to give wholesome relief from all her complaints. In a woman with DUB with family history of ovarian and endometrial cancers suggesting Lynch syndrome or BRCA1 / BRCA2 families hysterectomy can be combined with BSO to substantially decrease the risk of her getting these familial endometrial, breast and ovarian carcinomas in later life. Hysterectomy is not required with BRCA1 and BRCA2 genes but can be done to treat her DUB complaints.

While the above arguments are in favor of hysterectomy in some circumstances, it also has its flip sides. It is a major operation with 30% morbidity and mortality of 0.5-2 per thousand. The rate of visceral damage is 0.5-2%. Hospital stay is longer, has risks of infection and thrombo embolism and chances of premature menopause by 4-5 years even if ovaries are preserved. The complications are further increased if the woman has had previous laparotomies, adhesions due to any infections, PIDs etc.

Hysterectomy could affect woman?s bowel, bladder and sexual functions. These effects are negligible with both sub total and total hysterectomies as uterosacral ligaments are clamped medially in these procedures and lateral nerves supplying the bowel and bladder are still intact. Orgasm is better preserved with sub total hysterectomy by retension of cervix with cervical and lat vaginal nerves along with lubrication and preserved normal length of vagina. Also sub total hysterectomy is easier with lesser blood loss, shorter hospital stay , lesser haematomas and vault granulomas though it needs regular cervical smear follow up and woman may not like small bleeding from remaining endocervical tissues. The chance of stump cervical carcinoma is negligible in a well cervical smear screened woman. The vault prolapse seems similar with varying reports in several studies and needs more trial. Vaginal hysterectomy too seems a very cost effective procedure with competent surgeon.

Hystectomy as a procedure depends on various other co existing conditions apart from DUB, treatment history, age of the patient, patients choice of treatment, her fertility needs and it definite has a place in treatment of DUB.
Posted by Remi A.
Dysfuntional uterine bleding[DUB] is menorrhagia[>80ml per cycle] for which no pathology has been identified.
Treatment options for DUB are medical treatment,levonorgestrel intrauterine system[LIUS],Endometrial ablation and Hysterectomy.
Each treatment modalities has a role depending on the age,parity,fertility desires and presence of co-morbidities.
The merit of medical treatment is that it avoids the surgical morbidity and mortality.fertility potential is also preserved.
NSAIDS like mefenamic acid,Combined cotraceptive pill[COCP],Traxenamic acid are effective in reducing menstrual loss,and are relatively safe.COCP and NSAIDS are also effective in releiving dysmenorrhoea.COCP is also contraceptive.
High dose prostagens given for at least 21 days per cycle are also effective.
Danazol and GNRH analogue are effective,but are limited by their side effect profile,and that they are recommended for not more than six months.
LIUS reduces menstrual loss by 70% in six months,and by 90% in 12 months.Amenorrhoea rate is 35%.Sponteneous expulsion rate is 5%.It provides contraception,and is reversible with return of cycle within a month of removal.Drawbacks include irregular bleeding 3-4 months post insertion[pre-insertion counselling important],difficulty with insertion especially in Nullips,and prostogenic side effects like mood swings and fluid retention.
Surgical options are 1st or 2nd generation endometrial resection techniques and hysterectomy.Drawback are surgical/anaesthestic morbidity and mortality,it affects fertility and is irreversible
Endometrial resection is effective with 80% satisfaction rate,20-40% amenorrhoea rate,and 38% reoperation rate in 3 years.Its associated with lower morbidity and quicker recovery compared to hysterectomy.Risk includes uterine perforation and fluid overload.
Hysterectomy is the definative treatment of DUB.Morbidity includes haemorrhage,infection and DVT. Subtotal may reduce morbidity in carefully selected cases.Presence of co-mobidities like prolapse, in women who have completed their families,and in those who desires amenorrhoea may favour hysterectomy.
However,other treatments should have been considered before deciding on hysterectomy.

