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PA Boards 86: DUB Management

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SHOW NOTES:
Today we’re going to answer a students question regarding the management of DUB:

“I was reading over DUB on the phone app this morning and saw that treatment involves OCPs and NSAIDs. I’m confused with the NSAIDs aspect because I would think these would cause increased bleeding due to their COX-2 inhibition. Can you shed some light on this if the mechanism is known. Thanks!”

Most common cause of heavy menstrual bleed are leiomyomas.

First line treatment: estrogen-progestin contraceptives or levonorgestrel IUD (comparable to endometrial ablation). Avoid estrogen contraception if the patient has refractory hypertension or an increased risk of thrombosis.

But, its a personal preference: daily dosing vs IUD, menses (withdrawal bleed) vs amenorrhea, short term option vs long term option.

Progestin only methods usually result in initial irregular bleeding which eventually becomes light and absent altogether.

Cyclic oral progestin therapy taken daily for 10 to 14 days each month are effective in patients who have irregular bleeding secondary to anovulation but not so much in patients who have heavy menstrual bleeding secondary to other causes.

Patients who are anovulatory who present with irregular bleeding are at increased risk of endometrial cancer – oral contraception helps to decrease the risk of cancer in these patients. Women who have anovulation who have ablation are at increased risk of masking signs/diagnosis of cancer.

Ablation will prevent bleeding which can signify cancer. It will also be difficult to perform biopsy and sonohysterogram post ablation.

Oral contraception with fewer hormone free days are most effective. The most effective contraceptive is the levonorgestrel IUD (comparable to endometrial ablation). The three-year cumulative expulsion rate is 10 per 100 users – and seems to be higher with those who have fibroids. Keep in mind there is technically a contraindication for the IUD for those women who have a distorted uterine cavity secondary to fibroids – but may still be offered.

Other options include tranexamic acid and NSAIDs.

Tranexamic acid is a fibronolytic that blocks the conversion of plaminogen to plasmin. Patients can take this if there is a contraindication to hormonal therapy and/or if the patient is trying to conceive. Patients only take this during menses.

NSAIDs can be used to treat abnormal uterine bleeding that is not secondary to anovulation. NSAIDs cause a decline in the rate of prostaglandin synthesis in the endometrium. This leads to vasoconstriction and in turn a reduction of bleeding.

Andrew