Dysfunctional uterine bleeding

Posted On April 24, 2018


Dysfunctional uterine bleeding (DUB) is an old terminology for abnormal uterine bleeding occurring in the absence of any obvious pelvic  pathology.
Management strategies are discussed below:

Acute episode of DUB in the perimenopausal period:

In the perimenopausal period the patient is most likely to be suffering from anovulatory bleeding.However it is mandatory to rule out pregnancy and pelvic infection as possible causes of bleeding.
Hypothyroidism is common in this age group, and should be ruled out by history and clinical examination.It is not necessary to do endocrinological tests for hypothyroidism in all patients with abnormal uterine bleeding(27).
A careful medical history should be taken to rule out diseases of the liver,adrenals.
She should be questioned regarding the use of anticonvulsants.
When all functional causes of abnormal bleeding are ruled out a diagnosis of DUB is made.
In this age group it is mandatory to do an endometrial sampling to rule out carcinoma(26).

Scenario Abroad:In some countries,endometrial sampling is done using 3mm plastic suction cannulas, the names of some of them being ,Pipelle, Explora,vabra aspirator, Z-Sampler,&Endosampler(2). Studies have found office endometrial sampling superior to D & C(28).

An alternative is to do a transvaginal ultrasonography on day 4,5,or 6(17). An endometrial thickness of <5mm rules out endometrial hyperplasia.

In cases where it is more than 5mm or when the image is not clear, a procedure called saline infusion sonohysterography could be performed. In this procedure, the uterine cavity is slightly distended with saline and then,TVS done. This delineates the endometrium better, and allows for better diagnosis of endometrial polyps and small submucous myomas sonographically.

Dilatation and curettage is done only when medical treatment fails .Whenever curettage is done it is best done hysteroscopically as a blind D& C has proved to miss out lesions quite often(28).

Indian scene: In our country, endometrial sampling devices are not common. Thus in cases as the one mentioned above,wherever vaginal sonograpy is available it could be done and if the endometrial lining is <5mm on day 4,5 or 6 of the period,one could reasonably rule out hyperplasia and go in for medical treatment.
In centres where vaginal sonography is not possible, and in cases where the endometrium is >5mm on day 4,5 or 6,a dilatation and curettage is mandatory to rule out malignancy.
A hysteroscopic biopsy as a primary diagnostic modality for DUB may not be practical in our setup.
In cases where a vaginal sonogram picks up an endometrial polyp, in well informed and willing patients, a hysteroscopic polypectomy would be ideal.
After a D&C, quite often, the bleeding abates, but it is better to put the patient on maintenance medical therapy to avoid recurrence.

Medical management : In most of the literature,I-V estrogens or high dose OC-pills are cited as the first line of treatment.(25,26,28).From a survey conducted in India, we find that progestogens, and in particular, norethisterone is the most popular drug used in India.

Norethisterone or Medroxyprogesterone could be used to arrest an acute episode of bleeding.

Majority of doctors in the survey were using Norethisterone in the dose of 15mg /day to stop acute bleeding. But if a dose of 15mg of Norethisterone/Norethindrone does not stop bleeding, one should step up the dose before calling it a failure of therapy.
Norethisterone could be given in doses of upto 30mg/day. 16% of doctors in the survey were found to be using Norethisterone in this dose.
Once the bleeding has stopped, the dose could be tapered to 15mg daily and this dose continued for 21 days.

Medroxy progesterone could be given in a dose of 60-120mg on the first day and 20 mg daily in the subsequent days.

Monophasic OC pills could also be used to control acute uterine bleeding.
To stop an acute episode of bleeding, OC-pills should be given in the dose of 1 tablet four times a day (25,26,28).
Even if the bleeding stops, the treatment should be continued for 7 days. In such a high dose, the patient may experience severe nausea or vomiting and antiemetics should be given simultaneously.
After 7 days, the dose should be reduced to one/day and continued for 21 days.(28) .
Another regimen is to give Regular oral contraceptives containing 35mug of ethinylestradiol in a regimen of 4 tablets for the first day, 3 for the second day, 2 for the third day, and then 1 per day until the pill pack is finished.(12)

