Elsevier

Maturitas

Volume 47, Issue 3, 15 March 2004, Pages 159-174
Maturitas

Current treatment of dysfunctional uterine bleeding

https://doi.org/10.1016/j.maturitas.2003.08.002Get rights and content

Abstract

Objectives: We performed a review of the treatment modalities for dysfunctional uterine bleeding. Methods: Dysfunctional uterine bleeding can be treated medically or surgically. Medical treatment consists of anti-fibrinolytic tranexamic acid, non-steroidal anti-inflammatory drugs, the combined contraception pill, progestogen, danazol, or analogues of gonadotrophin releasing hormone. The levonorgestrel releasing intra uterine device is developed for contraception, but is also effective in the treatment of dysfunctional uterine bleeding. Surgical treatment includes endometrial ablation of the first and second-generation, and hysterectomy. This review contains current available evidence on the effectiveness of these therapies. Results: Antifibrinolytic tranexamic acid is the most effective medical therapy to treat dysfunctional uterine bleeding. In general medical therapy is not as effective as endometrial resection in terms of patient satisfaction and health related quality of life. The levonorgestrel releasing intra uterine device is an effective treatment for dysfunctional uterine bleeding. No difference in quality of life was observed in patients treated with a levonorgestrel releasing intra uterine device as compared to hysterectomy. Ablation techniques of the first generation are effective and safe when used by trained surgeons, but have a learning curve. Ablation techniques of the second generation are effective, but long-term follow-up data are not available. Similarly, there are no large randomised controlled trials comparing the levonorgestrel releasing intra uterine device to first and second-generation ablation techniques. Hysterectomy, the traditional standard of care, has a relatively high complication rate, but it generates a high satisfaction rate and good health related quality of life scores. Conclusion: Since none of the treatments for dysfunctional bleeding is superior to one of the others, and since all treatments have their advantages and disadvantages, counselling of patients with dysfunctional bleeding should incorporate medical approach, levonorgestrel releasing IUD, endometrial ablation and hysterectomy.

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

References (124)

  • R. Hurskainen et al.

    Quality of life and cost-effectiveness of levonorgestrel-releasing intrauterine system versus hysterectomy for treatment of menorrhagia: a randomised trial

    Lancet

    (2001)
  • R.S. Neuwirth et al.

    Excision of submucus fibroids with hysteroscopic control

    Am. J. Obstet. Gynecol.

    (1976)
  • M.H. Goldrath et al.

    Laser photovaporization of the endometrium in the treatment of menorrhagia

    Am. J. Obstet. Gynecol.

    (1981)
  • R. Garry et al.

    Six hundred endometrial laser ablations

    Obstet. Gynecol.

    (1995)
  • M.S. Baggish et al.

    Endometrial ablation: a series of 568 patients treated over an 11-year period

    Am. J. Obstet. Gynecol.

    (1996)
  • R. Teirney et al.

    Menstrual blood loss measured 5–6 years after endometrial ablation

    Obstet. Gynecol.

    (2000)
  • P. Martyn et al.

    Long-term follow-up of endometrial ablation

    J. Am. Assoc. Gynecol. Laparosc.

    (1998)
  • P.G. Crosignani et al.

    Endometrial resection versus vaginal hysterectomy for menorrhagia: long-term clinical and quality-of-life outcomes

    Am. J. Obstet. Gynecol.

    (1997)
  • H. O’Connor et al.

    Medical research council randomised trial of endometrial resection versus hysterectomy in management of menorrhagia

    Lancet

    (1997)
  • G.A. Vilos et al.

    Genital tract electrical burns during hysteroscopic endometrial ablation: report of 13 cases in the United States and Canada

    J. Am. Assoc. Gynecol. Laparosc.

    (2000)
  • F.W. Jansen et al.

    Complications of hysteroscopy: a prospective, multicenter study

    Obstet. Gynecol.

    (2000)
  • J.M. Cooper et al.

    Late complications of operative hysteroscopy

    Obstet. Gynecol. Clin. North. Am.

    (2000)
  • A. Mall et al.

    Previous tubal ligation is a risk factor for hysterectomy after rollerball endometrial ablation

    Obstet. Gynecol.

    (2002)
  • R.F. Valle et al.

    Endometrial carcinoma after endometrial ablation: high-risk factors predicting its occurrence

    Am. J. Obstet. Gynecol.

    (1998)
  • C.P. Pugh et al.

    Successful intrauterine pregnancy after endometrial ablation

    J. Am. Assoc. Gynecol. Laparosc.

    (2000)
  • M. Pinette et al.

    Successful planned pregnancy following endometrial ablation with the YAG laser

    Am. J. Obstet. Gynecol.

    (2001)
  • A.M. McCausland et al.

    Depth of endometrial penetration in adenomyosis helps determine outcome of rollerball ablation

    Am. J. Obstet. Gynecol.

    (1996)
  • C. Overton et al.

    Audit of currently available endometrial ablative techniques

    Baillieres Clin. Obstet. Gynaecol.

    (1995)
  • J. Donnez et al.

