D.G.F. CME CASE STUDY DISCUSSIONAbnormal Uterine Bleeding MODERATOR : Dr. Ila Gupta Dr. Sharda Jain PANELIST : Dr. Jyoti Agarwal Dr. Raj Bokaria Dr. Dipti Nabh Dr. Vandana Gupta

1. 15TH SEPTEMBER, Delhi
CASE STUDY DISCUSSION
Abnormal Uterine Bleeding
D.G.F. CME

2. CASE DISCUSSION
MODERATOR : Dr. Ila Gupta
Dr. Sharda Jain
PANELIST : Dr. Jyoti Agarwal
Dr. Raj Bokaria
Dr. Dipti Nabh
Dr. Vandana Gupta

4. CASE STUDY 1
• A busy 30 years old lawyer from an affluent class had NVD 9
months ago.
• She complains of heavy bleeding and dysmenorrhoea since past 5
months.
• She is currently breastfeeding and concerned about the effects of
medicines on her baby.
• Not comfortable with taking tablets daily due to her hectic life
style
• Pelvic examination revealed no abnormality.pap smear normal
• What further investigations are required. Is there any need of EB
in this case.

5. INVESTIGATION
• CBC
• THYROID PROFILE
• Pelvic USG
• No need of EB

6. • What options can be suggested
for her menorrhagia issue ?

7. MANAGEMENT OPTIONS
• LNG IUS
• Anti-fibrinolytics like Tranexamic acid and NSAID
• MPA
• DMPA
• Surgical methods like TCRE, EA, Hysterectomy
• COC pills
• Progesterone Only Pill

8. DISCUSSION
• Pills/Injectables
– Compliance is an issue
– Pills are Category 4 for breastfeeding as estrogen is excreted in the breast
milk
• Surgical methods:
– Irreversible
– Risk of complications
• Anti-fibrinolytics
– Daily compliance is a problem
– Efficacy not very great in reducing blood loss
– Can’t be used on a long term basis
WHO medical eligibility criteria for contraceptive use; 5th edition, 2015. Available at : http://www.who.int/reproductivehealth/publications/family_planning/Ex-Summ-MEC-5/en/
Last accessed on February 29, 2016

9. LNG IUS VERSUS ORAL MEDICAL THERAPY
• LNG IUS proved significantly superior to Tranexamic acid and NSAID in
reducing blood loss and was the only treatment that achieved
normalization of menstrual blood loss
• In addition, the duration of bleeding was not altered by either
Tranexamic acid OR NSAID and the frequency of side-effects with these
forms of treatment was greater than with LNG IUS
Reduction in
menstrual blood
loss
Milsom I, Andersson K, Andersch B, et al. A comparison of flurbiprofen, tranexamic acid, and a levonorgestrelreleasing intrauterine contraceptive device in the treatment of idiopathic
menorrhagia. Am J Obstet Gynecol 1991;164:879–83
LNG IUS-
3 months
LNG IUS-
6 months
LNG IUS-
12 months
Tranexamic
Acid Flurbiprofen

10. LNG IUS versus Medroxy Progesterone Acetate (MPA)
• The absolute reduction in median menstrual blood loss (MBL) was
significantly greater in the LNGIUS group (– 128.8 mL) than in the MPA
group (– 17.8 mL).
Levonorgestrel-releasing intrauterine system or medroxyprogesterone for heavy menstrual bleeding: a randomized controlled trial.
Kaunitz AM, Bissonnette F, Monteiro I, Lukkari-Lax E, Muysers C, Jensen JT.

11. DISCUSSION
• Levonorgestrel Intra Uterine System
– Considered as the first line management therapy in Menorrhagia
– Studies have shown that LNG IUS has no effects on breast-feeding
performance, infant growth and infant development1
• Shaamash AH, Sayed GH, Hussien MM, Shaaban MM. A comparative study of the LNG IUS versus Copper T380A during lactation: breast-feeding performance, infant growth and
infant development.
• **Murad F, & Haynes RC. (1985). Estrogens and progestins. In Goodman and Gilman's the Pharmacological Basis of Therapeutics, pp. 1412-1439. Edited by LS Goodman, AG
Gilman, TW Rall & F Murad. New York: Macmillan Publishing Company.

12. CASE STUDY 2
• A girl aged 15 years reports with severe cyclical bleeding since last 2
months along with pain and intense abdominal cramps
• She had menarche at 13 yrs.Periods were normal for two years.
• No medical illness/ pelvic pathology/ family history
• On blood investigation, Hemoglobin dropped to 8.7g/dl
• WHAT DO YOU THINK IS PROBABLE CAUSE OF AUB IN THIS CASE
• And what further investigations are required.