Maintenance therapy: Progestins are commonly used in North America and the UK. (28)This is also true in India.
Oral medroxyprogesterone acetate 10 mg a day from days 16 through 25 each cycle may be given.
Alternatively, Norethindrone/Norethisterone 5 to 10 mg one to three times a day may also be used to manage recurrent anovulatory dysfunctional uterine bleeding.
Progestins are generally administered for 7 days (minimum duration for the prevention of hyperplasia) to 12days of each cycle.(26)
For anovulatory patients who are difficult to treat, the course of progestin therapy can be extended for 14 to 21 days each month.
Prolonged use of high-dose progestins is associated with side effects, which include fatigue, mood changes, weight gain, and atherogenic changes in the lipid profile.(13)
Dydrogesterone,a progesterone that has a structure very similar to progesterone and micronised progesterone, which is natural progesterone in the micronised form has also been studied for the treatment of DUB.
Both agents are costly (Dydrogesterone-Around Rs.10 for a 5mg tablet&micronised progesterone Rs 18 for a 100mg tablet).
Dydrogesterone may be given in the dose of 10mg b.i.d (together with estrogen) for 5-7 days to arrest bleeding & in the dose of 10mg b.i.d (together with estrogen) from 11th- 25th day of the cycle to prevent bleeding.
In a study comparing the effects of micronized progesterone (300 mg per day) and the progestin norethisterone (15 mg per day) in premenopausal women, menstrual cycles were well controlled with either agent, but cessation of dysfunctional uterine bleeding was achieved more frequently in the women who took micronised progesterone(26)
Another alternative is to use Combined oral contraceptive pills which have been shown to effectively reduce menstrual bleeding by up to 60% in normal uteri. OC pills given for 2-3 months result in a stable, atrophic endometrium.
The most common side effects include weight gain, abdominal discomfort, and midcycle breakthrough bleeding.

DUB in the reproductive age group:
In women in the reproductive age group, pelvic infection and pregnancy should be ruled out by pelvic examination, urine pregnancy test, and if necessary vaginal ultrasonography. Any abnormality detected should be treated accordingly.
A routine haemogram should be done.
If there are no abnormalities detected, a diagnosis of dysfunctional uterine bleeding should be made.
Dysfunctional uterine bleeding in this age group could be ovulatory in nature,although typically the history of regular menstruation on a monthly basis indicates ovulatory cycles.
In practice, a specific diagnosis often is not sought if the patient is not immediately desirous of pregnancy.
Instead empirical medical therapy is begun.(30)
Women with ovulatory dysfunctional bleeding are usually not lacking in progestin, but have underlying imbalances in prostanglandins.
Nonsteroidal antiinflammatory drugs like Mefenamic acid 500mg , Ibuprofen 400mg three times a day,Diclofenac sodium could correct the prostaglandin imbalance.(13)
NSAID�s are known to reduce flow by 20%. NSAIDs need not be used through out the cycle.
Tranexamic acid in the dose of 2g/day could be used as an antifibrinolytic agent.
Ethamsylate was used as a plasminogen activator inhibitor, but controlled studies show conflicting results about it�s efficacy.
. It is used extensively in India. 20% of doctors in our survey have mentioned the use of drugs like Ethamsylate,NSAIDs,etc for the control of bleeding in the reproductive age group
.Preparations containing vitaminK,,Vitamin C ,and flavonoids (e.g:GynaeCVP,Styptovit,Styptomet) have been found useful for the treatment of menorrhagia, though the last study on the use of Vitamin K (Menadione) was done 57 years ago.
If the above measures do not reduce bleeding, hormonal therapy with progestogens or oestrogen could be tried.T

he long-term treatment for women with ovulatory dysfunctional uterine bleeding is the most difficult type of dysfunctional uterine bleeding to manage and a combination of one or more of the agents mentioned above may be required along with hormonal treatment.

Heavy DUB in the very young girl in the menarchal age group:
At the outset, any pelvic abnormality should be ruled out. A pelvic examination may be embarassing for the patient and may not yield much information in an unwilling patient. An abdominal ultrasound examination can rule out most of the pelvic pathologies. Once uterine or ovarian pathologies are excluded, a bleeding diathesis should be ruled out.
Recent studies have shown that as much as 20% of patients with menorrhagia may have a bleeding diathesis(29).History of easy bruisability, bleeding from minor trauma should be taken.
A detailed physical examination must be done to look for pallor, bleeding spots and hepatosplenomegaly.
A total count, haemoglobin value, bleeding time, clotting time, prothrombin time and Activated partial thromboplastin time should be done.
A correct diagnosis of coagulopathy made at this time will have important implications for the management of future pregnancies, as APH and PPH can be anticipated and treated(28).

