Chronic Dysfunctional Uterine Bleeding

A SUPPLEMENT TO

Ob.Gyn. News®

Mary Jane Minkin, MD, ChairYale University School of MedicineNew Haven, Conn.

Charles E. Miller, MDUniversity of ChicagoChicago

Malcolm G. Munro, MD The David Geffen School of

Medicine at UCLALos Angeles

Robert K. Zurawin, MDBaylor College of MedicineHouston

Chronic DysfunctionalUterine Bleeding:Identifying Patients and Helping ThemUnderstand Their Treatment Options

Consequences of Heavy Menstrual Bleeding

Types, Patterns, and Causes of Abnormal Uterine Bleeding

Treatment Options:Entering the Dialogue

Helping Patients Choose

Considering Cases

C L I N I C A L H I G H L I G H T SFA C U LT Y

OBGynecare 8/31/04 4:03 PM

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Ob.Gyn. News®

The articles in this supplement arebased on clinical dialogues with thefaculty.

This supplement was supported byan educational grant from

The supplement was produced by themedical education department ofInternational Medical News Group.Neither the Editor of OB.GYN. NEWS,the Editorial Advisory Board, nor thereporting staff contributed to its con-tent. The opinions expressed in thissupplement are those of the facultyand do not necessarily reflect theviews of the supporter or of thePublisher.

Copyright 2004 Elsevier Inc. Allrights reserved. No part of this pub-lication may be reproduced or trans-mitted in any form, by any means,without prior written permission ofthe Publisher. Elsevier Inc. will notassume responsibility for damages,loss, or claims of any kind arisingfrom or related to the informationcontained in this publication, includ-ing any claims related to the prod-ucts, drugs, or services mentionedherein.

3 Introduction

4 Consequences of Heavy Menstrual Bleeding

4 Types, Patterns, and Causes of Abnormal Uterine Bleeding5 Evaluating the Endometrial Cavity

6 Treatment Options: Entering the Dialogue7 Medical Therapy

9 Surgical Interventions

11 Endometrial Ablation Procedures

Considering Cases:8 An Overweight Patient

10 A Patient Who Prefers to Avoid Hysterectomy

14 A Patient With Postsurgical HMB

13 Helping Patients Choose

15 Conclusion

15 References and Additional Suggested Reading

Mary Jane Minkin, MD, FACOG, ChairClinical ProfessorDepartment of Obstetrics and Gynecology

Yale University School of MedicineNew Haven, Conn.

Charles E. Miller, MD, FACOGClinical Associate ProfessorDepartment of Obstetrics and GynecologyUniversity of Illinois at ChicagoClinical Associate Department of Obstetrics and Gynecology

University of Chicago

Malcolm G. Munro, MD,FRCS(c), FACOG ProfessorDepartment of Obstetrics and GynecologyThe David Geffen School of Medicine at UCLA

Los AngelesAttending StaffDepartment of Obstetrics and GynecologyKaiser Permanente Los Angeles Medical Center

Robert K. Zurawin, MD, FACOGAssociate ProfessorDepartment of Obstetrics and GynecologyBaylor College of MedicineHouston

Faculty/authors must disclose anysignificant financial interest or rela-tionship with proprietary entitiesthat may have a direct relationship tothe subject matter. They must alsodisclose any discussion of investiga-tional or unlabeled uses of products.

Dr Miller is a consultant to Gyne-care Worldwide. Dr Minkin devel-oped a Web site for Gynecare and ison the Speaker’s Bureau at Berlex,Inc. Dr Munro has received fundingfor clinical grants from KaiserResearch Foundation and Karl StorzEndoscopy-America, Inc. He is also a consultant to Boston ScientificCorporation, Gynecare, and KarlStorz Endoscopy. Dr Zurawin is aconsultant to and a speaker forGynecare.

In this supplement, the faculty mem-bers discuss the off-label use of several medications and devices totreat heavy menstrual bleeding: oralcontraceptives, postmenopausal hor-mone replacement formulations,leuprolide acetate, and the progestin-releasing intrauterine device.

Chronic Dysfunctional Uterine Bleeding:Identifying Patients and Helping ThemUnderstand Their Treatment Options

C O N T E N T S

FA C U LT Y FA C U LT Y D I S C L O S U R ES TAT E M E N T


CHRONIC DYSFUNCTIONAL UTERINE BLEEDING 3

Table 2. Two Types of Dysfunctional Uterine Bleeding (DUB)

Ovulatory DUBPresents with the symptom of menorrhagia, but occursunrelated to:

systemic coagulopathy

pharmaceutical agents

any structural anomalies of the uterus

Anovulatory/Oligoovulatory DUBOccurs secondary to anovulation or oligoovulation; insome cases, menstrual bleeding is heavy

A ccording to the seminal study on this topic,heavy menstrual bleeding (HMB)—at least80 mL per month—affects about 20% of

menstruating women worldwide.1 Approximately 550,000hysterectomies are performed in the United States eachyear, with more than 230,000 of these performed becauseof symptomatic menstrual bleeding.2 In 35% to 50% ofthese cases, no pathology of the uterus is identified.2 Evenwhen pathology exists, in many instances it causes nosymptoms and is unrelated to the cause of the bleeding.

Once a clinician has evaluated a patient for problemssuch as structural abnormalities of the uterus and coag-ulopathies, he or she has the opportunity—and theresponsibility—to offer the extensive variety of effectivetreatment options available. This “menu” approachempowers the patient to make personally appropriatetreatment choices.

The discussion of dysfunctional uterine bleeding(DUB) is a complex topic, beginning with terminology(Table 1). For example, although many clinicians wouldsimplify this discussion by using the term “menorrha-gia,” menorrhagia very specifically describes heavy butpredictable, cyclic bleeding, which generally implies ovulation. However, many clinicians, particularly in theUnited States, use the term to include heavy uterinebleeding that occurs in the context of menses that areunpredictable in timing, a situation that generally

reflects anovulation. In fact, there are two types of DUB(Table 2). One type, which could be called “ovulatoryDUB,” presents with the symptom of menorrhagia, butoccurs unrelated to systemic coagulopathy, pharmaceuti-cal agents, or any structural anomaly of the uterus.The other type of DUB occurs secondary to anovulationor oligoovulation; in some instances, heavy bleeding manifests. Some clinicians have begun to use the term“heavy menstrual bleeding” (HMB) to encompass thesetwo entities.

Further complicating the discussion of HMB is theissue of quantification: What does “heavy” really mean?According to a classic definition of menorrhagia,1 it is the loss of 80 mL or more of menstrual blood per period.However, some women with less blood loss than this con-sider their menstrual bleeding to be heavy, particularlywhen it interferes with their social and/or professionalquality of life. Their clinicians would concur. In contrast,others who bleed heavily—especially if this is a long-term condition—do not consider their blood flow to beabnormal because it is not uncommon for patients tobecome accustomed to and accept as “normal” their ownbody’s functions. Thus, HMB should be defined as anyheavy uterine bleeding in the reproductive years thatseems to be ovulatory.

Currently, no consensus exists among gynecologistsregarding the diagnostic and treatment issues sur-rounding DUB and HMB. Despite the fact that abnor-mal menstrual bleeding has multiple etiologies, manyphysicians consider menstrual bleeding disorders as ahomogeneous group. Consensus guidelines have beendeveloped by gynecology specialists in several countries(Table 3 on page 4), but as yet, worldwide agreementhas not been achieved. In an effort to clarify many

Table 1. Defining Terms for Abnormal Menstrual Bleeding

Breakthrough Bleeding that occurs despite the use Bleeding of drugs such as oral contraceptives

that are given to control uterinebleeding.

Heavy Menstrual Menstrual bleeding that may be Bleeding either ovulatory (menorrhagia) or

anovulatory.

Menometrorrhagia The symptom of heavy bleedingbetween menstrual periods.