13. DISCUSSION DIAGNOSIS
• While there are many etiologies of AUB, the one most likely among
otherwise healthy adolescents is DUB.
• The most common cause of DUB in adolescence is anovulation, which is
very frequent in the first 2–3 post-menarchal years and is associated
with immaturity of the hypothalamic – pituitary – ovarian axis (HPO
axis)1.
• Management of AUB is based on the underlying etiology and the
severity of the bleeding and primary goals are prevention of
complications, such as anemia and reestablishment of regular cyclical
bleeding.2
1. E.H. Quint and Y.R. Smith. Abnormal Uterine Bleeding in Adolescents. Journal of Midwifery & Women’s Health. Volume 48, No. 3, May/June 2003
2. Efthimios Deligeoroglou, Vasileios Karountzos & George Creatsas (2013) Abnormal uterine bleeding and dysfunctional uterine bleeding in pediatric and adolescent gynecology,
Gynecological Endocrinology, 29:1, 74-78, DOI: 10.3109/09513590.2012.705384

14. Differential Diagnosis of AUB in Adolescents
Efthimios Deligeoroglou, Vasileios Karountzos & George Creatsas (2013) Abnormal uterine bleeding and dysfunctional uterine bleeding in pediatric and
adolescent gynecology, Gynecological Endocrinology, 29:1, 74-78, DOI: 10.3109/09513590.2012.705384

15. • CBC
• COAGULATION PROFILE
• THYROID PROFILE
• UPT
• PELVIC SONOGRAPHY
• EUA

16. How would the treatment protocol be prepared
for this patient

17. MANAGEMENT OPTIONS
• Combined Oral Contraceptives (COCs)
• Progestogens- MPA or DMPA
• Non steroidal anti-inflammatory drugs (NSAIDs)
• Tranexamic acid (anti-fibrinolytic)
• GnRH analogues- Danazol and
• Desmopressin- Synthetic analog of Arginine-
Vasopressin
• Levonorgestrel releasing intra uterine system
(LNG IUS)
.
Efthimios Deligeoroglou, Vasileios Karountzos & George Creatsas (2013) Abnormal uterine bleeding and dysfunctional uterine bleeding in pediatric and
adolescent gynecology, Gynecological Endocrinology, 29:1, 74-78, DOI: 10.3109/09513590.2012.705384

18. Management of Dysfunctional Uterine Bleeding
Hemoglobin
level
Bleeding
Intensity
Management
Hb>10 g/dl
1) Reassurance and education;
2) Iron Supplementation
3) Menstrual calender
4) Consider oral contraceptives if desired by patient
5) Prostaglandins inhibitors
6) Periodic re-evaluation
Hb < 10g/dl
No active bleeding
1) Consider referral or consult with a physician
2) Iron supplementation
3) Therapy: oral contraceptives
4) Levonorgestrel-releasing intrauterine device if appropriate
5) Cyclic progestin therapy; prostaglandin inhibitors
6) Reevaluation in 3 to 6 months
Active bleeding but
stable
1) Consider referral or consult with a physician
2) Cascade oral contraceptive regimen: 30 to 35-mcg ethinyl estradiol
a) 1 pill qid for 4 days
b) 1 pill tid for 4 days
c) 1 pill bid for 4 days
d) 1 pill qd until two pill packs are finished
3) Iron supplementation
4) Reevaluate by phone in a few days; if bleeding not slowed down, physician
consult
5) Continue treatment for 1 year; then reevaluate
Acute Hemorrhage Immediate consult with physician for possible transfusion and admission
E.H. Quint and Y.R. Smith. Abnormal Uterine Bleeding in Adolescents. Journal of Midwifery & Women’s Health. Volume 48, No. 3, May/June 2003

19. CASE STUDY 3
• A middle class lady 40 years old, P2 with 12 months of
heavy, painful, irregular and often long periods with clots
and cramps.
• She also c/o relapsing weight gain
• She was referred by her primary care provider after she
failed to respond to 2 months of intensive oral iron therapy
for severe Iron Deficiency Anemia (IDA); although she admits
she missed few pills
• Pelvic examinations was normal.
• Pelvic sonogrphy revealed endometrial thickness of 11 mm
with normal adenexa
• What further investigations are to be done ?

20.  CBC,THYROID,BLOOD SUGAR
 Endometrial aspiration/biopsy---- method?
purpose
 Whether D&C to be done or not?
 What is the role of hysteroscopy
 Any role of 3D/4D or MRI or sonohysterography

21. • What therapeutic measures need to be
initiated to control her heavy bleeding?