Posted by varsha S.
DUB is one of the common problems seen in gynaecology OPD.With invent of new alternatives being available , number of hysterectomies have gone down for this indication.
Aim in these cases is to control bleeding ,thereby preventing progressive anaemia & susceptibility to infections as well as overall quality of life .
Alternative therapies include1) Intrauterine progestogens-Mirena IUS,PROGESTASERT 2)Conservative surgical procedures such as Thermal balloon ablation,TCRE 3)Oral progesterone supplements 4)others -Tranexamic acid , mefenamic acid,Gnrh analogues, danazol.
Mirena IUS has shown promising results in reducing bloodloss by 80%, by the end of 3mths -6mths of therapy & almost 97% by the end of a year.This has brought down hysterectomy cases as patients waiting for surgery decided to continue with this.( 62-63%).Advantages include single time therapy , decreased morbidity & mortaliy by preventing major surgery ,can be inserted in outpatient with local paracervical block.,additional contraception ,can be continued as progesterone arm in HRT.
Disadvantages are erratic bleeding, amenorrhoea ,ovarian cyst formation, difficult insertion because of wider diameter, few systemic side effects such as weight gain,can not take care of associated morbidity , such as pain or prolapse,can not provide complete cure ,symptoms can recur.
Progestasert has very similar effect , but is effective only for a year as compared to 5 years in case of Mirena.
conservative procdures such as Thermal ballon ablation & TCRE , aim at causing destruction or thinning of endometrium thereby controllong bleeding.Disadvantages are symptom recurrence , requires anaesthesia, patient satisfaction is poor , complications such as perforation, injury to bowel or bladder ,risk of occult endometrial ca can not be ruled out , though failure to get relief is the commonest problem.
Oral progesterone , such as norethisterone appeared to be quite effective in controlling bleeding comparable to MIRENA-IUS, but the patients continuation rates were less because of compliance in taking 3-4 tabs per day .
Tranexamic acid brought down bleeding by 44% & mefenamic acids by 25% & are good as temporary measures .
Hysterectomy is a time tested solution for menorrhagia.Provides complete cure by removal of uterus & can also treat associated problems such as prolapse.Good patient satisfaction when it comes to relief of bleeding .
Disadvantages are- its a major operation & is associated with increased morbidity & mortality.Complications include haemorrhage, infection, bladder, bowel , ureteric injury , thromboembolism,complications of anaesthesia,childbearing not possible . not suitable for young female who has not completed her family,psychological effect in young patients as aresult of losing uterus.Requires expertise ,admission in the hospital, leave from work.
To conclude , one has to balance the benefit against the risks of conservative measures versus hysterectomy after proper patient selection, aim to achieve in that particular case ,& most importantly patient\'s wishes after detailed conselling.
But still there is a role for hysterectomy as a definitive measure & method to rely on if conservative measures fail.
Posted by neera  B.
One in five women in U.K have hysterectomy before 60 yrs.Of these half are for menorrhagia , of which half have a normal uterus removed .
But hysterectomy is associated with considerable mortality and morbidity. Morbidity may be psychological or due to increase rate of thromboembolism, infection , anaesthetic risk, bleeding, urological injury, long term vault prolapse,sexual dysfunction & voiding difficulties.
These can now be avoided in many cases by effective alternative methods to treat DUB such as endometrial ablation,LNG-IUS,long-acting progestogens or second-line medications as danazol,gestrinone & GnRH analogues.
Endometrial ablation can be performed on OPD basis,gives 30% amenorrhoea rate,60% satisfaction rate. But 20% have persistent symptoms for which hysterectomy is needed. Additinal contraception is required. If concomitently dysmenorrhoea or PMS are present,they are not relieved.