Menorrhagia The symptom of heavy menstrualbleeding; a term specifically used todescribe ovulatory bleeding (that is,a normal, regular, and predictablecycle ranging from 21 to 35 days,most often 28 days).

Metrorrhagia The symptom of bleeding betweenmenstrual periods; theunpredictable timing of the flowgenerally reflects anovulation.

I N T R O D U C T I O N Mary Jane Minkin, MD, Chair


4 CHRONIC DYSFUNCTIONAL UTERINE BLEEDING

issues regarding abnormal uterine bleeding—begin-ning with defining the types according to patterns andother factors—an international consensus conferenceis being planned for 2005. This conference is supportedby the International Federation of Obstetricians andGynecologists. Meanwhile, for purposes of this dis-cussion, the faculty proposes a systematic way ofapproaching a woman with abnormal uterine bleeding.

The purpose of this supplement is to provide a bal-anced overview of patient options and some areas of discussion that may help practitioners and patientsestablish a treatment plan that is most likely to yieldthe best results in terms of both clinical outcome andpatient satisfaction in cases of DUB and HMB. All of the faculty members contributed to the main document,tables, and charts; where individual faculty membershave made comments—in the responses to the case presentations on pages 8, 10 and 14 as well as state-ments of personal opinion throughout this supplement—attributions are specified.

Table 3. Current Guidelines For Diagnosis and Treatment of Abnormal Uterine Bleeding

Gynecologists in a number of countries (includingAustralia, Canada, and the United Kingdom) have devel-oped consensus guidelines for the evaluation and treat-ment of abnormal uterine bleeding, many with an algo-rithmic format. The following is a list of Internet Web siteson which several of those can be found.

At this time, no formal, evidence-based guidelinesdeveloped by gynecologists exist in the United States.Guidelines have been published by the American Board ofFamily Practice, the American College of Nurse-Midwives,the American College of Radiology, the Madigan ArmyMedical Center, and the Minnesota Health TechnologyAdvisory Committee.

A complete roster of links to the Web pages for otherinternational and American guidelines can be found at theWeb site for the Geneva Foundation for Medical Educationand Research (www.gfmer.ch). Click on “Databases, links,”choose “Obstetrics, gynecology: guidelines” from the pull-down menu. When the guidelines page appears, choose“Menstruation disturbances, female gonadal disorders.”

Consequences of Heavy Menstrual Bleeding

Women with HMB may developanemia, with fatigue and othermanifestations of chronic blood loss.The amount of iron lost in 80 mL ofblood is replaced each month withthe iron content in a normal diet.However, in the large numbers ofwomen whose iron intake is muchlower than normal, lesser degrees ofmenstrual blood loss may result in areduction in iron stores and thedevelopment of anemia. Iron defi-ciency is a particular risk amongvegetarians, so patients with HMBshould be asked about their dietarypreferences.

Other important consequences ofHMB include the potential compro-mise of the quality of a woman’s lifein the areas of sexuality, social function, and career. The need forfrequent changes of pads or tam-pons interferes with daily function,and HMB may be associated withcramps or pelvic pain and anuncomfortable sensation of lower-abdominal heaviness.

In addition, as noted already,many women with HMB undergohysterectomy. It is not possible todetermine how many of thesewomen had this surgery because itwas the most appropriate choice forthem, or in how many patientsanother option—or several otheroptions—would have been preferredhad such options been discussedand made available.

Types, Patterns, and Causes of Abnormal Uterine Bleeding

The selection of appropriate ther-apy depends on the determination ofthe cause of chronic abnormal uter-ine bleeding (Table 4 on page 5).Structural pathology of the myo-metrium (such as leiomyomas) andadenomyosis identified or suggest-ed on physical examination may beunrelated to the cause of the bleed-ing while that which is present inthe endometrial cavity is missed.Critical to the evaluation of thepatient with HMB, and especially to those with ovulatory bleeding, is

a structural examination of theendometrial cavity.

Abnormal bleeding can occur sec-ondary to a variety of disorders, buteach generally results in bleedingfrom the endometrium lining theuterine cavity. Some entities—suchas hyperplasia, carcinoma, endome-trial polyps, or endometritis (suchas that secondary to Chlamydia)—are associated with a fragile epithe-lium that randomly bleeds. Suchbleeding may or may not be heavyin nature. Some structural abnor-malities (for example, leiomyomas)exist beneath the endometriumitself and, for unknown reasons,seem to interfere with the normalmechanisms of endometrial hemo-stasis. Unusual lesions such asarteriovenous malformations arelikely to bleed spontaneously andmanifest with overt bleeding byestablishing a connection with theendometrial cavity.

In addition, chronic abnormaluterine bleeding in the absence ofsignificant structural abnormalitiesinvolving the endometrial cavity

C L I N I C A L R E V I E W : C H R O N I C DY S F U N C T I O N A L U T E R I N E B L E E D I N G



appears to occur secondary to disor-ders of hemostasis that may beeither systemic (such as the inherit-ed coagulopathies) or localized tothe endometrium itself.

Although all of the mechanismsinvolved with endometrial hemosta-sis have yet to be clarified, it seemsclear that there exist a number ofproperties that make the endo-metrium unique among other bodytissues. For example, it has beendemonstrated that most women with ovulatory DUB have enhancedendometrial fibrinolysis,3 character-ized by increased local levels of plas-minogen activator. As a result, forwomen with ovulatory DUB, theadministration of antifibrinolyticssuch as tranexamic acid (not current-ly available in the United States)during menses can reduce menstrualvolume by more than 50%.4

Another mechanism identified asbeing important to endometrialhemostasis is the relative amount ofendomyometrial prostaglandin (PG)that exerts vasoconstrictive activityas opposed to prostaglandins thatcause vasodilatation. It appearsthat PG F2α is an important vasocon-strictor, whereas PG E2 and PG I2are potent vasodilators and arefound in increased relative orabsolute quantities in women withovulatory DUB.5,6

Anovulation or oligoovulation seems to be the most common cause of HMB in the United States,particularly—but by no meansexclusively—in women in the peri-menarcheal years and those whoare nearing menopause. Disruptionin the feedback mechanisms involv-ing the hypothalamus, pituitary,and ovaries is most commonly idio-pathic or is related to stress, exer-cise, obesity, or relatively rapidchanges in weight. Less often, adefinable endocrinopathy can befound, including hypothyroidism,hyperprolactinemia, or conditions in which circulating androgen isincreased, such as polycystic ovari-an syndrome.

A number of pharmacologicagents can affect ovulation, includ-

ing gonadal steroids and agents thataffect dopamine metabolism. Thelatter include tricyclic antidepres-sants and phenothiazines as well asmore recently introduced antipsy-chotic drugs, including risperidoneand olanzapine.

Anovulatory women do not pro-duce progesterone in the latter partof the menstrual cycle and, conse-quently, endometrial biosynthesis ofa number of substances in thesepatients is dramatically reduced,including vasoconstrictors such asPG F2α and endothelin-1. The resultis that bleeding occurs in variousportions of the endometrium and atdifferent rates. In essence, theabsence of progesterone-dependentvasoconstrictors creates a disorderof local endometrial hemostasis,so the bleeding may be heavy or continuous.

The work-up of patients with ab-normal uterine bleeding should takethese possible causes into account.

The factors that should be ad-dressed in the history and the labo-ratory tests that should be consid-ered are summarized in Table 5 onpage 6.