22. COUNSELLING AND OPTIONS
• She was counseled about her condition, and the fact that her chronic IDA
is due to excessive menstrual losses which are not being adequately
replenished due to impaired iron absorption in the gut
• She was also counseled that her relapsing weight gain is likely due to
ovulatory dysfunction causing abnormal uterine bleeding
• Options available:
– COC Pills
– Trenexamic acid and NSAID
– Progesterone only pills
– DMPA
– LNG IUS
– TCRE/EA/Hysterectomy

23. DISCUSSION
• OCP and progestin only pills and tranexamic acid
– Since the woman is forgetful , there are compliance issues for the pills
• DMPA1
– erratic heavy bleeding,
– further weight gain and
– osteoporosis (in case of prolonged DMPA use)
• TCRE/ EA/ Hysterectomy
– Irreversible
– Risk of complications
– Higher surgical cost
1. PINKERTON. Pharmacological therapy for abnormal uterine bleeding. Menopause: The Journal of The North American Menopause Society
Vol. 18, No. 4, pp. 453/461. DOI: 10.1097/gme.0b013e318212499c
2. Dennis A. Hidlebaugh. COST AND QUALITY-OF-LIFE ISSUES ASSOCIATED WITH DIFFERENT SURGICAL THERAPIES FOR THE TREATMENT OF ABNORMAL UTERINE
BLEEDING. OBSTETRICS AND GYNECOLOGY CLINICS OF NORTHAMERICA. VOLUME 27 • NUMBER 2 • JUNE 2000

24. DISCUSSION
• LNG IUS
– First choice therapy in management
of menorrhagia
– Rapidly induces clinically and
statistically significant long-term
reductions in MBL, paralleled by
increases in Hb and serum ferritin levels
– Long term management option for
control of symptoms and improvement in
quality of life

25. • ROLE OF SERM AND SPRM

26. CASE 4
• 32 years old banker 5’4” in height and with a body weight of 60 kgs.
• Sexually active and wants effective contraception but couldn’t enjoy
properly due to heavy bleeding issues and severe abdominal pain
• She wants a lasting solution which will effectively reduce bleeding and at
the same time no surgical procedures being involved
• Not keen on pregnancy for at least 3-4 years.
 What options available for her?

27. Options:
• LNG IUS
• COC Pills
• Anti-fibrinolytics
• Barrier methods
• Surgical therapy

28. Discussion
• LNG IUS:
– 2 pronged approach to cater both
• Contraception
• Menorrhagia
– Most effective with a failure rate of 0.1% in the first year – similar to or
even better than female sterilization
– Provides significant reduction in MBL within few months of insertion
(>90% reduction)

29. Case 4
• 18 years old girl.
• H/o MTP done 12 months ago. Pregnancy occurred after being prescribed
oral contraceptive pills.
• She is sexually active
• Wants information regarding contraception.
 What options are available for her ?

30. Options available:
• OCP’s.
• Rings or patch.
• DMPA
• Cu IUD
• LNG-IUS

31. Contraception for adolescents
• Adolescents are eligible for all contraceptives which are suitable for adults
• Proper counseling regarding its use is important.
• DMPA – can interfere with bone growth
• However, an adolescent girl tends to start and stop injections
• Dual protection be stressed upon
• Abstinence can be promoted as a method
• OC pills with benefits beyond contraception should be stressed upon along
with disciplined usage

32. Case 5
• A healthy, lean 36-year-old woman who is a heavy smoker (since past 2
years) requests advice about contraception.
• She used to take OC pills 3 years back but stopped after 6 months due to
peer pressure on bad effects of OC pill !!
• She notes that her menstrual periods are irregular than previously, and
she also reports severe abdominal pain and cramps along with heavy
bleeding.
• She is in a new relationship after a divorce, and she is sexually active.
• She asks if she can begin to use an oral contraceptive or any other
methods are available for her ?

33. Options available:
• Combined Oral Contraceptive Pills
• Progestin Only Pills
• Vaginal rings
• Intra Uterine Contraception
– Cu T
– LNG IUS
• Barrier methods- by both partners

34. Combined Oral Contraceptive Pills
• COCs can provide her with effective contraception
• Also by decreasing the menstrual related pain and cramps, the compliance
and tolerability with the COC pill increases
• COCs can also help to regularize the cycles and thus help in achieving a
good cycle control
• COCs are generally not advisable in females more than 35 years and who
are smokers due to cardio vascular risks