LNG-IUS is as effective as EA after 1 year,provides additional contraception,is out-patient reversible effective method with no anaesthetic or surgical risks.
Long acting progestogens like DMPA effectively control some cases of DUB but weight gain and irregular spotting are side effects . Use of danazol is limited by androgenic side effects and Gn RH analogues by menopausal side effects.
All these alternate methods will fail to control some cases and fail to give satisfaction to all women. In such cases hysterectomy provides permanent cure , gives highest patient satisfaction rate, though at the cost of increased morbidity , mortality longer hospital stay and increased cost.Cocomitant ovarian disease can also be treated at the time of hysterectomy.I t also gives relief in dysmenorrhoea.
The complications of hysterectomy have been decreased by effective thromboprophylaxis, antibiotic prophylaxis, use of laparoscopic and vaginal hysterectomy compared to abdominal hysterectomy.
Hence, hysterectomy has a definite place in the treatment of DUB, though many cases can be effectively controlled by alternative methods.

Posted by Ebeinheizer S.
Dysfunctional uterine bleeding (DUB) is usually caused by hormonal disturbance rather than an underlying organic pathology. 40% women with menorrhagia undergo hysterectomy within 4 years of having menorrhagia. However, hysterectomy carries surgical and anaesthetic risks and is slowly falling out of favour as first line of treatment.

Hystercetomy is an invasive surgical procedure which carries the risk of postoperative pain, fever and infection. There are also risks of bleeding needing transfusion, injury to visceral organs and thromboembolic events. Anasthetic risks and respiratory complications such as atelectases and pneumonia could also occur. Hysterectomy carries a 25% risk of morbidity and 15% risk of mortality.

As more women are postponing pregnancy to a later age, hysterectomy during reproductive age when DUB frequently occurs is undesired. Women who have undergobe hysterectomy have higher regret rate when wishing to conceive at later age. Surrogacy involves tedious procedures and is unacceptable to many members of the society; even illegal in some countries.

Uterus is a sign of femininity to many women.A lot of patients suffer psychosexual morbidity after hystercetomy.Some complain loss of libido.Hystercetomy,though might be useful for DUB might give rise to pschological complications.

Medical management using non-hormonal (mefenemic acid and tranexamic acid) and hormonal (COCP,progestogen,danazol and GnRH analogues) have proven value in managing DUB. 20-30% patients achieve amaenorrhoea and patient satisfaction rate nears 60-70% using them.

Usage of Mirena IUS has also proven to achive high amenorrhoiec rates, better than medical treatment. The procedure is of great value especially for patients who find pill-taking or injection to be cumbersome.Mirena insertion is easy and can be performed as outpatient procedure.

Endometrial ablation techniques, both first (TCRE,Roller-ball Diathermy) and second (MEA,Thermal Baloon) ablation techniques achive very good control of DUB.Even though these are surgical procedures, they are less invasive and carry less risks compared to hysterectomy.

Some patient might undergo oopherectomy during hystercetomy.Even for those where ovaries have been preserved,there are some evidence to suggest that ovarian viability is reduced by 30% after hysterectomy.This raises the issue of Hormone Replacement Therapy especially when menopausal symptoms cause fall in the quality of life.However,in turn it would cause major concerns due to increased risk of thromboembolism,breast cancer,coronary artery disesase and cerebrovascular accidents.