Medical therapy:
Any anaemia should be treated with haematinics or blood transfusion according to severity.
Acute bleeding can be controlled with hormone therapy even in the patient with coagulation disorders.
Thus while the results of the blood tests are awaited, hormone therapy could be started.
a) Oral contraceptive pills with 35micrograms of estrogen and a progestin 6-8hourly could be tried along with antiemetics if necessary for 24-48 hours(26). If the bleeding continues the dose should be increased by using pills containing 50micrograms of oestrogen every 6 hours. When the bleeding stops, the dose should be tapered over a week to 1 pill daily. When the initial packet is empty, she should immediately begin a new 28 day packet of 35microgram pills. The menstrual period immediately following the treatment may be heavy due to the estrogenic content of OC �pills.

b) Progestins: Norethisterone/Norethindrone could be tried in the dose of 30 mg/day in divided doses for 3 days . The dose could be tapered to 15mg /day once the bleeding abates and continued for a total of 21 days.
Medroxy progesterone acetate in the dose of 60-120 mg during the first day of admission and 20 mg/day for the following 10 days was found effective in one study(16).

Maintenance therapy could be given with either Norethisterone(5-10mg one to three times/day) or Medroxyprogesterone 10mg a day on days 16 through 25 each cycle(13) . For anovulatory patients who are difficult to treat, the course of progestin therapy can beextended for 14 to 21 days each month. Cyclic administration of combination oral contraceptives is effective in reducing the risk of recurrent bleeding episodes.

Minimal but irregular bleeding in the adolescent:
If the adolescent girl can tolerate the bleeding emotionally and physically, she can be followed without hormonal intervention. NSAIDs could decrease the flow and a multivitamin with iron could be given prophylactically. Although convincing studies are not there, Ethamsylate, preparations like Gynae CVP,Styptovit, etc could also be tried. But if the girl is anemic (History of being too tired to study is often given), or is bothered that the bleeding affects her day to day life, a combined oral contraceptive containing 30-35 microgram of estrogen can be prescribed along with iron. All patients taking oral contraceptives should be seen at 1,3,and 6 months. If the adolescent has done well and does not wish to continue the oral contraceptive, it may be stopped at that time.

Minimal irregular bleeding in the perimenopausal woman:
A cervical polyp should be ruled out. A transvaginal sonogram should be done to rule out endometrial polyps. If no obvious cause is found, the intermittent vaginal spotting is probably associated with minimal(low) estrogen stimulation(estrogen breakthrough bleeding). (3) In this circumstance, where minimal endometrium exists, the beneficial effect of progestin treatment is not achieved, because there is insufficient tissue on which the progestin can exert action. 1.25mg Conjugated estrogen or 2mg estradiol daily can be prescribed for 7-10 days. All estrogen therapy should be followed by progestin withdrawal or continued OCP.

Post-menopausal bleeding :
The golden dictum was that a woman with postmenopausal bleeding should be diagnosed to have endometrial carcinoma unless proved otherwise. But in the changed scenario of today a lot of other factors have to be taken into consideration. Awareness of hormone replacement therapy having increased, a lot of general practitioners have also started using hormone replacement therapy. Patient should be directly questioned on the use of hormone replacement therapy. If she is on estrogens, the dose should be adjusted or alternate therapy advocated. Other wise the management is the same as for the perimenopausal woman.

Q:If a 48 year old woman comes with intermenstrual bleeding with occasional menorrhagia presents to the OPD, and pelvic examination shows a normal uterus with non tender pelvis and a normal looking cervix, what should be the line of management?

A:This is a case of dysfunctional uterine bleeding, as no obvious cause for bleeding can be found. Intermenstrual bleeding is generally the hallmark of oestrogen deficiency in the perimenopausal lady, like the one mentioned here. In this case, since there are occasional bouts of menorrhagia, there is a possibility of endometrial polyps. However, in the perimenopausal period the patients may present with episodes of ovulatory bleeding (which are predictable, because they are regular), interspersed with episodes of anovulatory bleeding which is erratic. This becomes confusing to the patient and the physician. This happens due to decreased inhibin levels, and variable estradiol levels with normal FSH levels.

