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Vamsi Balakrishnan Abnormal Uterine Bleeding

Abnormal Uterine Bleeding


I. Workup
a. Transvaginal Ultrasound (TV-US)
i. Good for detecting structural problems (e.g. fibroids) that might be
missed by EMB.
ii. Endometrial thickness measurement of <4-7 cm  rarely cancer; EMB
not needed.
b. Endometrial biopsy (EMB)
i. Most commonly used test for DUB.
1. Good: Can diagnose endometrial problems 90-100%
2. Bad: Fails to detect polyps, fibroids.
3. Indication:
a. (female) with DUB >35 since risk of cancer is so
high.
b. (female) with amenorrhea for >1 year who then has
uterine bleeding.
4. Note: do it late in the cycle to determine if ovulation has
taken place.
c. D&C
i. Good: allows more extensive sampling of the uterine cavity; diagnostic
AND therapeutic. If D&C + EMB  ~100% detection rate. Detects
dysplasia and malignancy.
ii. Used if EMB is inadequate, the cervical os is stenotic, or DUB treatment
fails
iii. Bad: Asherman’s, damage to uterus/cervix.
1. So, never used for young people who are unlikely to have
endometrial cancer.
d. Hysteroscopy
i. Good: More sensitive. Can be used in place of D&C for diagnosis (meaning no Asherman’s); allows direct visualization.
Much better than anything else at diagnosing polyps + submucosal fibroids.
ii. Bad: Often misses endometritis (inflammation of the lining of uterus).
1. Complications: entering the uterus via cervix will increase risk of developing endometritis  D&C,
hysteroscopy, placement of IUD.
II. Treatment – treatment of choice depends on the cause, severity, fertility status,
need for contraception.
a. IV (E) – intravenous estrogen is for acute, heavy, uncontrolled bleeds; use until
bleeding stops.
b. OCPs – moderately heavy DUB.
i. Conjugated
1. Good: Will stabilize epithelium, slough excessive buildup,
provide contraception.
2. If already on OCPs, then get DUB  increase dosage.
ii. POP – progesterone only
1. Better at contraception, doesn’t help as well with bleeds.
iii. SE – nausea/vomiting
c. D&C
i. Treatment of choice if bleeding is severe and/or requires blood
transfusions.
d. Ablation
i. Thermasure – thermal uterine balloon.
1. Water balloon  filled with D5  raise to 87C for 8
minutes.
2. Fits contours well.
ii. Novasure
1. Insert coil on fan shaped device  electrical induced heat
burning. Faster. Probably not as good as thermal balloon.
e. Hysterectomy
i. Good – 100% curative, better sexual functioning than other
treatments overall.
ii. Bad – 6/10,000 die, longer heal times than ablation.

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