Dysfunctional uterine bleeding. Case: Previous 3 LSCS with AUB

by Dr.Prof.Suvarna Khadilkar,

43 years old female c/o polymenorrhagia since 6-8 months. She has reported in consulting that she wants to undergo hysterectomy in view of :

USG report showing uterus slightly bulky with two 0.5 cm fibroids in the body of uterus right side, Postmenstrual ET  6 mm, ovaries normal, no other abnormalities

Pr MH: 6-7days/20-24days irregular, no dysmenorrhea, heavy flow with clots+

Past MH occasional h/o of menorrhagia

OH: 3 FTLSCS bilateral TL done with last LSCS done 10 yrs back

No h/o malignancy in the family or any other major illness in past

O/E: PS healthy PV uterus RV parous mobility restricted fornices clear.

Discussion:

  1. What is the cause of polymenorrhagia in this case?

Out of the following which one is more likely?

hormonal/ fibroids/    post TLsyndrome/   scarred uterus

Hormonal cause is more likely as two small 0 .5cm fibroids are unlikely to be the cause. The post sterilization syndrome also does not have  conclusive literature support. Multiple scarring on uterus may prevent contraction and may lead to excess bleeding, but this theory  is not well supported in the literature.

  1. How will you proceed with diagnosis and work up of this case?

All routine tests, repeat USG may be done as very often such small fibroids may not be present, if present then their proximity to endometrium  may give you the guideline for further management.

Diagnosis by hysteroscopy guided endometrial biopsy will be the gold standard. With three scars , blind D& C  is not recommended. However,  if  premenopausal women have endometrial thickness of 6 mm or more, sampling may not be required.

  1. What are the therapeutic options in this case if malignancy has been ruled out?

Nonhormonal: Mefenemic acid , Tranexamic acid and ormiloxifene may be used as a first line for symptomatic control.

Hormonal:

Oral progestogens: norehisterone is the best hemostatic progestogen 20mg in divided dosages. Use minimum dose required to arrest bleeding and then use  tapering dosages when wish to discontinue the treatment.

Danazol 200mg bid for 4- 6 months. This will have a beneficial effect even on fibroids.

Progesterone IUD which will work for 5- 7 years and after that  she may improve and may have  menopause which will be a permanent cure.

Thermal balloon Endometrial Ablation: this is a good option with  80 % relief of symptoms.

Hysterectomy: will be chosen only as a last resort if she does not respond to any of the above. However some patients insist on hysterectomy

{ This patient was put on Danazol 200 mg bid  and followed up till 6months developed amenorrheoea}

  1. Should we do hysterectomy on demand?

This  is most controversial  and should be individualized. It is  not recommended unless other effective options are explored. Patient must be counseled for  all the options and pros and cons of each . Most patients will understand and make a choice which suits them the best. However it is treating doctors’ duty to put forth all the facts and figures before a patient, and let the patient make the choice. These are the views of the author. No consensus has been reached so far in this regard in literature. When the patients leave the decision entirely to the treating doctor, we must always offer from noninvasive to invasive and radical treatment options step by step.

  1. Whether Ovarian conservation should be done or bilateral Oophorectmy should be done in this case?

If women is at premenopausal or at postmenopausal age upto 60 years,  the healthy ovaries should be conserved. It is now learnt that postmenopausal ovaries secrete amount of estrogen just sufficient to protect tissues upto 10 years. But if at the time of hysterectomy ovaries appear to be involved in disease like endometriosis, Pelvic inflammatory disease, or appears unhealthy, they should be removed. Unilateral oophorectomy does not offer any beneficial effect. Since her age is 43, if ovaries are healthy , they should be conserved.

Correspondence;

Dr.Suvarna Khadilkar:

suvarnakhadilkar@yahoo.com

Phone; 9820078703, 24324606