EVALUATING THEENDOMETRIAL CAVITY

Although it is appropriate to perform a manual examination ofthe pelvis on all patients, a diagno-sis of the cause of HMB shouldnever be made on this basis alonebecause findings may be mislead-ing. For example, a leiomyoma iden-tified on bimanual palpation mayhave no relationship to the endo-metrial cavity and, consequently,is unlikely to be the cause of apatient’s abnormal bleeding. Inaddition, failure to appreciateleiomyoma on a bimanual examina-tion does not necessarily eliminatethis as a possible cause of HMBbecause clinically significant lesionsmay be located within or adjacent to

Table 4. Dysfunctional Uterine Bleeding

Anovulation or OligoovulationIdiopathic (most common)

Related to stress, exercise, obesity, or rapid changes in weight

Attributable to a definable endocrinopathy (hypothyroidism, hyperprolactinemia, or conditions in which circulating androgenis increased, such as polycystic ovarian syndrome)

Pharmacologic agents that affect dopamine metabolism (including tricyclic antidepressants, and phenothiazines and other antipsychoticdrugs such as risperidone and olanzapine)

Disorders of Hemostasis (local)Enhanced endometrial antifibrinolytic activity

Absolute or relative increases in endometrial vasodilating substances (PGI2, PGE2)

Absolute or relative decreases in endometrial vasoconstricting substances (PGF2α, others)

Disorders of Hemostasis (systemic)Inherited disorders of coagulation (most commonly, von Willebrand’s disease)

Other (eg ITP, TTP, leukemia)

Structural Pathology of the PelvisEndometrium

• hyperplasia • polyps• carcinoma • endometritis (eg Chlamydia)

Myometrium• leiomyomas • arteriovenous malformations• adenomyosis

Cervix (cervicitis, polyps, carcinoma)

OtherSource: Courtesy of Malcolm G. Munro, MD



Table 5. Working Up the Patient With Dysfunctional UterineBleeding: History and Laboratory Tests

History Bleeding pattern

Menses cyclic and predictablyoccur every 21 to 35 days, thepatient is probably ovulatingnormally.Menses irregular in timing andflow, perhaps with episodes ofamenorrhea, is more likely toindicate anovulatory bleeding.

Medication useGonadal steroidsAgents that affect dopaminemetabolism (eg, tricyclicantidepressants, phenothiazines,risperidone, olanzapine)

CoagulopathyFamily/personal history suggestingcongenital coagulopathy*Lifelong history of HMBBleeding associated with surgeryor dental workHistory of mucous membranebleedingBruising without petechiae

Laboratory Tests The following laboratory tests shouldbe considered for all women withHMB, as appropriate:

Test for pregnancyComplete blood countHemoglobinHematocritPlatelet countFerritinThyroid-function tests(particularly including thyroid-stimulating hormone level),especially if the bleeding patternsuggests anovulatory HMB

When the clinical picture suggestshyperprolactinema or hyperandro-genic states, the following laboratorytests may be indicated:

Serum prolactinAndrogen levels

Possible additional tests:†

Fasting glucoseInsulin levels

HMB = heavy menstrual bleeding

*Such bleeding disorders may be more common than is usually appreciated. For example, the US Centers for Disease Control andPrevention published a case-controlled study in which von Willebrand’s disease was found in 10.7% of American women diagnosedwith menorrhagia.1 Patients at high risk for inherited coagulopathy based on historical screening should be considered for refer-ral to a hematologist, where appropriate testing may vary according to the specifics of their historical profile. Such testing mayinclude a prothrombin time, partial thromboplastin time, and, if von Willebrand’s disease is suspected, von Willebrand’s factor andristocetin cofactor assays.2

†Although many women with polycystic ovarian syndrome are insulin-resistant, the precise role for measurements of fasting glu-cose and insulin levels has not yet been determined.

References1. Dilley A, Drews C, Miller C, et al. von Willebrand disease and other inherited bleeding disorders in women with diagnosed men-

orrhagia. Obstet Gynecol. 2001;97:630-636.

2. Lusher JM. Screening and diagnosis of coagulation disorders. Am J Obstet Gynecol. 1996;175:778-783.

Radiographic imaging with iodine-based dyes (hysterogram) is fraughtwith a relatively high incidence offalse-positive and false-negativeresults; therefore, findings fromsuch studies should be interpretedwith caution. On the other hand,magnetic resonance imaging is veryaccurate7 and is particularly appli-cable when SIS or hysteroscopy isinappropriate or difficult, such asfor the evaluation of young or vir-ginal women or in the presence ofsevere cervical stenosis.

Whereas some clinicians feel it isimportant to obtain an endometrialbiopsy with all abnormal bleeding,this is neither cost-effective normedically necessary. In postmeno-pausal patients, who are not thesubject of this supplement, trans-vaginal ultrasound with measure-ment of endometrial thickness is a

suitable substitute or replacementfor endometrial sampling. However,in the premenopausal woman thereis a great deal of overlap in the sono-graphically determined thickness of histopathologically normal andabnormal endometrium. Consequent-ly, an office-based endometrial biop-sy is the most appropriate methodfor assessing endometrial histologyin premenopausal women.

Treatment Options:Entering the Dialogue

When appropriate investigationhas determined that chronic HMB isunrelated to structural pathology,systemic coagulopathies, and iatro-genic causes such as intrauterinedevices and pharmacologic agents, awoman can be said to suffer fromeither ovulatory DUB, anovulatoryDUB, or DUB of an undetermined

the endometrial cavity where theyare not readily palpable.

Although an endometrial biopsy isappropriate to evaluate women atrisk for endometrial neoplasia, suchan assessment is unsuitable foridentifying the structural character-istics of the endometrial cavity.(Approaches to the selection ofwomen appropriate for endometrialsampling is provided in Table 6 onpage 7). Consequently, the dual pur-pose of a comprehensive endometri-al cavity evaluation is to aid in thedetermination of the cause of HMBand to ensure that HMB is not inap-propriately ascribed to abnormali-ties that are not related.

In most instances, imaging of theendometrial cavity is adequatelyachieved with one or a combinationof sonographic- and endoscopic-(hysteroscopic) based techniques.7

Transvaginal sonography is atechnique that appears to be quitesensitive for identifying leiomyomasin general, although recent evidencesuggests that it may be insufficientto evaluate accurately for potential-ly significant small intracavitaryleiomyomas or endometrial polyps.8

A more sensitive and specificmethod is saline infusion sonogra-phy (SIS), also referred to as “sono-hysterography.” With SIS, a salinesolution is used as a contrast medi-um to outline the endometrial cavi-ty during transvaginal ultrasoundscanning. Such a procedure can beperformed in the clinician’s officewith little or no patient discomfort.

Hysteroscopy, which also can becomfortably performed in the officesetting, can be considered as analternate to SIS or can be used whenperformance or interpretation of SISis difficult. In addition, hysteroscopycan be coupled with targeted excisionof selected lesions, such as polypsand small myomas. If this techniqueis performed in the office setting, itobviates the need for an institution-al-based hysteroscopic procedure.For this reason, a number of clini-cians prefer office hysteroscopy overSIS as a primary method for evaluat-ing the endometrial cavity.



origin. For such patients there existsan impressive range of medical andsurgical management options. Anumber of medical interventionshave been demonstrated effective,and an ever-expanding set of surgi-cal options are now available.

MEDICAL THERAPY

For women with chronic DUB whowish to retain fertility, medicalapproaches are the only currentlyavailable options. For any womanwith DUB who experiences heavyflow, iron replacement is essential.In some instances, relief of fatigue isthe patient’s only goal; in thesecases, iron replacement therapymay be all that is necessary. Of theother medical approaches, some areeffective only for anovulatory DUB,some are useful only with ovulatoryDUB, and still others may be effec-tive for both.

Cyclooxygenase inhibitors (non-steroidal antiinflammatory agents[NSAIDs]) such as mefenamic acid(250 to 500 mg two to four times perday), naproxen (1,000 mg per day individed doses), and ibuprofen (600to 1200 mg per day) have beenshown to be effective in reducing themenstrual volume in women withovulatory DUB by 20% to 40%.9 It islikely that this effect occurs by

reducing the excess local PG E2 andPG I2 present in many women withovulatory DUB. Such an approach isextremely accessible to women andmay be particularly helpful inpatients with coexistent primarydysmenorrhea.