    Goserelin acetate (Zoladex) plus endometrial ablation for dysfunctional uterine bleeding: a 3-year follow-up evaluation

    Fertil. Steril.

    (2001)
  • W.R. Meyer et al.

    Thermal balloon and rollerball ablation to treat menorrhagia: a multi-center comparison

    Obstet. Gynecol.

    (1998)
  • D. Grainger et al.

    Thermal balloon and rollerball ablation to treat menorrhagia: two-year results from a multicenter prospective, randomized clinical trial

    J. Am. Assoc. Gynecol. Laparosc.

    (2000)
  • F.D. Loffer

    Three-year comparison of thermal balloon and rollerball ablation in treatment of menorrhagia

    J. Am. Assoc. Gynecol. Laparosc.

    (2001)
  • F.D. Loffer et al.

    Five-year follow-up of patients participating in a randomized trial of uterine balloon therapy versus rollerball ablation for treatment of menorrhagia

    J. Am. Assoc. Gynecol. Laparosc.

    (2002)
  • G.A. Vilos et al.

    Clinical trial of the uterine thermal balloon for treatment of menorrhagia

    J. Am. Assoc. Gynecol. Laparosc.

    (1997)
  • S.L. Corson et al.

    Interim results of the American Vesta trial of endometrial ablation

    J. Am. Assoc. Gynecol. Laparosc.

    (1999)
  • S.L. Corson et al.

    One-year results of the vesta system for endometrial ablation

    J. Am. Assoc. Gynecol. Laparosc.

    (2000)
  • Royal College of Obstetricians and Gynaecologists. The management of menorrhagia in secondary care;...
  • M.P. Vessey et al.

    The epidemiology of hysterectomy: findings in a large cohort study

    Br. J. Obstet. Gynaecol.

    (1992)
  • R. Luoto et al.

    Socioeconomic variations in hysterectomy: evidence from a linkage study of the Finnish hospital discharge register and population census

    J. Epidemiol. Commun. Health

    (1997)
  • T.H. Chimbira et al.

    Relation between measured menstrual blood loss and patient’s subjective assessment of loss, duration of bleeding, number of sanitary towels used, uterine weight and endometrial surface area

    Br. J. Obstet. Gynaecol.

    (1977)
  • M.J. Gannon et al.

    A new method for measuring menstrual blood loss and its use in screening women before eudiometrical ablation

    Br. J. Obstet. Gynaecol.

    (1996)
  • L. Hallberg et al.

    Menstrual blood loss—a population study

    Acta. Obstet. Gynecol. Scand.

    (1966)
  • P. Vasilenko et al.

    A new end simple method of measuring menstrual blood loss

    J. Reprod. Med.

    (1988)
  • J.M. Higham et al.

    Assessment of menstrual blood loss using a pictorial chart

    Br. J. Obstet. Gynaecol.

    (1990)
  • P. Vercellini et al.

    The role of transvaginal ultrasonography and outpatient diagnostic hysteroscopy in the evaluation of patients with menorrhagia

    Hum. Reprod.

    (1997)
  • F.P.H.L.J. Dijkhuizen et al.

    Comparison of transvaginal ultrasonography and saline infusion sonography for the detection of intracavitary abnormalities

    Ultrasound Obstet. Gynecol.

    (2000)
  • Lethaby A, Farquhar C, Cooke I. Antifibrinolytics for heavy menstrual bleeding (Cochrane Review). The Cochrane Library,...
  • Lethaby A, Augood C, Duckitt K. Nonsteroidal anti-inflammatory drugs for heavy menstrual bleeding (Cochrane Review)....
  • Iyer V, Farquhar C, Jepson R. Oral contraceptive pills for heavy menstrual bleeding (Cochrane Review). The Cochrane...
  • Lethaby A, Irvine G, Cameron I. Cyclical progestogens for heavy menstrual bleeding (Cochrane Review). The Cochrane...
  • Cited by (40)

    • Identification and verification of effective components of Huanghuai for dysfunctional uterine bleeding based on network pharmacology and molecular docking

      2021, Chinese Herbal Medicines
      Citation Excerpt :

      DUB can be treated medically or surgically. Medical treatment of DUB includes anti-fibrinolytic tranexamic acid, non-steroidal anti-inflammatory drugs, the combined contraception pill, progestogen, danazol, or analogues of gonadotrophin releasing hormone (Bongers et al., 2004). Surgical treatment includes hysteroscopic surgery and hysterectomy.

    • An RCT: Use of Oxytocin Drip during Hysteroscopic Endometrial Resection and Its Effect on Operative Blood Loss and Glycine Deficit

      2011, Journal of Minimally Invasive Gynecology
      Citation Excerpt :

      Absorption of glycine solution during TCRE may cause dilutional hyponatremia, with symptoms of fluid overload that can include nausea and cerebral edema [1,5]. In addition to fluid overload and hyponatremia, other immediate complications associated with TCRE include uterine perforation, air embolism, transient blood oxygen desaturation, hypercapnia, and coagulopathy [7–9]. However, we did not notice any of these complications among the women enrolled in our study.

    View all citing articles on Scopus
    View full text