Standard Treatment Guidelines: Hysterectomy

Below are some of the publications from certified agencies clearly states that Hysterectomy should be the last
choice for treating DUB.

Standard treatment guidelines released by WHO

(STANDARD TREATMENT GUIDELINE FOR PRIMARY HOSPITALS, Drug Administration and Control
Authority,January 2010)
Standard treatment guidelines by WHO were published to stop the irrational use of drugs and surgeries. In the section
where it jots down the guidelines for treating DUB says that it should be treated at three levels:
First line treatment
Alternative Treatment
Referral ( Referring to other or next tier hospital for Surgery)
It says for DUB as a first line treatment a patient should be prescribed with Norethisterone, Prostaglandin inhibitors or
NSAID in suggested doses. If it does not help the next alternative should be Combined Oral Contraceptive pills or
Danazol. If even this proves to be of no help then she should be referred for surgical management.

Anovulatory DUB

Treatment:

The treatment depends on the age of the patient, her desire for contraception or fertility, and the severity and
chronicity of the bleeding. The objectives of the treatment are:
1. To control active bleeding
2. To prevent recurrences, restoration of normal cycle
3. To induce ovulation in patients desiring to conceive.

Control of active bleeding:-

First line

Norethisterone, 5 mg 6 hourly PO for 2-3 days followed by 5 mg PO daily for ten days with or without
Medoxyprogesterone, 10-25 mg/6 hourly, PO until bleeding stops
Dosage forms: Tablet, 5mg

Alternative

High dose of Combined Oral Contraceptive pills (COC) 3-4 tablets /day until the bleeding is controlled and
then the standard dose of the COC one tablet/day for 21 days.

Restoration of the cycle: -

Combined oral contraceptive pills for 3-4 months.

Norethisterone 5mg/day from day 14-24 of the menstrual cycle each month for three months.

If fertility is desired

Ovulation induction using clomiphene citrate is one modality of treatment.

Referral:

If there is suspicion of endometrial pathology, like women in perimenopausal period.

Ovulatory dysfunctional uterine bleeding

Treatment:

Before embarking on treatment, organic causes should be ruled out beyond shadow of doubt.

First line

1. Prostaglandin inhibitors or NSAID: Drugs are given through the bleeding or the first three days of the
bleeding.
2. Ibuprofen, 400 mg 3 times /day or Indomethacin 25-50mg P.O TID (For S/Es, C/Is and Dosage forms, see
page 113 and 292 respectively)

Alternative

Danazol , 200-400 mg daily for 12 weeks S/Es: -nausea, dizziness, menstrual disturbance, and emotional
instability C/Is: - pregnancy, lactation, genital tumors, cardiac, renal, or hepatic dysfunction
Dosage forms: Capsule 100mg, 200-mg

Referral:

If there is a clinical suspicion of endometrial pathology, refer patient for surgical management.
Standard treatment guidelines, Ministry of Health & Family Welfare, Government
of India

(STANDARD TREATMENT GUIDELINES, Developed by, ARMED FORCES MEDICAL COLLEGE In collaboration
with MINISTRY OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF INDIA And WORLD HEALTH
ORGANIZATION, INDIA OFFICE)
Standard Treatment Guideline has been defined as a systematically developed statement designed to assist
practitioners and patients in making decisions about appropriate health care for specific clinical circumstances. It is
designed by Armed Forces Medical College.
According to STG, the treatment of DUB should be done at 4 levels. At the first and second level NSAIDs should be
administered. If the treatment does not help and the mentioned referral criteria are full filled then the patient should be
treated at the next level. At the next or the third level she should be given hormonal therapy for minimum three
months. On failure of medical or drug treatment for three cycles she should be treated at next level. The fourth level
says that if the medical management does not respond then the suitable endometrial ablation procedure or
hysterectomy can be performed.