In view of these,hysterectomy should be reserved after exhausting other options.Patients desires,acceptability and wishes should also be taken into consideration.Each patient should be assessed individually to achieve the best outcome.
Posted by Ismatara B.
Dysfunctional uterine bleeding has an impact on many women’s lives. In UK one of five women have hysterectomy before 60 years. Of this half these are due to menorrhagia. Of which half have a normal uterus removed. But hysterectomy has its morbidity and mortality. There are increased rate of infection, bleeding, injury (bladder, ureter, bowel etc), anaeshetic risk, thromboembolism, vault prolapse, sexual dysfunction, voiding difficulties and psychological morbidity. This complication can now be avoided by alternative methods like, Medical, LNG IUS, endometrial ablation/ resection..
Medical: COCP, NSAIDs, tranexamic acid, mefenamic acid are relatively safe, have proven value in managing DUB and reduce blood loss about 35%. COCP and NSAIDs are and effective treatment in dysmenorrhoea and COCP is contraception. Mefenamic acid reduce blood loss 20-30% with less dysmenorrhoea. but epigasric pain and peptic ulcer limit its use. Tranexamic acid reduce blood loss 40-50%, but there are risk of central thrombosis, especially with longer useage.
High dose progesterone given for 21 days per cycle is also effective in reducing blood loss. There are risks of progestogenic side effects. Depot medroxy progesterone acetate (DMPA) is not licensed for treatment of DUB. Amenorrhoea rates are 30% and 55% after 4th dose. It is also effective contraception. There are risks of irregular bleeding, bone mineral loss in long-term treatment.
Danazol, GnRh analogue are effective but limited their use for significant side effects (Danazol- virilisation, GnRh analogue-estrogen deficiency-boneloss) and should only be used not more than 6 months courses. DMPA, Danazol, GnRh analogue are not used as first line treatment.
The LNG-IUS reduce blood loss up to 97% at 1 year with 35% amenorrhoea rate, increase Hb and ferritin, effective contraception and effective if dysmenorrhoea. 5 yearly replacements is the major advantage. Insertion is easy and day case procedure but patient may not be cooperative-may need GA. There are irregular bleeding in first 3-4 months, difficulties with insertion, progestogenic side effects and not resulted in a significant reduction of number of hysterectomies for DUB.
Surgical treatment may be considered for intractable DUB when medical treatment fails. Endometrial ablation techniques, both first (TCRE, Roller-ball Diathermy) and second line (Thermal ballon, Microwave endometrial ablation) techniques achieve good control of DUB, 20-40% amenorrhoea rate, 80% satisfaction rate, lower morbidity and quicker recovery compared to hysterectomy with a significant improvement in Hb and quality of life. There are risks of fluid over load, associated with reoperation rate of up to 38% at 3 yrs (10-20% require hysterectomy after 3-4 yrs). Women need to continue contraception, as there is risk of pregnancy. The effect on dysmenorrhoea remains uncertain. Pre-operative counselling and patient selection is vital-should not expect amenorrhoea, should have completed family and may need hysterectomy if necessary.
Hysterectomy still remains the definitive treatment with high satisfaction rate. It is still debatable about the advantages and disadvantages of total versus subtotal hysterectomy. About associated salpingoophorectomy is also controversial, because usually the ovary may stop its function after 3-4 yrs of hysterectomy. This raises concerns about HRT with its risks and benefits, which should also be discussed.
Hysterectomy remains definitive, effective and a present treatment especially women, who desire amenorrhoea. Medical treatment and LNGIUS should be offered to all considering hysterectomy for DUB.
After reviewing of these, each patient should be assessed individually and
Patient\'s desires, acceptability and wishes should also be taken into consideration to achieve the best outcome.
Posted by SWATI M.
DUB is menorrhagia for which no pathology has been identified and it is one of the common indication for the hysterectomy.
Although hysterectomy is traditional modality of treatment for DUB, recently medical therapies,conservative surgeries ,mirena are available as an alternative treatment.Even with the availability of these modalities of treatments, rates of hysterectomy which was expected to decline has not been observed.
Medical treatment includes non hormonal drugs such as mefenamic acid,tranexamic acid which reduces blood loss by 30-40% .Hormonal treatment includes COC pills , high dose progestogens for 21 days are also effective.COCP provides additional contraception and relieves dysmenorrhea.Medical therapy has fewer side effects, preserves fertility and may be choice in young woman where fertility is an issue and symptoms are not intractable.
Levonorgetrel releasing intrauterine system ? mirena ? is suitable alternative even in presence of dysmenorrhea .It reduces blood loss by 97 % by end of 1 year of use and provides additional contraception.It causes Amenorrhoea in about 35 % .Irregular bleeding for 3-6 months after insertion ,side effects due to progesterone may occur and may be unacceptable to the woman.
Conservative surgeries include endometrial resection / ablation by diathermy, laser, thermal balloons,microwave .These treatments require shorter hospitalization,has quicker recovery and causes oligo-amenorreha .About 1/3rd women may need further treatment and can not be employed if fertility is desired .It should not be adviced if significant dysmenorrhea is present as effects are uncertain.Amenorrhea occurs in 30 % and can not be predicted ,hence if it is desired hysterectomy should be the choice.Hysterectomy is definitive form of treatment and is associated with greater satisfaction rate.Additional oophorectomy help relieve dysmenorrhea if any.This is a major surgery ,has complications such as haemorrhage,injuries,thromboembolism and induces menopause 3-4 years earlier than expected.Fertility will be compromised.
Hysterectomy has place for the treatment of DUB in a woman who has intractable symptoms,failed medical treatment , desires complete amenorrhea and fertility is not an issue.All modalities should be offered to the woman with information of benefits and risks of treatments to make an informed choice.
Posted by Samir A.
DUB constitutes 75% of menorrhagia cases in the UK.Different
lines of treatment are available including hystrectomywhich its role has been challenged last 2 decades with the advent of new modalities of treatment.