Tranexamic acid is an antifibri-nolytic that has been demonstratedeffective at reducing the volume ofbleeding in women with ovulatoryDUB by more than 50%.10 In mostcountries around the world, tranex-amic acid is a first-line therapy forovulatory DUB, and in some coun-tries (including Sweden) is availableover the counter. However, the drug

Table 6. When Should An Endometrial Biopsy Be Performed?

The faculty suggests that an endometrial biopsy should be considered in any patient with an increased risk for endometrial cancer. These risk factorsinclude:

Age >40 years

Obesity

Conditions that may result in unopposed estrogen (including estrogenreplacement therapy unopposed by a progestational agent, obesity,polycystic ovarian syndrome, nulliparity, late menopause, estrogen-producing tumors, anovulation, oligoovulation)

History of pelvic radiation therapy

Personal or family history of breast, ovarian, or endometrial cancer

The American College of Obstetricians and Gynecologists* has issued thefollowing guidelines for performing an endometrial biopsy in women withabnormal menstrual bleeding:

In women <35 years of age: Perform biopsy only if the patient has beenexposed to unopposed estrogen for a prolonged period of time orbleeding does not respond to medical therapy

In women >35 years of age: Perform biopsy whenever anovulatory bleedingis suspected

*American College of Obstetricians and Gynecologists Practice Bulletin #14, March 2000.

currently is not available in theUnited States. The therapeutic effectis achieved with 1 gram taken orallyfour times per day for the first 3 or 4days of the cycle. Gastrointestinaland other side effects are no more frequent with this drug than withother agents, such as NSAIDs, andconcerns regarding thromboembolicevents seem to be unfounded.

Progestins may be administeredorally in continuous or cyclic regi-mens, by depot injection, or via anintrauterine delivery system. Luteal-phase progestins have been demon-strated ineffective at treating ovula-tory DUB,11 but when cyclicallyadministered, progestins seem effec-tive for anovulatory DUB, providedthe endometrium is not otherwiseexposed to progesterone.11,12 Mostpublished regimens are based uponnorethindrone (usually, 15 mg perday),13-15 and there has been no cri-tical evaluation of medroxyproges-terone acetate, the most commonlyprescribed and available progestin inthe United States. Norethindronedoses usually range from 5 to 15mg/day, with many clinicians usingless than 15 mg/day. Dr Munro notesthat in his experience, most womenrespond to 10 to 20 mg per day for 10to 14 days of each month.

There are no available studiesevaluating the impact of depot prog-estins (such as depot medroxyprog-esterone acetate) on either ovulato-ry or anovulatory DUB. However,there is genuine concern regardingthis approach because the regimenused for contraception is associatedwith an approximately 50% inci-dence of irregular bleeding.

Continuous local delivery of theprogestin levonorgestrel via anintrauterine device (IUD) originallydesigned for reversible contracep-tion has been evaluated in high-quality trials and been shown toreduce the volume of ovulatory DUBby over 80% at three months and90% at one year.16 In a study byLahteenmaki and colleagues inFinland,17 patients on the waitinglist for hysterectomy for DUB were randomized to either continue

“The key to optimum

management of a patient with

HMB, I think, is to understand

the mechanism, the

pathogenesis, and all the factors

involved in the problems. Rather

than think of HMB as a single,

confusing, heterogeneous group

of disorders, it should be

considered as a pretty well-

defined group of disorders

which, with appropriate

investigation, allows one to tailor

therapy to individuals, and with a

fairly successful outcome.”

— DR MUNRO —



C O N S I D E R I N G C A S E S : A n O v e r w e i g h t P a t i e n t

A 55-year-old woman with a 4-year history of heavy,irregular vaginal bleeding.Weight, 240 lbs; height, 5'7”.Patient is otherwise healthy.She has had two pregnancies, both resulting in live births.Ultrasonography, including transvaginal ultrasono-gram, performed 2 years ago revealed a small (2 cm)fibroid in the endometrial cavity.An endometrial biopsy performed 1 year agorevealed no hyperplasia.

This patient declined intervention in the past,opting to wait for menopause “to handle theproblem naturally.” However, she now wishes tobe treated for this problem. What are thispatient's treatment options?

THE OPINIONS OF THE FACULTY APPEAR BELOW.

Given the patient's age and the fact that she is overweight, I must be concerned about the possibility of endometrial hyperplasia and cancer, even with thenormal results of a biopsy performed 1 year prior.However, the 2-cm fibroid tumor must be considered.

Thus, in this case, I would perform a hormonal work-up to check for ovarian reserve: a day-3 luteiniz-ing hormone (LH) level, a follicle-stimulating hormone(FSH) level, an estradiol level, and an ultrasoundexamination. Hypothyroidism could be detected withthe TSH test. The other studies would provide clues to the presence of polycystic ovarian syndrome. If thepatient has any signs of abnormally increased androgen levels, I would obtain an androgen profile.

In addition to these laboratory studies, I would perform an endometrial biopsy. Because this patienthad no previous evidence of hyperplasia or cancer,and no history of abnormal Papanicolaou smears werenoted, I would recommend a hysteroscopic myomecto-my and endometrial ablation, which can be done verysafely. Alternatively—and, again, providing the patienthas a history of normal Pap smears—I would also consider offering her a laparoscopic supracervical hysterectomy. — DR MILLER

I would definitely want to avoid performing a hys-terectomy on a 55-year-old, heavy woman. Further, it islikely this patient is less than 3 years from menopause.

This patient is at such high risk for endometrial can-cer, so I would want to make sure I have sampled herendometrium thoroughly. To ensure this (althoughmany clinicians today consider it almost “politicallyincorrect”), I would probably want to perform a hys-teroscopy and dilation and curettage (D&C). Presumingshe has no hyperplasia, she is an ideal candidate for ahysteroscopic myomectomy and ablation procedure. Inaddition, I would strongly urge her to join and attend agym regularly to try to reduce her weight. In additionto helping her to manage her bleeding problem, as aprimary care physician—which I consider myself to be,as a gynecologist—I would teach her about the risks ofmetabolic syndrome associated with obesity, and followher carefully to encourage and support her in thisweight control regimen. —DR MINKIN

This case is complicated by the mixed problem:the patient is anovulatory and she has an intracavitarymyoma, which may simply have the impact of increas-ing the volume of anovulatory bleeding. It is reasonableto repeat the biopsy. Also, of course, if the thyroid-func-tion tests suggest the presence of hypothyroidism, thefirst step is to treat that problem and reevaluate thebleeding subsequently.

This patient certainly has choices. One option is surgical, but, as Dr Minkin points out, onset ofmenopause can be anticipated to occur soon. The tests that Dr Miller recommends—particularly the 3-day FSH and the estradiol level—may provide additional information in this regard. Consequently,such a patient may be offered temporary therapy with a gonadotropin-releasing hormone agonist,as we describe in the main text of this supplement,anticipating that menopause may occur within the year. Although no studies have been performed to specifically evaluate this approach, it is certainlyworth considering.

In addition, this patient might even be a candidate for a trial of cyclic progestin therapy, but I would anticipate that, because of the myoma, this regimenwould not be successful. Although oral contraceptivesmay have similar chances for success, the slightlyincreased risks associated with these agents makethem a less attractive choice. —DR MUNRO

Given the previous suspicion of uterine fibroid on ultrasound in this patient, I would perform a hysteroscopy to evaluate and, ultimately, remove the intracavitary abnormality, and then perform a complete D&C following the hysteroscopy. If thepathologist's examination of the resected lesion and the endometrial biopsy are normal, this patienthas several options.

I would recommend that she consider a trial of cyclic progestin. Alternatively, the levonorgestrelintrauterine system would provide localized progestinto reduce menstrual flow and also mitigate the development of hyperplasia. It is unlikely that shewould need a hysterectomy, unless a malignancy is encountered. Assuming no other abnormalities are detected on ultrasound examination (such as intramural fibroids, ovarian cysts, adenomyosis),either of these hormonal treatments may provide satisfactory relief of this patient's symptoms in the remaining year or two before menopause is likely to ensue.