In this patient, pelvic examination is normal. Thyromegaly and hypodsthyroidism should be looked for and treated, if present. Pelvic ultrasound, both abdominal (suprapubic) and transvaginal, is recommended as a first-line procedure for the etiological diagnosis of Abnormal uterine bleeding(AUB) (Grade A)3. Doppler ultrasonography provides additional information useful for characterizing endometrial and myometrial abnormalities (Grade B).
Endometrial biopsy should be performed in women older than 35 years of age, or younger if risk factors for endometrial hyperplasia or malignancy are present. Thus it is indicated in this patient.
If no abnormality is seen, then put her on conventional Combined oral contraceptive pills (COCs) with 30mcg EthinylEstradiol, as her intermenstrual bleed may be because of estrogen breakthrough. This will also correct her Menorrhagia. Continue for at least six cycles and then stop the COCs. Intermittent anovulation during the perimenopause may be associated with physical complaints like hot flashes, and night sweats. Oral contraceptive pills regulate menstrual cycles, decrease vasomotor symptoms, improve bone mineral density, and decreases the need for surgical intervention for DUB1. Additionally, endometrial and ovarian cancer rates are reduced in women using oral contraceptive therapy. Generally, oral contraceptives are well tolerated and enhance menstrual health and quality of life for the perimenopausal woman.
Uterine exploration: Hysteroscopy or hysterosonography can be suggested as a second-line procedure when ultrasound suggests an intrauterine abnormality or if medical treatment fails after 3�6 months (Grade B)3.
Q: What should be looked for in Transvaginal ultrasound(TVUS) in a patient with peri menopausal bleeding PV with normal pelvis on per vaginal examination?
A: A uterus appearing normal on pelvic examination sometimes has endometrial polyps or tiny submucous fibroids which may not be revealed on pelvic examination but which can be picked up on TVUS. In premenopausal women, endometrial thickness varies between the proliferative phase (4 to 8 mm) and the secretory phase (8 to 14 mm), and TVUS should be scheduled between days 4 to 6 of menstrual cycle, when the endometrium is the thinnest1. A cut off of 5mm of endometrium is useful in ruling out endometrial cancer in post menopausal women. A thin endometrium can reassure the physician that there is no endometrial pathology and medical treatment can be embarked upon. A patient with thick endometrium needs further evaluation with endometrial biopsy, saline sonography or hysteroscopy.
Q: What is Endometrial sampling? Should Endometrial sampling be done for all women with increased thickness of endometrium?

A: Endometrial sampling is a technique of taking a biopsy of the endometrium to rule out malignancy. Generally, this was done by dilatation and curettage in the past, but now, it is has been found that sampling the endometrium using special devices like an endometrial pipelle can also rule out malignancy. It is necessary to rule out malignancy this way for women in the reproductive and perimenopausal age group, ie: >45 years with abnormal uterine bleeding. It is also deemed necessary when high risk factors for malignancy, are present,viz;Age > 45, history of infertility, family history of colonic carcinoma, and nulliparity4,5.. All post menopausal women presenting with uterine bleeding, and women on Tamoxifen/Letrozole post-CA Breast should also undergo endometrial sampling.
Q: What is sonohysterogram? When does the gynaecologist order this investigation?

A: Sonohysterogram or SIS ( Saline Infusion Sonography ) infuses saline into the endometrial cavity during Trans vaginal ultrasonography (TVUS) to enhance the image. Many alternate terms have been used to describe this technique: echohysteroscopy, hydrosonography, sonohysterography, sonohysterogram, sonohysterosalpingography, and sonoendovaginal ultrasound. SIS allows the clinician to evaluate the uterus for intracavitary lesions more accurately than TVUS. The indications for SIS are3,6:
1.Abnormal bleeding in premenopausal or postmenopausal patients
2.Evaluation of an endometrium that is thickened, irregular, immeasurable or poorly defined by
conventional transvaginal ultrasound (TVUS).
3.Irregular endometrial appearance by TVUS in women using tamoxifen.
4.The need to differentiate between sessile and pedunculated masses of the endometrium.
5. Presurgical evaluation of intracavitary fibroids.
Q: If endometrial sampling is normal, what should be the first line of management?

A: In the perimenopausal age, anovulatory bleeding is more likely to be the cause of DUB. This has to be tackled with progestogens or oral contraceptive pills as first line of management. In hypertensive and diabetic patients, oral contraceptives with high dose oestrogen may be harmful. Some patients cannot tolerate hormones. Some patients may not respond to hormone treatment or may take treatment irregularly leading to more irregularities in bleeding. Alternative medical treatment methods or conservative surgical measures have to be resorted to in such patients.

