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Definition
Dysfunctional uterine bleeding (DUB) is defined as abnormal uterine bleeding in the absence
of organic disease.2
It usually presents as heavy menstrual bleeding (menorrhagia).
The diagnosis of DUB can only be made once all other causes for abnormal, or heavy,
uterine bleeding have been excluded. The pathophysiology is largely unknown.
80% of women treated for heavy menstrual bleeding have no anatomical pathology.3
Menorrhagia is clinically defined as a total menstrual blood loss of more than 80 mls per
menstruation.
NICE defines heavy menstrual bleeding as "excessive menstrual blood loss which interferes
with the woman's physical, emotional, social and material quality of life, and which can
occur alone or in a combination with other symptoms."
Epidemiology
Dysfunctional uterine bleeding (DUB) is more common around the menarche and
perimenopause.
The perception of what is heavy menstrual bleeding is subjective and 30% of women
consider their bleeding to be excessive.4
Only half of women complaining of heavy menstrual bleeding fit the clinical criteria of more
than 80 mls blood loss per cycle.5
Pictorial blood-loss assessment charts are available.6
Among women aged 30-49, one in 20 consults her GP each year with menorrhagia.2
Heavy menstrual bleeding accounts for 12% of all gynaecology referrals in the UK. 7
Each year around £7 million is spent in the UK on prescriptions in primary care to treat
menorrhagia.2
History
Examination
Signs of underlying pathology: bruising, typical hypothyroid features, features of PCOS
(hirsutism, acne, overweight), pallor, koilonychia.
Abdominal examination: tenderness, palpable masses (uterine, ovarian).
Pelvic examination: vulval inspection, speculum examination, bimanual palpation for
masses.
Cervical smear: as appropriate.
Infection screening: high vaginal and endocervical swabs as appropriate.
Routine investigations
Every woman presenting with heavy menstrual bleeding should have a full blood count
taken.1
Serum ferritin, female hormone testing and thyroid testing are not routinely recommended.
Only carry out these blood tests if there is strong clinical suspicion of underlying pathology. 1
A woman with heavy menstrual bleeding referred to specialist care should be given information
before her outpatient appointment.1 NICE's information for patients - 'Understanding NICE guidance'
- is available from the link below.
Pelvic ultrasound scan: first-line diagnostic tool for identifying structural abnormalities.
Endometrial thickness may also be assessed.
Endometrial biopsy.
Hysteroscopy.
If hormonal treatments are not acceptable to the woman, then either tranexamic acid or NSAIDs
can be used.
1. Levonorgestrel-releasing intrauterine system (LNG-IUS)
2. Tranexamic acid
Oral antifibrinolytic.
If no improvement, stop after three cycles.
Can be used in parallel with investigations.
Not a contraceptive.
Unwanted outcomes: indigestion; diarrhoea; headache.
Has been reluctance to prescribe due to potential increased risk of thrombosis.
Studies in Sweden have shown that incidence of thrombosis in women treated with
tranexamic acid is comparable with the spontaneous frequency of thrombosis in women.
10A Cochrane Review showed that there are no data available within randomised
controlled trials which record the frequency of thromboembolic events during treatment
with tranexamic acid.11
Dose: 500 mg tablets. 2 to 3 tablets three to four times daily for three to four days.
Therapy is indicated only after heavy bleeding has started.12
3. NSAIDs
4. COCPs
1. Endometrial ablation
Second-generation: non-hysteroscopic, general anaesthetic not required, can be done as day
case, easier, quick recovery period.
Unwanted outcomes: vaginal discharge; increased period pain even if no further bleeding;
need for additional surgery; infection; perforation (very rare).Contraception after
endometrial ablation is still advised even though fertility is usually not retained.
2. Hysterectomy
In the acute situation, a bleeding episode may be so disabling for the woman that treatment
with high-dose norethisterone (30 mg daily) needs to be used. This is continued until
bleeding is controlled, but is then tailed off.