I tend to be reluctant to perform endometrial ablation in a woman such as this who is so close tomenopause and who has a risk factor (in this case,obesity) for developing endometrial neoplasia. Thispatient is at risk for endometrial abnormalities for two main reasons: she is 55 years of age and is stillhaving menstrual flow, and she is overweight.In contrast to thinner women, obese women tend tohave higher estrogen levels, which predisposes them to polyps, hyperplasia, and, ultimately, endometrialcancer. In addition, this patient's excess weight predisposes her to diabetes, which, in turn, is a risk factor for endometrial neoplasia. —DR ZURAWIN



using an appropriate progestin,with or without estrogen, to controlsymptoms and reduce osteopenia.24,25

There is some evidence that evenwhen therapy is stopped, anovulato-ry women may experience sustainedbenefit up to months later. Althoughthis approach may be appropri-ate for women with impendingmenopause, particularly if they arenot suitable candidates for surgery,it currently is not practical foryounger women who do not antici-pate menopause for many years.

In some instances, women withchronic HMB (including DUB), willpresent with acute bleeding requir-ing immediate intervention. Al-though some affected women requirean immediate surgical procedure,hemodynamically stable patientswith adequate hemograms may becandidates for acute medical thera-py. In such circumstances, many cli-nicians use multidose monophasiccombination OCs, which seem to beeffective; however, there is no sup-porting evidence for this treatment.An alternative approach is the use ofhigh-dose, orally administered prog-estins, such as medroxyprogesteroneacetate, at loading doses as high as120 mg.26 The only approach that hasundergone rigorous clinical exami-nation in a randomized trial27 isintravenous conjugated equineestrogens, administered at a dosageof 25 mg every 4 hours.

their current medical therapy or tohave a progestin IUD inserted. After6 months, more than 64% of patientsin the IUD group had canceled theirhysterectomy and opted to continueusing the IUD. Intrauterine prog-estins have been compared head-to-head with hysteroscopic endome-trial ablation and one nonhystero-scopic approach with compara-ble results.16,18-20 As a result, thisapproach is especially useful forwomen with ovulatory DUB whowish to retain reproductive function.However, patients must be advisedthat intermenstrual spotting is com-mon for the first 3 to 6 months afterinsertion of the device. Althoughthere have been no reports specifi-cally evaluating women with anovu-latory DUB, there are no specificreasons to exclude patients from atherapeutic trial.

Surprisingly, the use of combina-tion oral contraceptives (OCs) forDUB has had relatively little eval-uation. Although OC use is widelyperceived as effective to treatHMB, the data to support their effi-cacy are sparse. However, availableevidence suggests that the drugs,cyclically administered, may beeffective in both ovulatory andanovulatory DUB.21,22 As with theprogestin IUD, combination OCsprovide effective and reversiblecontraception. If combination OCtherapy works, results cannot beexpected during the first month butwill generally be seen duringmonths 2 to 3. Additional data fromrandomized, controlled trials arenecessary to judge the role of OCsin DUB therapy.23

The principle role for gonado-tropin-releasing hormone (GnRH)agonists, such as leuprolide acetate,is in the temporary management ofabnormal uterine bleeding, includ-ing DUB, while a woman considersher options, replenishes her ironstores, and/or prepares for a surgi-cal intervention. In selected circum-stances, women in the late repro-ductive years can use GnRH ago-nists in a prolonged fashion, if necessary with “add-back” therapy

SURGICAL INTERVENTIONS

Dilation and CurettageDilation and curettage (D&C) is

an intervention that may havevalue in treating selected womenwith acute abnormal uterine bleed-ing. However, unless D&C is accom-panied by additional proceduressuch as polypectomy, its effect istemporary, as the underlying mech-anisms involved in causing theHMB are not affected. Indeed, aseminal study by Nilsson and Rybo28

demonstrated that the degree ofabnormal bleeding resumed by thesecond postoperative cycle. Conse-quently, D&C is not curative andhas no role in the management ofwomen with chronic DUB except forendometrial sampling in those inwhom samples cannot be obtainedusing office-based techniques.

HysterectomyHysterectomy is a clearly effective

therapy for women with abnormaluterine bleeding and should be con-sidered if less invasive treatmentsfail, if there are additional benefits tobe gained, or because of patientchoice. Interestingly, patient prefer-ence for a hysterectomy seems to bedriven by both geography and familyhistory and attitudes, leading to whatmight be called “cultural hysterec-tomies.” In addition, a patient whohas completed her childbearing plansand who endured HMB for some timemay be drawn to the prospect of per-manent and complete amenorrhea.

Also affecting the preference forhysterectomy is the perceived “ease”of the procedure. Vaginal hysterecto-my has been demonstrated to be lessmorbid than abdominal hysterecto-my and many women are aware thatthere exist other, less invasive alter-natives to abdominal hysterectomysuch as laparoscopic total andsupracervical hysterectomy.29 Each ofthese approaches allows avoidance ofthe large abdominal incision associ-ated with abdominal hysterectomyand, consequently, each is associatedwith a much shorter recuperationtime. Indeed, laparoscopic supracer-vical hysterectomy in women with

“If a patient has a normal or aminimally enlarged uterus and

HMB, if she doesn't have cancer,and if she's maintaining her

hematocrit, I try to offer a lot ofoptions other than hysterectomy.

Once I've ruled out cancer andchecked her iron stores and

performed any other blood andlaboratory tests that are

appropriate for her, I tell thepatient I would be willing to

perform any of the treatmentsshe's a candidate for.

At that point, the decision has to depend on the patient's

beliefs and choice.”

— DR MINKIN —


However, many patients are notaware that even minimally invasivehysterectomy techniques are consid-ered to be major surgery and carrysignificant surgical risks. Further-more, questions remain about theeffect of hysterectomy on postsurgi-

chronic DUB has been demonstrat-ed equivalent to hysteroscopic endo-metrial ablation with respect to surgical morbidity and institutionalstay, with reduced reoperations andsuperior levels of patient satis-faction.29


cal sexual and urinary tract functionas well as vaginal vault prolapse.However, recent high-quality evi-dence suggests that supracervicalhysterectomy is not superior to totalhysterectomy with respect to sexualand urinary tract function.30,31

C O N S I D E R I N G C A S E S : A P a t i e n t W h o P r e f e r s t o A v o i d H y s t e r e c t o m y

A 40-year-old business owner who complains ofsevere fatigue and heavy menstrual bleeding withcramping. The symptoms often interfere with herability to complete a workday.Weight, 135 lbs; height, 5'4”.Patient is a sports enthusiast and engages in swim-ming and tennis regularly.Patient describes herself as “careful” with her diet,which consists of mostly vegetarian meals.She has three children (the youngest is 17 years ofage) and has determined that her family is com-plete. Her husband has had a vasectomy.A menstrual diary documents that her periods areregular. A pictorial chart suggests that the quantityof bleeding is about 70 mL/month, but she considersher blood loss to be excessive.Patient's mother had similar problems and under-went a hysterectomy at age 43.

This patient states a preference to avoid a hys-terectomy, citing her desire to maintain anactive lifestyle without a prolonged convales-cence. What are this patient's treatment options?


This patient is not interested in future fertility butclearly does want to have treatment to control herbleeding and cramping; however, she also wants to beable to resume her normal activities as quickly as possi-ble. In my opinion, this patient is an ideal candidate forendometrial ablation. Studies have demonstrated thatdysmenorrhea can be reduced in two out of threepatients with the thermal balloon and radiofrequencyelectricity devices. Therefore, both bleeding and paincan be reduced following these procedures.— DR MILLER

This case echoes a common scenario. I have had many patients relate their family's history of hysterectomies, and they tell me they do not want to follow in their mother's footsteps.

Given that fertility is not an issue for this patient,she would definitely be a candidate for an ablation procedure. It would likely give her significant alleviation, if not total relief from her symptoms.It would cause her minimal inconvenience, requiringher to be “out of commission” for only a day or two,barring unforeseen complications.