Derangements in the local haemostatic mechanism may cause ovulatory bleeding . Antiprostaglandins like Mefenamic acid and antifibrinolytic agents like Tranexamic acid may be useful in the management of such patients. Patients with ovulatory DUB must be evaluated for intracavitary uterine pathology (with SIS or hysteroscopy), since hormonal dysfunction is not the likely cause of bleeding. Intracavitatory causes like endometrial polyps or submucous fibroids have to be ruled out. If such pathology is diagnosed, there is an option of hysteroscopic resection in centres with facilities for such procedures.

Q: Should hysteroscopy be done for all patients with dysfunctional uterine bleeding?

A:All patients with DUB need not undergo Hysteroscopy. However, all patients of ovulatory DUB are best evaluated with a hysteroscope, because patients with ovulatory DUB are more likely to have intracavitary uterine pathology, since hormonal dysfunction is not the likely cause of bleeding. In these patients, if on TVS, the endometrial thickness is irregular, the endo-myometrial interface is ill defined, then hysteroscopy offers a better chance of diagnosis. Patients with anovulatory DUB, where concomitant intra -cavitary lesions are suspected, may also be offered hysteroscopy2,6.

Q: What are the medical treatment modalities available for treatment of DUB?
A: Combined Oral Contraceptive pills, Progesterone Preparations, NSAIDs, I/V CEEs for acute bleeding (not available in India), Danazol, (not very frequently used due to unacceptable side effects), GnRH Analogues, LNG IUS : Mirena, Antifibrinilytic Agents : Trenaxemic Acid.

Q: What is Tranexamic acid? What is the dose and how long in an index month can it be given?

A: Tranexamic acid is an Antifibrinolytic Agent and is a synthetic lysine derivative which blocks lysine- binding sites on plasminogen. It prevents plasmin from binding to fibrin, thus inhibiting fibrinolysis . Tranexamic acid has been shown to reduce menstrual bleeding by approximately 50% 7,8. In most studies tranxemic acid was administered from days 1 to 4 or 5 of menses in a dose of 4 g/day1,7,8. Maximum of 4 gms can be given per day in divided doses. It has been studied in the dose of 1.95gm daily was also found to be effective in one study9.
Q; What is ormeloxifene? For how many months can treatment with ormeloxifene be given?

A:Ormeloxifene (also known as centchroman) is one of the selective estrogen receptor modulators, or SERMs, a class of medication which acts on the estrogen receptor. It is best known as a non-hormonal, non-steroidal oral contraceptive which is taken once per week. Ormeloxifene may be effective for dysfunctional uterine bleeding and advanced breast cancer. It can be used for the treatment of DUB at any age. However, it is not suitable for women desiring pregnancy, due to it�s contraceptive effects. Doses: Dysfunctional uterine bleeding: 60 mg twice a week for the 1st 12 weeks and then 60 mg once a week for up to next 12 weeks10

Q: Is there any difference in medical treatment if there is metabolic syndrome?

A: Women with metabolic syndrome tend to be diabetic and hypertensive in the perimenopausal age. Giving high dose oral contraceptive pills may be harmful in these patients. Such patients can be treated by giving them withdrawal bleeds without allowing them to go into prolonged periods of amenorrhoea. If she has PCOS, metformin may be helpful. Progestogens or antifibrinolytic agents will have to be chosen instead of COC�s. Ormiloxefene is a new option. The LNG-IUD, is another option.

Q: What is LNG-IUD? What are the effects and side effects?

A: The LNG-IUS is an intrauterine delivery system, which delivers levonorgestrel @ 20mcg per day. The IUS has a similar shape to the Nova-T 380 copper IUD with the vertical stem containing a mixture of 52 mg levonorgestrel and polydimethyl siloxane (PDMS), surrounded by a rate-controlling PDMS capsule11. The total length of the system is 32 mm, and the T-shaped plastic frame is impregnated with barium sulphate, making the device radio-opaque. Two threads are attached to the loop at the base of the IUS to aid removal. This system allows a steady, local release of 20 mg levonorgestrel per day initially, and has few systemic side-effects (approximately the equivalent of taking two progestogen- only pills/week). Following insertion of an IUS, women frequently complain of menstrual disturbance. Approximately 17% of women will complain of prolonged bleeding (>8 days) in the first month of use, with this falling to 3% at 3 months. Some complaints include mood changes, nausea, headache, bloating, breast tenderness, fluid retention and skin problems.

Q: How long can you give medical treatment?