35. LNG IUS
• In long-term studies comparing LNG IUS and Cu-IUDs, the use of LNG IUS
results in significantly higher levels of hemoglobin, serum ferritin and
serum protein than in the use of Cu-IUDs*
• LNG IUS has no clinically significant effects on serum lipids, carbohydrate
metabolism, liver enzymes or the coagulation system*
• LNG-IUS provides a good alternative to systemic hormonal methods,
particularly in diabetics with vascular disease, smokers, and women with
a history of thrombosis**
• Women with coagulopathies, including those on warfarin, experience a
reduction in bleeding with the LNG-IUS**
* Luukkainen T. (1991). Levonorgestrel-releasing intrauterine device. Ann N Y Acad Sci 626, 43-49.
** Bednarek and Jensen International Journal of Women’s Health 2009:1 45–58

36. Case 6
• 27 year old female, recently married, infected with HIV past 4 years wants
to have contraception
• Husband’s HIV status unknown
• Using Condoms since past few months, but wants a more sustained and
long acting contraception
• What options can be suggested to her ?

37. Options:
• IUD
• COC Pills
• DMPA
• Barrier Methods

38. Discussion
• IUD shows high efficacy and reversibility, and it requires minimal
interval maintenance, which is especially appealing to women using
complex antiretroviral regimens
• There is limited evidence on disease progression in HIV-infected
women who use hormonal contraception versus women who do
not, because no study has directly evaluated markers of disease
• Hormonal contraceptives probably do not increase disease
progression or risk of transmission (Level B).
• Caution should be used in prescribing COCs to women on
antiretroviral medications, which increase or decrease contraceptive
steroid or antiretroviral area-under the- curve.
Teal, Ginosaur; Obstet Gynecol Clin N Am 34 (2007) 113–126

39. Discussion
• Reproductive-aged women are one of the fastest growing demographics
acquiring HIV infection
• Concerns regarding contraception in women who have HIV include
possible promotion of disease progression, exacerbation of sequelae,
increased risk of transmission, and interaction with antiretroviral therapies
Teal, Ginosaur; Obstet Gynecol Clin N Am 34 (2007) 113–126

40. Case Study 7
• 31 years old sexually active female, suggested sterilization for
contraception about one and half year back, but she didn’t opted for
surgery rather practiced barrier methods
• Now complains of regular heavy intermenstrual bleeding along with pain
in abdomen area intermittently
• She was also diagnosed with PID, 7 months back which got completely
resolved
• She is now in need of an option to solve her bleeding troubles and a
reversible contraceptive which will cater to her lifestyle and might provide
some additional benefits
• What options would you recommend for her ?

41. Discussion
• Barrier Methods
• Combined Oral Contraceptive pill
• Progestin only Pill
• Injectables
• LNG IUS

42. LNG IUS as the First Line therapy for Menorrhagia
Group 1:
• LNG IUS
Group 2:
(Usual Medical treatment)
• Tranexamic acid, or
• Mefenamic acid, or
• COC pill or
• Progestins: Oral/Injectable
The primary outcome was the score on the Menorrhagia Multi-Attribute Scale (MMAS) (scores
range from 0 to 100, with lower scores indicating greater severity).
Mean MMAS scores are shown for the two groups at 6, 12, and 24 months.

43. LNG IUS versus Sterilization
• The younger the woman is at the moment of sterilization, the more likely
she is to regret the procedure in later life
• Women under the age of 30 at the time of the procedure were twice as
likely as women older than 30 to report regretting having the procedure
performed
Hillis SD, Marchbanks PA, Tylor LR, et al. Poststerilization regret: findings from the United States Collaborative Review of Sterilization. Obstet Gynecol. 1999;93:889–895

44. Discussion
Levonorgestrel Intra Uterine System:
• The rate of pelvic inflammatory disease is lower with use of LNG IUS,
compared to the Cu-IUD at 3 and 5 years
• LNG-IUS may actually protect against upper genital tract infection by
thickening of cervical mucus
Therapy Removal Rate due to Pelvic Inflammatory Disease (5years)
Cu T 2.2
Mirena 0.8
* Levonorgestrel-releasing and copper-releasing (Nova T) IUDs during five years of use: a randomized comparative trial.
Andersson K, Odlind V, Rybo G.

45. Additional Benefits:
• Contraception:
– Highly effective long-acting reversible contraceptive
– Efficacy lasts for 5 years
– Pearl Index of 0.2 at 1 year and a cumulative failure rate of 0.7 at 5 years
• Endometrial Protection from Endometrial Hyperplasia during Estrogen
Replacement Therapy:
– Proven efficacy in endometrial protection
– Easy transition from contraception to ERT
– Convenience and ease of use – “fit and forget”
– High compliance for long-term ERT

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