She also would be a candidate for a progestin-releasing intrauterine system, but she would have to understand that she may end up with more frequent bleeding at first. Since her flow is more annoying than severely heavy, she may not want to endure frequent spotting.

Patients like this one, whose medical picture isuncomplicated and who, therefore, have the broadestrange of treatment options available to them. They shouldbe reminded that even if they choose one therapy thatdoes not work optimally, they—in partnership with you,as an advocate—will progress through the alternativesuntil the problem is completely resolved. —DR MINKIN

This patient seems to be a candidate for any of theoptions we have discussed in this supplement. Forexample, the fact that she bleeds less than 80 mL/month and because pain is a component of her problem,simple nonsteroidal antiiflammatory drugs may be sufficient to manage both her bleeding problem and primary dysmenorrhea. If she lives outside the UnitedStates, tranexamic acid would be an excellent choice.This patient also may want to consider endometrialablation, as well as the progestin-releasing IUD.

—DR MUNRO

My first step would be to evaluate this patient's fatigueby obtaining a complete blood count and metabolic profile.Although her symptoms are most likely due to anemiafrom chronic blood loss, other conditions such as thyroiddisease or hepatitis must be ruled out. Based on thesefindings, iron, folate, and/or therapy to balance her serumthyroid hormone should be instituted.

A low-dose contraceptive either in pill or patch form, combined with nonsteroidal antiinflammatorymedication might be considered first as a diagnosticand therapeutic trial for 3 months. If the patient choos-es this strategy and it works, she can either continue on this regimen or be offered extended-dosecombination pills and have menses every 3 monthsinstead of monthly. If the 3-month trial of hormonesand antiinflammatory drugs does not work, the patientmay have adenomyosis and/or endometriosis. (The success of medical therapy in these conditions is low,and hysterectomy is the usual treatment.)

Another option is endometrial ablation, which notonly reduces heavy menstrual bleeding but has beenshown to be effective in reducing dysmenorrhea. Shemay also want to consider a 3- to 6-month trial ofleuprolide, which would eliminate the heavy bleedingand the attendant cramping. Successful leuprolidetherapy supports the diagnosis of endometriosis and/oradenomyosis, and the patient should be counseledabout surgical options. In this instance, it would beimportant to educate the patient about laparoscopic-assisted vaginal hysterectomy or laparoscopic supracervical hysterectomy. A patient may not beaware that, assuming no complications ensue, theseprocedures offer a faster recuperation time than doesthe traditional hysterectomy. —DR ZURAWIN


most clinicians in the United Stateshad not acquired the considerabletraining necessary to perform suchprocedures.

Another reason for slow adoptionof resectoscopic RF techniques ofendometrial ablation were compli-cations that included perforationand issues relating to distentionmedia. The distention media usedwith monopolar RF resectoscopy,such as glycine and sorbitol, havebeen associated with electrolyte dis-turbances and fluid overload ifabsorbed to excess. The develop-ment of bipolar systems that usesaline as a medium eliminate therisk of hyponatremia, but the prob-lem of fluid overload persists.Nevertheless, there now exist de-vices that allow continuous monitor-ing of fluid balance; when these areused appropriately, the risk for fluidoverload is largely eliminated.


“Cyclic birth control pills

are sometimes effective for

controlling HMB, assuming

any other problem, such as

thyroid disease, has been

identified and treated. I usually

have the patient take

about three rounds of

therapy—that’s 3 months’

worth—and that would be it.

Then I would move

on to another

type of treatment.”

— DR ZURAWIN —

The potential complications of hysterectomy are well known andinclude those related to anesthesia,hemorrhage, visceral injury to thegastrointestinal and urinary tract,and infection of the vaginal vault aswell as, in the case of abdominal hys-terectomy, the abdominal incision. Inaddition to the potential for surgicaland anesthesia-related complica-tions, women who undergo simplehysterectomy—despite ovarian con-servation—are known to experienceonset of menopause an average of 2years earlier than they otherwisewould.

Health insurance company orhealth maintenance organizationapproval may affect the decision toinclude or exclude hysterectomy asa treatment option for chronic DUB.In many cases, approval for surgerydepends on the patient’s hematocritlevel (and the results of other labo-ratory studies such as thyroid func-tion tests) and whether other thera-pies—hormonal therapy, in particu-lar—have been tried and failed toresolve the problem.

Consequently, given the fact thatreasonable and less morbid alterna-tives to hysterectomy are availableto many women, a physician whoperforms a hysterectomy withoutapprising a patient of her full rangeof options could justifiably facemedicolegal exposure if complica-tions do arise. The contention maybe that the hysterectomy was“unnecessary surgery.”

ENDOMETRIAL ABLATIONPROCEDURES

Despite their apparent effective-ness, traditional resectoscopic endo-metrial ablation procedures havenever been widely accepted in theUnited States. Although laser-basedtechniques were in common use inthe 1980s, the application of urolog-ic resectoscopes that work with eas-ily accessible radiofrequency (RF)current now dominate the land-scape. Our colleagues abroad usesuch endometrial ablation proce-dures far more commonly than wedo in this country, largely because

These factors combined to create aneed for techniques that ablate the endometrium without the needfor use of the uterine resectoscope.There now exist five devices ap-proved in the United States thatmeet this criterion, each of which uti-lizes a different technology: thermalballoons, RF electricity, microwaves,free heated fluid, and freezing (oftencalled cryosurgery). A recently pub-lished review by the internationalEndometrial Ablation Group32 con-cluded that, based on published dataand the experience of participants inan international workshop, the effi-cacy of the nonresectoscopic proce-dures is as good as that observedwith the resectoscopic ablative tech-niques. In addition, complicationsare lower with nonresectoscopic procedures, including a lower risk for perforation.

Long-term clinical evidence hasdemonstrated that these proceduresare safe and effective with appropri-ate use in appropriately selectedpatients—those who are past thepoint of childbearing, have a normaluterus, and have ovulatory DUB.The following sections considersome of the design and function dif-ferences (Table 7) that may makeone procedure more appropriate thananother for particular patients.

Degree of Cervical DilationThe thermal balloon and cryo-

therapy devices require far less dilation—5.0 mm and 5.5 mm,respectively—than the other instru-

Table 7. Ablation Technologies Approved for Use in the United States

TYPE OF TECHNOLOGY USE WITH HYSTEROSCOPY CERVICAL DILATION REQUIREDREQUIRED?* (MAXIMUM), MM

Hot fluid, contained No 5.0 (thermal balloon)

Hot fluid, free Yes (during procedure) 8.0

Freezing (cryotherapy) No 5.5

Radiofrequency No 8.0 electricity

Microwaves Yes (prior to procedure) 9.0

*Although only two of these devices require use with a hysteroscope, diagnostic hysteroscopic evaluation of the endometrialcavity should be performed prior to use of any of these instruments.



ments, which require that the cervix be dilated to 8.0 to 9.0 mm indiameter. The advantages of lessdilation include greater ease of performance, reduced requirementsfor anesthesia, and a decreased riskof cervical trauma or perforation ofthe corpus. In some instances, therequirement for dilating the cervixto 7 mm or more may preclude performing the procedure in anoffice setting.

Procedure TimeThe duration of a procedure com-

prises all of the time consumed fromthe moment the patient enters theprocedure room until she leaves.This includes administration ofanesthesia, equipment setup, anyadditional procedures necessarybefore or after the treatment, theactual treatment time, and the timethat the patient stays in the roomafter the procedure. To date, therehave been no rigorous comparisonsof the procedure times required.

