The normal menstrual cycle ranges between 21 – 35 days , lasts 2 – 4 days , with an average blood loss of 20 – 40 ml per cycle . Abnormal uterine bleeding is defined as changes in the frequency , duration and the amount of blood flow . Menorrhagia is defined as regular , heavy , cyclical bleeding occurring over several consecutive cycles . Though the exact amount of blood loss is difficult to quantify , most women who bleed more than 7 days , or use more than 10 towels per cycle or experience night time soiling or daytime embarrassment or have to miss social or work engagements due to periods are said to have ‘ heavy periods ‘. Objectively, blood loss more than 80 ml per cycle is termed as heavy periods or menorrhagia. Although this is an age old definition , this serves the purpose because
more than 2/3rd. of these women suffer from menstruation related anaemia leading on to weakness , irritability , lethargy , infections , ill – health and generally a poor quality of life . Blood and blood product transfusions may be required with their own risks and complications and rarely the blood loss may be of fatal magnitude .
The list of causes of Abnormal Uterine Bleeding is extensive but an accurate diagnosis can be reached by a systematic evaluation within the framework of a good history and physical evaluation . The first thing to do is to rule out bleeding from the gastrointestinal and urinary tract . The causes of abnormal uterine bleeding can then be categorized into 5 main groups and this has lead to a set of ‘ diagnostic rules’ so as to avoid common pitfalls in clinical practice . The primary concern is to rule out pregnancy , then rule out infections , trauma , benign conditions like fibroids , polyps , especially if the endometrium is secretory and consider malignancy in the older age group . Determine the presence of any systemic disorder especially coagulopathy which is much more common than previously thought . If all these causes have been ruled out then the bleeding is dysfunctional in nature .
Dysfunctional uterine bleeding is thus defined as heavy , prolonged , or frequent bleeding of endometrial origin not due to pregnancy , local or systemic causes . Most of the patients of DUB are anovulatory due to disordered HPO axis . The type of bleeding in these cases depends on the levels of estrogen . Insufficient follicular development and low estrogen leads to poor proliferation or atrophy of the endometrium and intermittent bleeding . Persistent follicle is associated with high estrogen levels and periods of amenorrhoea followed by heavy bleeding ( metropathia haemorrhagica ). In ovulatory DUB , the HPO axis is not disordered , the cycle is normal , and the defect essentially local – either increased vasodilator activity or increased fibrinolysis .
For the diagnosis of DUB , all causes of abnormal bleeding must be ruled out . Do complete blood counts to determine the type and degree of anaemia , rule out pregnancy , and coagulopathy – BT, PT, APPT and platelet count .Further testing – TSH, FSH, LH, Progesterone, PAP smear and endometrial evaluation is dependant on clinical suspicion .
There are several ways of evaluating the endometrium . Transvaginal sonography (TVS) is an indirect but convenient way . To improve the diagnosis of intrauterine masses on TVS, saline infusion can be done in the uterine cavity ( sonohysterography – SHG). Biopsy of the endometrium may be required for hormonal assessment and to rule out malignancy especially in all older women , in the younger woman if she has not responded to medical treatment over 3 months and in those with chronic anovulation . For biopsy of the endometrium , usually an office biopsy with the probet endometrial sampler is adequate , a blind D & C is not indicated and the best is , of course , Hysteroscopic biopsy , which is excellent not only for intracavitary masses but also for endometrial evaluation and can be used both for diagnosis and treatment at the same sitting .
If a patient presents with acute bleeding , first determine whether she is hemodynamically stable . If not , volume resuscitation is in order followed by high dose estrogens for repair and regrowth of the endometrium . Once bleeding is controlled , lower doses of estrogens are given with progesterone in the last 10 days to stabilize this endometrium . Once both are withdrawn , bleeding occurs which is not prolonged . A more convenient way is to give high dose oral contraceptive pills and then taper off .
Patients with chronic anovulatory bleeding are treated according to their requirements – if only cycle control is required , progestrogens are given for 10 – 12 days in each month , oral contraceptive pills if additional contraception is the need and ovulation induction if the patient desires pregnancy at the same time as control of DUB .
Patients with ovulatory DUB are much more difficult to manage . In such patients it is prudent to re – evaluate to rule out local and systemic causes . Many drugs are available to control the bleeding – NSAIDs, Flavonoids, Ethamsylate, Antifibrinolytics, venom isolates, vit K analogues, oral contraceptive pills, Depot P, LNG – IUS, Danazol, GnRHa, SERMs, and SPRMs . Even though medical management is the first line of treatment for DUB, there may be many problems due to the drugs themselves , their doses and actions . Some patients may not tolerate them, some may not respond and others may simply be unwilling to take them . In patients who have completed their family it might be better to explore surgical options.
D & C cannot be considered as a surgical option because of it’s temporary effect. Hysterectomy is a permanent cure for DUB but it is a major procedure with considerable morbidity and mortality . It also involves loss of an organ and premature onset of menopause even when ovaries are retained . In this age of fast track , long hospitalization and prolonged recovery are often not acceptable . Surgical options other than hysterectomy include ablation or destruction of the offending part of the uterus – the endometium , rather than removing the uterus itself . The age of first generation ablative techniques like TCRE are long over because of high complication rates , significant mortality and the need for great expertise .
The second generation ablative techniques require much less skill , have lower complications yet are equally effective . They use different forms of energy for global ablation of the endometrium and are even less minimally invasive than the Hysteroscopic first generation ablative techniques . Of the 4 techniques approved by FDA , the Thermachoice Uterine Balloon Therapy has been used in more than 2 lakh women worldwide and has the longest safety track record . It is as simple as inserting an intrauterine device and the controller unit automatically monitors, controls, and displays the preset pressure, temperature and the time . The treatment cycle takes just 8 minutes .
The treatment is considered successful if the patients report normal or less than normal periods or amenorrhoea . The success rates of the Thermachoice Uterine Balloon Therapy are as high as 93% and it is now considered as the new Gold Standard instead of TCRE . It has insignificant major complications and the minor complications are easily amenable to simple measures . It also effectively controls the bleeding in high risk patients in whom medical or surgical therapy are either contraindicated or dangerous .
Even though medical therapy is the first line of treatment for DUB and hysterectomy the last resort , the Uterine Balloon Therapy has the potential to be the last resort and can save several lakh hysterectomies per year . However , a patient should have completed her family before she can be considered for uterine balloon therapy because pregnancies following this treatment have high complication rates . Therefore , if a patient does not desire future childbearing , of all the choices available , the Thermachoice Uterine Balloon Therapy is probably the best choice .