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Dysfunctional uterine bleeding is defined as abnormal uterine bleeding in the absence of organic disease. It usually presents as menorrhagia without an underlying cause, and it affects women's health both medically and socially. Among women aged 30-49 years, one in 20 consults her general practitioner each year with menorrhagia; making dysfunctional uterine bleeding one of the most often encountered gynaecological problems. About 30% of all women report having had menorrhagia, and it accounts for two thirds of all hysterectomies and most endoscopic endometrial destructive surgery.
Excessive menstrual bleeding has several adverse effects, including anaemia and iron deficiency, reduced quality of life, and increased healthcare costs because it is a major indication for referral to gynaecological outpatient clinics. Each year around £7m (€10m; $14m) is spent in the United Kingdom on prescriptions in primary care to treat menorrhagia.
Menorrhagia is a disabling problem for many women and a major clinical challenge for gynaecologists. In half of women with menorrhagia there is no organic cause. Dysfunctional uterine bleeding is a therefore a diagnosis of exclusion.
The pathophysiology of dysfunctional uterine bleeding is largely unknown, but it occurs in both ovulatory and anovulatory menstrual cycles. Ovulatory dysfunctional bleeding occurs secondary to defects in local endometrial haemostasis, while anovulatory bleeding is a systemic disorder, occurring secondary to endocrine, neurochemical, or pharmacological mechanisms. Since diagnosis is by exclusion, you must proceed through a logical, stepwise evaluation to rule out all other causes of the abnormal bleeding.
In most patients dysfunctional uterine bleeding is associated with anovulation, and anovulatory bleeding is common in the pubertal and perimenopausal periods. During these transitional states, the abnormal bleeding has a physiological basis and is secondary to an oestrogen withdrawal. Anovulatory bleeding can also be associated with chronic anovulation. The chronic unopposed oestrogen that characterises this disorder causes a continuous proliferation of the endometrium. This can result in abnormal bleeding and increases the risk of developing endometrial cancer. The goals of treatment for anovulatory bleeding are to stop the acute bleeding, avert future episodes, and prevent long term complications.
The guideline from the national Institute for Health and Clinical Excellence is in progress and was due to have been issued in January 2007.1 The Department of Health has agreed that the guideline should be extended to cover not only hysterectomy but the pathway for diagnosis and management of heavy menstrual bleeding.
The key points from the guidelines2 are
Dysfunctional uterine bleeding is a diagnosis of exclusion. Exclude other conditions such as uterine fibroids, endometrial polyps, and systemic diseases by appropriate investigations, such as a transvaginal ultrasound scan and a full blood count. In adolescent patients, perform investigations for a coagulopathy. In selected cases arrange for an endometrial biopsy with or without hysteroscopic assessment to exclude endometrial cancer.
Only 2% of endometrial carcinomas occur before age 40. They are more common in nulliparous women. Diabetes, obesity, and polycystic ovary syndrome predispose women to developing endometrial carcinoma.
Postmenstrual scans are often useful; after menstrual shedding, the endometrium should be at its thinnest, and polyps and cystic areas are more noticeable.
Tranexamic acid and mefenamic acid are among the most effective first line drugs for treating menorrhagia. Norethisterone, taken orally in the luteal phase, is probably one of the least effective agents, despite it being used extensively in the past.
Women needing contraception have a choice of combined oral contraceptive, the levonorgestrel releasing intrauterine system, or long acting progestogens.
Danazol, gestrinone, and gonadotrophin releasing hormone analogues are all effective in terms of reducing menstrual blood loss, but side effects and costs limit their long term use. They have a role as second line drugs for a short period in women waiting for surgery.
Endometrial ablation with the Nd:YAG laser, resectoscope, rollerball, and, more recently, other options such as bipolar devices, direct hot saline instillation, microwaves, and thermal balloons, are all available with evidence to support their use.
Refer patients with severe bleeding that is producing anaemia (haemoglobin level <80 g/l), irregular bleeding in women in their late 40s, and bleeding that is unresponsive to medical treatment.
Irregular heavy bleeding in women in their late 40s is often attributed to starting the menopause. This may be true, but you still need to investigate. Endometrial carcinoma can occur in the late 40s. About 6% of endometrial cancers can occur with heavy regular bleeds. Pathology can be missed on the ultrasound scan in the presence of an intrauterine contraceptive device. Reflections and shadowing can be difficult to assess, even by an experienced ultrasonographer.
Women with regular heavy bleeding do not initially need extensive investigation, except for a full blood count. Thyroid function tests are not routinely necessary and should be limited to women with symptoms of hypothyroidism. Investigation of other endocrine disorders is also not usually necessary, but irregular bleeding in a woman with a long history of using the combined oral contraceptive may prompt you to check her serum prolactin levels. Serum follicle stimulating hormone levels may be relevant if the woman is increasingly oligomenorrhoeic, especially in her 40s. You should refer older women for a pelvic ultrasound and for endometrial sampling if the endometrium is thickened.
Medical treatment should be tailored to each patient, taking into account, among other factors, age, fertility, contraceptive needs, and risk factors. Options include combined oral contraceptive, mefenamic acid, tranexamic acid, and the levonorgestrel releasing intrauterine system. For postpubertal women, try mefenamic acid first and, if this does not work, a low dose (20 µg) combined oral contraceptive. Tranexamic acid is the most effective treatment for curtailing menorrhagia while waiting for a hospital referral.
This is the fourth in a series of occasional articles featuring BMJ Masterclasses. These are designed to provide general practitioners with up to date information on managing common medical problems. For more information, contact Dr Cath McDermott, editor of BMJ Masterclasses (CMcDermott@bmjgroup.com), and see www.bmjmasterclasses.com