The five devices clearly differ interms of active treatment time. Forexample, the active treatment timewith the RF electrosurgical device is90 seconds, the thermal balloon 8minutes, and the free fluid device,10 minutes. All of these devices havemicroprocessor-controlled therapythat is largely time-fixed. The cryo-therapy and microwave devices arephysician-controlled, with ultra-sound feedback for the cryotherapydevice and temperature feedback forthe microwave device. Treatmenttimes will vary according to the sizeof the endometrial cavity, but gener-ally do not exceed 10 minutes.However, the microwave and free-fluid devices currently require hys-teroscopic evaluation prior to the ini-tiation of treatment, and the RFelectrosurgical device must be cali-brated to the specific endometrialcavity and a cavity integrity checkmust be performed; each of thesetasks consumes time. Thus, despitethe lack of any rigorous compar-isons, the actual procedure time forthe different devices is probablyquite similar.

Efficacy and SafetyThe efficacy of therapy with non-

resectoscopic devices in the US Food and Drug Administration(FDA) trials was determined by twoprinciple factors: improvement inuterine bleeding scores and patientsatisfaction. In each randomizedtrial, the study device was comparedto resectoscopic endometrial abla-tion or resection as performed bysurgeons with extensive experienceand expertise. In each instance, thesuccess and patient satisfactionassociated with the study device wassimilar to that reported for theresectoscopic procedure.

Differences did exist among theprocedures with respect to amenor-rhea rates. However, amenorrhea isnot—and should not be—the goal ofsuch therapy. In fact, most womendo not desire amenorrhea, but aresatisfied with amelioration of exces-sive bleeding. Patients who demandamenorrhea will be satisfied onlywith one of the various types of hys-terectomy.

All five of the devices are consid-ered to be safer than resectoscopicendometrial ablation or more inva-sive procedures such as hysterecto-my. However, the possibility existsthat perforation can occur and,therefore, the specter of thermalinjury to intraperitoneal viscera

exists. Although there have been norigorous comparisons of the relativesafety of these devices, Gurtcheffand Sharp33 searched the literatureand analyzed the FDA’s Manufac-turer and User Facility DeviceExperience (MAUDE) database.These authors reported complica-tion rates of 0.56/100,000 with thethermal balloon, 0.96/100,000 withthe free hot-fluid device, 1.2/100,000with the radiofrequency electricitydevice, and 1.0/100,000 with the cryo-surgery device. Because the micro-wave device was not released in theUnited States until late in 2003, itwas not evaluated in this study.

Whereas this study provides someimportant information, it is limitedfor at least three reasons. First,most surgical complications are not reported for inclusion in theMAUDE database, particularly ifthe complications are minor. Thus, itis likely that these data have anunderreporting bias. Second, it onlyincluded data collected through May 2003, when one of the deviceshad not been released. Third, inreporting complications for the thermal balloon, the authors includ-ed the results of a European survey,which increased the denominator inthat category. Nevertheless, the riskfor serious complications with theseprocedures is low and patientsshould feel confident that suchdevices appear to be safer than any other currently available andeffective surgical procedure forchronic DUB.

Patient CharacteristicsEndometrial ablation with non-

resectoscopic techniques is current-ly appropriate only in patients with a normal or near-normal-sizedendometrial cavity—that is, gener-ally between 6 and 10 cm in length.In addition, several of these tech-niques should not be performed inthe presence of significant congeni-tal abnormalities of the uterine cavity or if the cavity is distorted by submucous leiomyomas. Themicrowave device is the only onethat is FDA-approved for use in

“I think about treatment of

HMB as an algorithm

based on bleeding pattern,

laboratory results, physical

findings, and the patient's age

and desires. When a patient with

HMB is older, has a normal

uterus, and has completed her

childbearing, then early on in my

discussions with her, I bring up

endometrial ablation as a

treatment option. Whether we

perform endometrial resection

or a nonresectoscopic

procedure, ultimately we can

provide a great deal of patient

satisfaction.”

— DR MILLER —



patients with type 2 myomas andsome type 1 myomas 3 cm or less indiameter. However, there is high-quality evidence that the thermalballoon is also effective with type 2myomas that are 3 cm or less indiameter.34 Theoretically the devicebased upon free hot-fluid would alsobe appropriate in the presence ofmyomas and a small pilot studyseems to support this notion.35 Nodata are currently available on theRF electricity or the cryosurgerydevices with respect to use inpatients with uterine fibroids.

Although hysteroscopy is requiredto perform only the free hot-fluidtechnique, a diagnostic hysteroscopyis the best method of identifyingpreviously unsuspected septa,fibroids, and polyps.

Helping Patients Choose Determining the treatment strat-

egy is a two-tiered process thatshould include consultation with thepatient at all times. First, from theavailable options for chronic DUB,all those that are appropriate forthe patient should be presented, anda thorough explanation should beprovided, along with an explanationfor the reasons that certain optionswere included or excluded. Factoredinto the discussion should be thepatient’s age, previous experiencewith therapy, reproductive desires,and goals for any contemplatedinterventions. In addition, thepatient’s general health should beconsidered, including the presenceof comorbid conditions, such as obe-sity or diabetes, that could influenceher risks of surgery.

attempted, and if it fails or if shedetermines it to be unacceptable forany reason, the plan can be adjust-ed. To prevent frustration, a patientshould know that the treatmentchoice she and the clinician agree onis not one that she is bound to forthe remainder of her reproductiveyears.

This is particularly problematicwhen hysterectomy is highest onthe clinician’s list of therapeuticchoices. Although it may be that theultimate treatment is hysterectomy,unless there is a compelling med-ical reason, a woman should begiven the opportunity to choose oneor more less invasive options.Then, if those therapies fail to solvethe problem, the patient is morelikely to feel peaceful with the deci-sion to undergo surgery. As a result,her level of postoperative satisfac-tion and psychological response tohysterectomy is likely to be betterthan if she feels “directed” to thedecision.

CONSIDER THE PATIENT’SBELIEFS AND ATTITUDES

Clinicians must be exquisitelysensitive to a patient’s personalbelief structures and should takecare to elucidate, respect, andaddress those beliefs. For example, awoman may be strongly opposed totaking medication in general ormay, because of religious or otherbeliefs, reject the use of an IUD orOCs. She should not be made to feelthat these beliefs are inappropriate.Instead, other options should beoffered that do not conflict with herbeliefs.

Another example concerns thepatient for whom a hormonalmethod is contraindicated or is notdesired, or when one or more havebeen tried and proven unsuccessful.In such a case, endometrial ablationis a reasonable procedure. However,a woman’s desires concerning futurechildbearing should be carefully dis-cussed. Endometrial ablation obvi-ously is not an option if a womaneven thinks she might wish to pre-serve reproductive function.

During this iterative process,medical and surgical options shouldbe included or excluded from the listaccordingly. From the list of remain-ing therapies, the clinician shouldhelp the patient determine anappropriate strategic approach thatmeets her personal preferences andneeds (Table 8).

EXPLAIN THE ISSUESREALISTICALLY

Patients should be informed abouthow long they should expect to wait before a treatment takes effect.For example, if NSAID therapy isgoing to be effective in any patient,that benefit will be evident duringthe first month, whereas the fulleffects of a progestin-containingIUD cannot be expected before 6months, and if combination OCs aregoing to work, the therapeutic bene-fit will likely be seen within 3months.

Just as important, the goals oftreatment should be clearly articu-lated. If nothing less than totalamenorrhea is acceptable, a patientmust understand that this can beachieved only through hysterecto-my—for which she may or may notbe a suitable candidate.

DEMONSTRATE AN ATTITUDE OF FLEXIBILITY

A patient should be reassuredthat her treatment plan is justthat—a strategy. This means per-forming appropriate studies todetermine the mechanism for herHMB, then discussing together ahierarchy of options. She shouldunderstand that a treatment can be

Table 8. Five Key Questions For Patient Counseling

1. What do you hope or expect from treatment? Would you be satisfied to

bleed normally, or do you hope to stop bleeding completely?

2. What are your future plans for childbearing?

3. How do you feel about taking hormones long term?

4. Have you heard about any of the treatments we’ve discussed just now?

What have you heard?

