Current treatment of dysfunctional uterine bleeding
Introduction
Abnormal premenopausal uterine bleeding can be irregular, non-cyclic bleeding (metrorrhagia) or prolonged and/or heavy menstrual bleeding (menorrhagia). Menorrhagia is defined as heavy menstrual bleeding (menstrual blood loss more than 80 ml) with a cyclical character over several consecutive cycles, thereby implying that irregular vaginal bleeding, as well as other abnormal bleeding patterns should be excluded from the definition of menorrhagia [1]. Menorrhagia is a frequent problem in premenopausal women. It is estimated that a woman has a life time chance of 1:20 to consult her general practitioner for complaints due to menorrhagia [2], [3], [4].
Since only 40–50% of the women who complain of heavy menstrual bleeding suffer from objective menorrhagia, it is important to quantify the amount of menstrual blood loss [5], [6]. Gannon et al. found that, among women treated by endometrial ablation for heavy menstrual bleeding, those with quantified menorrhagia were more likely to be satisfied with the treatment result (OR 2.5, 95% CI 1.1–4.7), and less likely to require subsequent hysterectomy (OR 1.8, 95% CI 0.6–5.2), as compared to women who experienced their menstruation as heavy before the onset of treatment without having menstrual blood loss more than 80 ml [7]. Women with menstrual bleeding of more than 80 ml have a higher incidence of anaemia. Although a low serum haemoglobin (<12 g/dl) increases the chance of objective menorrhagia, a normal serum haemoglobin does not rule out menorrhagia (sensitivity 43%, specificity 94%) [8]. Since women’s perception of the heaviness of their menstrual blood loss does not always correlate well with the objective assessment, the severity of menstrual bleeding must be quantified. Hallberg introduced the alkaline haematin method to measure menstrual blood loss [9]. In the alkaline haematin method, menstrual blood is collected from towels and tampons, using a 5% NaOH solution. Such techniques require hospital-based equipment and staff [10]. Furthermore, the collection of pads and tampons makes the alkaline haematin method inconvenient for women. In order to get a semi-quantitative measurement of the menstrual blood loss, Higham et al. [11] developed a pictorial blood loss assessment chart. The pictorial chart consists of a series of diagrams representing lightly, moderately and heavily soiled pads and tampons. Multiplication of the number of slightly, moderately and heavily soiled pads and tampons with fixed absorption factors results in a Higham score. On the Higham chart, a cut-off score of 100 was found to correlate with menstrual blood loss of more than 80 ml. Janssen et al. [8] investigated the usefulness of a modified pictorial chart in a larger study, and recommended a cut-off score of 185. Although the use of a pictorial chart might implicate misclassification of menorrhagia, the method is clearly more accurate than history alone [8], [11], [12]. However, patient-selection in DUB trials is often not defined, not as blood loss in excess of 80 ml and not as a pictorial chart score.
Menorrhagia can be caused by intracavitary abnormalities, but it also can occur in women without such abnormalities. In the last decade, the introduction of transvaginal sonography, saline infusion sonography, and hysteroscopy has improved the possibility to diagnose intracavitary abnormalities [13], [14]. In case when intracavitary abnormalities are not present, women suffering from menorrhagia are said to have dysfunctional uterine bleeding. Dysfunctional uterine bleeding is defined as periodic uterine blood loss in excess of 80 ml per cycle occurring in the absence of structural uterine disease. The aim of the present review is to discuss the treatment options for women with dysfunctional uterine bleeding.
Section snippets
Medical treatment
Medical treatment of dysfunctional uterine bleeding includes treatment with anti-fibrinolytic tranexamic acid, non-steroidal anti-inflammatory drugs (NSAID’s), the combined contraception pill, progestogen, danazol, and analogues of gonadotrophin releasing hormone (GnRH analogues). The effectiveness of drug therapy for dysfunctional uterine bleeding was evaluated and reported in systematic reviews in the Cochrane library [15], [16], [17], [18], [19].
Antifibrinolytic tranexamic acid has proven to
Levonorgestrel releasing intra uterine device (IUD)
Another form of medical treatment is the levonorgestrel releasing intra uterine device (IUD) (Mirena®). The levonorgestrel releasing IUD is originally developed for contraception, but it has also proven to be an effective device in the treatment of dysfunctional uterine bleeding. Its efficacy is based on the local release of levonorgestrel in the uterine cavity, thus suppressing endometrial growth. The use of levonorgestrel releasing IUD considerably decreases the amount of menstrual blood loss
Surgical treatments for dysfunctional uterine bleeding
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 the blood loss before the D&C [40]. 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 bleeding [40].
First generation endometrial ablation techniques
Ashermann was the first to describe the association between D&C and women who became amenorrhoeic after an abortion. He found an obliterated uterine cavity at hysterectomy and described this condition as ‘amenorrhoea atretica’ or ‘amenorrhoea traumatica’. Since than, physicians have studied the possibility of controlled injury of the basal layer of the endometrium in order to treat dysfunctional uterine bleeding [41].
Hysteroscopic resection was the first efficacious ablation therapy for
Second generation endometrial ablation techniques
Second generation ablation devices have been introduced in the last decade of the 20th century (Fig. 1) [84], [85]. These devices require less skill of the surgeon, and bear less risk compared to devices of the first generation. However, these second generation ablation techniques do not have the advantages of direct visualization and detection of abnormal pathology with the hysteroscopic-guided ablation techniques. A preoperative endometrial biopsy should be performed prior to the ablation
Discussion
Dysfunctional uterine bleeding can be treated with medical therapy, a levonorgestrel releasing IUD, endometrial ablation using first and second generation techniques, and hysterectomy. In The Netherlands, where most patients with dysfunctional uterine bleeding are initially treated by the general practitioner, medical therapy is the treatment of first choice for most patients. However, the single RCT in which medical treatment has been compared to endometrial ablation indicates a significantly
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