Dysfunctional Uterine Bleeding (DUB, AUB)

High dose oral contraceptives — High doses of oral contraceptives (OCs) (eg, an OC containing 35 mcg ethinyl estradiol taken two to four times daily) will cause bleeding to subside in most women within 48 hours [2,17]. We use a cascading regimen (ie, five pills on day 1, four pills on day 2, three pills on day 3, two pills on day 4, and one pill on day 5). For women with moderate bleeding, we start with three pills daily. An antiemetic medication should be prescribed (eg, promethazine 12.5 to 25 mg per rectum, as needed).

Treatment with one pill daily of OCs should continue for at least one week after the bleeding subsides and then should be stopped for three to five days to allow for a withdrawal bleed. Standard dose OCs may then be restarted either to prevent recurrent menorrhagia or for contraception.

High dose progestins — Profuse or prolonged uterine hemorrhage related to anovulation can also be treated with high dose progestins alone. In women with a thickened endometrium, progestins inhibit further endometrial growth and organize and support the estrogen-primed endometrium, allowing effective sloughing upon hormone withdrawal [12]. However, if profuse, prolonged bleeding has resulted in a denuded endometrium, progestins are unlikely to be effective. Diagnosis of anovulation is discussed separately.

Options for progestin therapy include:

medroxyprogesterone acetate (10 to 20 mg two times per day)

megestrol acetate (20 to 60 mg two times per day)

norethindrone (5 mg once or twice per day)

Progestins are continued for at least 5 to 10 days [2,18,19]. In anemic patients who can tolerate this regimen, a one- to two-month treatment period in conjunction with iron allows an increase in the hemoglobin concentration.

(Above from UpToDate)
 
From Dr Longenecker, 2016:
The house with the egg on the second floor – a metaphor for the reproductive cycle:
Estrogen builds the “pipes” up to the “second floor” where the egg is resting in its cradle.
In the second couple of weeks, Progesterone shows up and buttresses all the fragile PVC pipes to keep them stable.
If pregnancy happens, Progesterone sticks around and keeps working.
If not, Progesterone leaves after 2 weeks and takes Estrogen with him, and all the structure falls down.
Image result for palm coein
When you get a menstrual complaint – think PIG – Pregnancy, Infection, GYN history
By GYN history, ask everything:
– menarche
– how frequent?
– when did birth control start?
– do they skip periods?
– does it hurt to have sex?
– etc, etc, etc.
Bleeding and pain with intercourse should make you think:  cervicitis, cervical dysplasia, or cervical cancer.
If the patient is having regular, but heavy, periods (menorrhagia), they’ve got enough progesterone.  Treatment options include NSAIDs, continuous progesterone – tilt balance in favor of progesterone > estrogen.
 
Symptomatic fibroids:  LNG-IUD (approved in women with non-distorted endometrial cavity and normal cavity size); combined OCPs, NSAIDs, danazol, tranexamic acid.
Don’t forget WEIGHT LOSS and IRON SUPPLEMENTS for women with a history of heavy menstrual bleeding – the weight loss will decrease endogenous estrogen, and almost all of them are iron-deficient.
Be careful with consultations!  Up to 38% of US women who underwent hysterectomy were never offered an alternative treatment option!  (AJOG 2015;212:304.e1-7)
 
Menometrorrhagia in a perimenopausal woman with obesity, hx of irregular periods:  we’re worried about anovulatory bleeding.  TVUS with endometrial biopsy -> disordered secretory endometrium (estrogen and progesterone are “out of phase”).
– treatment:  OCPs (if not a smoker); cyclic progesterone (take for 2 weeks every 4 weeks), combine with NSAIDs or transexamic acid (Lysteda).
– Lysteda (transexamic acid) – inhibits fibrinolysis, inhibits plasmin, also decreases inflammation by inhibiting complement.  $$$
Endometrial cancer is extremely unusual under the age of 45.  However, if they have multiple risk factors:  hx of PCOS, frequent bleeding over a long period, high exposure to estrogen (no pregnancies, long-term OCPs, obesity) – worry about it, and get a biopsy.
Young, very thin adolescent female with constant spotting – like lack of estrogen!  She doesn’t have Estrogen showing up to lay pipe, nor Progesterone to buttress the pipes – the myometrial (basement) pipes aren’t capped off and just ooze all the time.
Inherited bleeding disorder:  don’t use NSAIDs; use combination OCPs with no placebos
Adenomyosis:  It’s endometriosis of the uterine wall – it’s a structural cause (pipes and buttressing growing out of the blueprints!). – you have to suppress ovulation, so you can use DMPA or OCPs (continuous)
– don’t just use NSAIDs or transexamic acid – have to suppress the attempted (abnormal) cycling of estrogen/progesterone
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