5. Do you have any other concerns that we haven’t talked about yet?


PROVIDE AN OPPORTUNITYFOR BETTER LIFESTYLE CHOICES

The epidemic of obesity in theUnited States has significant bear-ing on the issue of DUB, not onlyfrom the point of view of its knownpropensity to be associated withanovulation but also because a


patient’s weight affects her poten-tial choices for therapy. Indeed, inseveral recently published studies of chronic DUB treatment, thepatients were young as well asobese. In the study of combinationOCs by Davis and colleagues,22 theaverage weight of the study partici-

pants was 172 lbs; in a hysterec-tomy study involving 63 patients byKuppermann and coworkers,36 theaverage body mass index was 32kg/m2 (moderately obese).

Obviously, obesity presents in-creased risks for surgical complica-tions. In obese patients who require

C O N S I D E R I N G C A S E S : A P a t i e n t W i t h Po s t s u r g i c a l H M B

A 35-year-old woman who had been using oral contraceptives (OCs), but then underwent tuballigation.Following the surgery, the patient noted her periods became—and remained—very heavy.

This patient blames the tubal ligation for the sudden change in her menstrual status. What are her treatment options?


As the other faculty members also note below,this patient truly has myriad options, and herchoice depends on whether she desires amenorrhea or eumenorrhea. The aggressive approach of hysterectomy will guarantee amenorrhea, but wemust counsel our patients regarding the increasedmorbidity of these procedures over other choices,including endometrial ablation.

The most conservative approach is to try an extended-dosage OC; menses, although remainingheavy, would occur only four times a year. Depotmedroxyprogesterone acetate also could be considered. Unfortunately, while menses generallyceases, problems such as weight gain, breast tenderness, breakthrough bleeding, and depressionare common.

Certainly if the patient is interested in eumenor-rhea an excellent option would be an endometrialablation procedure. These procedures are safe andoffer an excellent change of return to normal menses.If eumenorhea is the goal, endometrial ablation canprovide a reliable and satisfactory result.—DR MILLER

This case illustrates precisely the reason that I do not like to have a patient undergo a tubal ligationwhile taking OCs. Indeed, the patient may be havingcontrolled menorrhagia and not even know it. I usually ask my patients on OCs to stop taking themat least 2 to 3 months prior to surgery. In this way,we can assess their menstrual periods—that is, theheaviness of flow or cramping—both on and off theOCs. If a patient is unhappy with how she feels offthe Pill, I ask whether she really wants a tubal ligation or if she would prefer to resume the use of OCs.

Under the scenario described here, one wouldassume that, for some reason, the patient determinedthat she wanted to stop taking the Pill. This patientobviously has determined that she does not wishfuture childbearing. Because of her age, she is notlikely to be menopausal for at least another 15 ormore years, so she will need a relatively long-termsolution to her problem. This patient can be offered aprogestin-containing intrauterine system. She alsowould be an ideal candidate for an ablation procedure.Obviously, a hysterectomy is a fairly radical answer toher needs. —DR MINKIN

Provided that the menses remain regular and pre-dictable, it is unlikely that this patient has a coagu-lopathy or endometrial neoplasia. If transvaginalultrasound (including sonohysterogram, if necessary)is normal, this patient has a number of options—andthey are just that, her options. Her ultimate selectionwill depend on a number of factors, including herdesire for anemorrhea (versus normalization of bleeding) and her response to medical therapy, if she makes such a selection.

Outside the United States, many women wouldchose tranexamic acid, taken during the menses,which reduces ovulatory menorrhagia by about 50%.Cyclooxygenase inhibitors such as ibuprofen or mefenamic acid, also taken during menses, wouldlikely reduce ovulatory menorrhagia by about 20% to 40%, and oral contraceptives are an option as well.

The levonorgestrel intrauterine system will reduceovulatory bleeding volume by 80% or more by 3weeks, but the patient will likely have to endureintermenstrual spotting for 3 to 6 months.

Endometrial ablation will result in reduction of flow to normal or less in about 85% to 90% of cases.If amenorrhea is the desired outcome, hysterectomy is the most predictable approach. Morbidity is lowestwith either vaginal total hysterectomy or laparoscopicsupracervical hysterectomy, either of which can bedone with a total length of institutionalization of less than 24 hours. Supracervical hysterectomy shouldlikely be reserved for those women who have no histo-ry of cervical neoplasia and who continue to havereassuring Pap smears. —DR MUNRO

If this patient has been on OCs for many years, such hormone use would have obscured her underlying native menstrual pattern. Closequestioning might reveal that she had been given OCs as a teenager because of irregular or heavyperiods. If that is the case, the menorrhagia she nowexperiences is probably “normal” for her.

Endometrial ablation may be the most attractiveoption for this patient. She undoubtedly elected to have a tubal ligation because she wished to discontinue taking birth control pills. It is unlikelythat she would be willing to take OCs again to “control” her heavy bleeding.

Surgery would be problematic in this case.A patient who attributes heavy menstrual bleeding to a tubal ligation may blame the surgeon for actualor perceived complications following a hysterectomy(for example, loss of libido after laparoscopic-assistedvaginal hysterectomy, even if the ovaries are notremoved).

An intrauterine system is an alternative, but a patient who had undergone a tubal ligation wouldneed to understand that the IUD was being used for its progestational rather than its contraceptiveeffect. —DR ZURAWIN



hysterectomy, the alternative op-tions provide an opportunity forinterim treatment, during whichtime patients may accept assistancefor a weight loss regimen, includingnutritional and exercise elements.Obese patients with DUB face aconsiderable physical challengewith respect to exercise: they tend tofeel fatigued, and the discomfortand logistical issues associated withfrequent changes of tampons andpads add to the problem. Yet, formany obese patients, dietarychanges alone do not provide thedesired results, and the severecaloric restriction that would berequired for significant weight lossin the absence of exercise is notacceptable (or reasonable) as a long-term plan.

In such cases, the clinician canoffer a nonresectoscopic endometrialablative procedure as a means ofimproving chronic DUB that willallow—and perhaps motivate—apatient to increase her mobility, toembark on a regular regimen ofexercise, and to lose weight. Thegoal is to improve the patient’schances for an uncomplicated sur-gery, if surgery is still necessary.With sufficient weight reduction,

surgery may become unnecessary insome patients. In either case, thepatient has had the opportunity tocontrol her own healthcare strategy.

Conclusion The optimum therapy of HMB

depends on understanding themechanisms, pathogenesis, and pos-sible factors involved. Chronic DUBitself is not a single, homogeneousproblem but instead compriseseither anovulation (with its atten-dant unpredictable episodes ofbleeding) or a specific disorder oflocal hemostasis despite the exis-tence of ovulatory function. Withappropriate investigation, one cantailor therapy to certain classes ofindividuals, and with a reasonablysuccessful outcome.

Women who wish to preservereproductive function have at theirdisposal a number of medicalapproaches that, appropriately se-lected, can be effective and well tol-erated. Such options are also avail-able for women who have no desireto maintain their reproductive func-tion. In addition, these women canselect surgical approaches that obvi-ate the need for long-term medicaltherapy. For women whose desire is

amenorrhea, hysterectomy is theonly option that virtually guaran-tees achievement of this goal.Laparoscopic supracervical hys-terectomy is a promising minimallyinvasive procedure for some womenand can be performed in an outpa-tient setting.

However, for most women whohave completed their childbearingplans, endometrial ablation is aneffective alternative to hysterecto-my and nonresectoscopic endometri-al ablation technology seems to pro-vide equal efficacy with a greaterdegree of safety. These proceduresare attractive to clinicians as well,because their use requires less of alearning curve to achieve proficien-cy compared with that for resecto-scopic procedures. Moreover, therisk for complications is generallylow. Unfortunately, at this time nouniform guidelines exist for trainingclinicians in the use of the newerdevices and for certifying their pro-ficiency in performing these proce-dures. The faculty urges hospitalcredentialing committees to consid-er developing and implementingsuch guidelines so that these valu-able tools can be used appropriatelyand safely.

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Chronic Dysfunctional Uterine Bleeding

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