If COC pills, progestagens, trenaxamic acid , NSAIDs are used , then minimum of 6 months therapy is indicated. If LNG�IUS is used then it may even be continued for upto 5 years for extended contraceptive benefits2,3,8.

Q: In a woman with simple hyperplasia, in the perimenopausal period, is there any need for hysterectomy?

A: If medical treatment is not effective or is contraindicated, then first choice is hysterectomy as Ablation Techniques are contraindicated in women with hyperplasia due to the fact that hyperplasia is a risk factor for Endometrial CA. More so if the patient is obese, hypertensive and diabetic, as these are co-risk factors 1,2,3.

Q: In a woman with cystic glandular hyperplasia, in the perimenopausal age, is there any need for hysterectomy?

A: WHO classifies hyperplasia into two varieties, simple or complex types, each with atypical or non �atypical pathology. Studies have found high concentrations of progesterone receptors in hyperplasia without atypia whereas lower levels were found in atypical hyperplasia12,13. Hyperplasia without atypia may disappear completely with progesterone therapy. Progesterone therapy has to be given for 6 months. LNG IUD is another option. However, studies have shown discrepancies between endometrial pipelle specimens of endometrium /D&C samplings and hysterectomy specimens of endometrium12. So ideally, if a pipelle sample shows hyperplasia, a hysteroscopic directed biopsy should be taken to rule out atypical hyperplasia. If a hysteroscopic directed biopsy is negative for atypia, progesterone treatment may be tried. In women who show atypia, either on hysteroscopy or on pipelle sampling, the clinician must be worried that the patient may be harbouring endometrial carcinoma. A hysterectomy may be prudent in these women. Ablative procedures are not currently recommended for such patients.
Q:What are the other options beside hysterectomy for a woman who cannot tolerate medical treatment due to side effects or if she has a failure of medical treatment?
A: Endometrial Ablation Techniques: where controlled injury of the basal layer of the endometrium is done in order to treat DUB by creating intrauterine adhesions or an iatrogenic Asherman�s Syndrome-like situation.

Hysteroscopic resection was the first efficacious ablation therapy for DUB . It was introduced in 1976 by Neuwirth et al. and offered a surgical alternative to hysterectomy. Subsequently, laser ablation, radio-frequency monopolar resection, and rollerball ablation were developed. These are commonly called First Generation Techniques.Later the second generation techniques followed, Second-generation techniques mostly involve tissueheating as the method of endometrial destruction. They are blind in nature, not being performed under direct hysteroscopic vision with the exception of the HydroTherm AblatorTM. They therefore, avoid the risks of fluid distension media. Some techniques may be performed under local anaesthesia. For all methods, the woman should have no desire to retain her fertility. The uterus should be of 12 week size or less. Cryoablation, Free fluid thermal ablation, Impedance-controlled bipolar radiofrequency,ELITT, Photodynamic endometrial ablation, Thermal balloon endometrial ablation are some of the second generation ablation techniques14.15,16. Thermal balloon endometrial ablation is the most popular among these in India.
Q: What are the complications of the Ablation Techniques?
A: Endometrial ablation and endometrial resection both performed under hysteroscopic view, are safe procedures with a low morbidity. Peri – operative complications of hysteroscopic resection/Ablation procedures are : Perforation with the possibility of bowel injury, haemorrhage, visceral burn, genital tract burn and cardiovascular problems due to intravasation of distension fluid,characterised by hyponatraemia, water intoxication, cerebral edema and cardiac overload.
Second generation endometrial Ablation techniques, not employing the hysteroscope, like the thermal ablation system, have fewer complications.

Q: What is the failure rate of ablation methods? Is it better to do hysterectomy for once and for all?

A: Failure rate measured by re-intervention rates is dependent on the method of ablation chosen. Broadly it varies between 6% to 30% for various methods. Choosing hysterectomy over the ablation techniques depends upon individual patient counseling, her needs, whether she is compliant enough for further follow-ups, and whether the case is high/ low risk for surgery/anaesthesia 14,15,16.

Q: What is the role of D&C in the management of DUB?

A: Dilatation and curettage (D&C) causes a temporary reduction of menstrual blood loss for the first month, but at following cycles, the amount of blood loss tends to increase as compared to blood loss before the D&C . Therefore, D&C must be considered obsolete in the treatment of dysfunctional uterine bleeding, but unfortunately it is still performed on a large scale in women suffering from dysfunctional uterine bleeding1,2,3.

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