DUB could be treated medically(by antifibrinolytic, NSAIDs or hormonal treatment) ,minimal invasive surgery or the conventional hystrectomy with or without BSO.

What with this premise is that medical treatment with antifibrinolytic(Tranexamic acid) reduces blood loss by 50%,NSAID(mefenamic acid) reduces blood loss by 25%,COCP reduces blood loss by 50% with no age limit (as long as non smoker).Norethisteron is likely to reduce blood loss in ovulatatory DUB in dose of 15 mg/day for 21 days per cycle.Danazol reduces blood loss by 60-70%,so is quite effective treatment.GnRHa induces a state of menopause, so no more bleeding.
Mirena(levonorgestryl Intrauterine Sustem Device) reduces blood loss by 80% in the first 3-4 months and by 98% by the end of 12 months after insertion.as well as the easy insertion as outpatient.
Minmal inasive surgery(Endometrial abaltion) via endometrial resection or thermal ablation has a high satisfaction rate (80%) as a result of effective reduction of blood loss, rapid recovery and early return to work.
hystrectomy is a major surgery with 20% morbidity ( anaesthesia complication.haemorrhage,visceral injury: bladder, bowel,nerve plexuses,wound infection.vault prolapse.premature ovarian failure in 3-4 years with early requirment of HRT). Hystrectomy has mortality rate of 0.5-2/1000.

What is against this premise is that the antifibrinolytic and NSAIDs have sice effects( nausea,vomiting, gastric upset,diarrhoea and headache) are not toleratable by some women which results in poor compliance.The vitilizing effects of of Danazol( weight gain,acne, seborrhoea,hirsutism,breast atrophy and voice changes)as well as hot flushes are limitng factors against its use. The state of menopause induced by GnRHa and its bone demineralising effects (6% after 6 months use) are also limiting factors against this medication.
Mirena migt cause PMS-like symptoms in women with H/O PMS, irregular bleeding in first 3 months after insertion, and spontaneous expulsion.
Endometrial ablation has 40% reoperative rate in 3 years (15% need hystrectomy in 3-4 years).20-40% only could achieve amenorrhoea and the patient has to use a method of contraception since ablation does not guarantee contraception. Fluid overload is another risk. The iprovement of Dysmenorrhoea after ablation still controversial,
Hystrectomy still the definitive treatment of DUB guaranteeing amenorrhoea with no risk reoperation nor the need to use cotraception.Laparoscopic subtotal hystrectomy has got a high popularity among some women because of being minimal inasive, short hospital stay, the early recovery and quick return to work as well as the guarantee of amenorrhoea.
The patient wishes are determining factor in selection of the line of treatment after informed choice.
In conclusion, Hystrectomy is regressing as a line of treatment of DUB.However it still has its own important place.