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Abnormal Uterine Bleeding

Abnormal Uterine Bleeding. Naval Medical Center San Diego Department of Obstetrics and Gynecology CDR David Furlong, DO, FACOG. Introduction. 1/3 of all outpatient gyn visits are for AUB Majority of cases occur just after menarche or in the perimenopausal time period

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Abnormal Uterine Bleeding

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  1. Abnormal Uterine Bleeding Naval Medical Center San Diego Department of Obstetrics and Gynecology CDR David Furlong, DO, FACOG

  2. Introduction • 1/3 of all outpatient gyn visits are for AUB • Majority of cases occur just after menarche or in the perimenopausal time period • Among adolescents, AUB is most frequent cause of urgent admission to the hospital • World wide affects 50% of menstruating women • Of the half-million hysterectomies performed in the U.S., 50% or more are for AUB

  3. What is normal? • Normal uterine bleeding is defined as menses occurring ever 28 days (+/- 7 days) with a mean duration of 5 days and an average EBL of 30 cc • no more than 80 mL

  4. Regulation of Normal MensesOvary • Late in menses the hypothalamus generates timed pulses of GnRH • This stimulates the anterior pituitary to produce FSH and small amount of LH • FSH recruits a cohort of ovarian follicles • Estradiol is produced and a positive feedback loop increasing FSH until a LH surge occurs triggering ovulation of a dominant follicle (oocyte).

  5. Regulation of Normal MensesEndometrium • Rising levels of estradiol cause proliferative growth of the endometrium • Once the LH surge occurs, the ovum is released and the follicle collapses to become the corpus luteum (CL) • The CL produces large amounts of progesterone causing the secretory phase of the endometrium. • If implantation fails to occur, the CL involutes and progesterone is withdrawn causing endometrial collapse and menstruation.

  6. Menstrual changes

  7. Etiologic Bases of anovulatory bleeding • Estrogen-withdrawal • Results from unexpected decrease in estrogen levels • Examples include: • Iatrogenic after BSO • Recurrent midcycle spotting just before ovulation • Postmenopausal women

  8. Etiologic Bases of AnovulatoryBleeding • Estrogen-breakthrough • Chronic stimulation of endometrium • Unopposed proliferation results in insufficient structural support • Parts of the endometrium slough at irregular and unpredictable intervals • PCOS is classic example (No progesterone withdrawal increases risk for endometrial hyperplasia/cancer)

  9. Etiologic Bases of AnovulatoryBleeding • Progesterone-breakthrough bleeding • Progesterone-to-estrogen ratio is relatively high • Endometrium atrophies and ulcerates due to the lack of estrogen • Use of oral contraceptives is a classic example • Mirena or LNG based IUD • Nexplanon implant

  10. Etiologic Bases of BleedingProgesterone Withdrawal Normal menstrual physiology

  11. Old AUB terms • Oligomenorrhea – menses occurring less than monthly (35 days) • Polymenorrhea – bleeding that occurs more often than 21 days • Menorrhagia – menstrual blood loss greater than >80cc • Metrorrhagia – bleeding between periods • Menometrorrhagia – heavy bleeding that also occurs between periods • Dysfunctional Uterine Bleeding – bleeding related to anovulation or ovulatory disorder

  12. New AUB terms by etiology! • PALM: Structural Causes • Polyp (AUB-P) • Adenomyosis (AUB-A) • Leiomyoma (AUB-L) • Submucosal (AUB-Lsm) • Other myoma (AUB-Lo) • Malignancy & Hyperplasia (AUB-M) • COEIN: Nonstructural Causes • Coagulopathy (AUB-C) • Ovulatory dysfnc (AUB-O) • Endometrial (AUB-E) • Iatrogenic (AUB-I) • Not yet classified (AUB-N)

  13. New AUB terms • Heavy menstrual bleeding • Intermenstrual bleeding

  14. Etiology of AUB by age • Birth • Estrogen withdrawal • Birth to age 12 • Foreign body, infxn, sarcoma botryoides, trauma, ovarian tumor • Age 13-18 • Hormonal contraceptives, pregnancy, pelvic infection, coagulopathy or tumors • Age 19-39 • Pregnancy, structural lesions, anovulatory cycles, hormonal contraception, endometrial hyperplasia • Age 40 to menopause • Anovulatory cycles, endometrial hyperplasia/cancer, endometrial atrophy, leiomyomas

  15. Evaluation of AUB Medical history Physical examination Laboratory tests Diagnostic/Imaging tests Tissue sampling

  16. Medical History • Age of menarche and menopause • Menstrual bleeding patterns (menstrual diary is helpful; there’s an APP for that!) • 40% of women with blood loss > 80 cc consider their menses light or moderate • 14% of women with blood loss < 20 cc consider their menses heavy • Severity of bleeding (clots or flooding; nighttime bed protection) • Pain (severity and treatment) • Medical conditions • Surgical history • Use of medications • Symptoms and signs of possible hemostatic disorder

  17. Physical Examination • General physical • Obesity • Signs of PCOS (hirsutism and acne) • Signs of thyroid disease (thyroid nodule) • Signs of insulin resistance (acanthosis nigricans of the neck) • Signs of a bleeding disorder (ecchymosis, petechia, skin pallor or swollen joints) • Galactorrhea • Pelvic examination • External • Speculum with pap test, if needed • Bimanual

  18. Laboratory Evaluation Pregnancy test CBC TSH GC/CT Targeted screening for bleeding disorders (if indicated) Prolactin (oligo or amenorrhea)

  19. Diagnostic/Imaging Tests • Transvaginal ultrasonography • Useful, low cost initial screening test • Remember your patient! Peds or virginal adolescent consider abdominal u/s or Gyn referral • Endometrial thickness is not helpful or validated for premenopausal women • Saline Infusion Sonohystogram • Gyn performed. Targeted for intracavitary lesions

  20. Tissue Sampling • Office endometrial biopsy • 45 yo • 35-44 yofor significant risk • Obesity • PCOS • Failed medical management • Persistent AUB • Hysteroscopy directed endometrial sampling (office/operating room via dilatation and curettage)

  21. Treatment of AUB • MEDICAL THERAPY • FIRST LINE • Lifestyle modifications • NSAIDs • Progestins (oral, injectable, intrauterine) • Combined hormonal contraceptives • SECOND LINE • IV or high dose estrogens (inpatient) • Continuous combined hormonal contraceptive • GnRH agonists • Antifibrinolytics (tranexamic acid)

  22. Treatment of AUB • Cyclooxygenase (COX) – inhibitors • Within the endometrium, cyclooxygenase (COX) converts arachidonic acid into prostaglandins • NSAIDs reduce MBL by 20-50% • Premedication with Naprosyn starting 3 days prior to menses is effective

  23. Treatment of AUB • Progestins • Can be administered cyclic, continuous or as IUD • Cyclic progestins useful for anovulatory bleeding • Continuous progestins (Provera, Depo provera or Norethindrone) can produce amenorrhea • Mirena IUD/LNG IUD system • Reduce volume of bleeding by 80-90%, amenorrhea 40% at 12 months • 75% of pts chose to continue it compared to 20% of oral norethindrone • 60-80% of pts canceled hysterectomy due to satisfaction with IUD.

  24. Treatment of AUB • Combined Oral Contraceptives • Useful for ovulatory and anovulatory bleeding • Reduces menstrual volume by about 50% • Acute bleeding may be treated with a taper

  25. Treatment of AUB • Parenteral estrogens • Acute bleeding in adolescent girls usually results from anovulation • IV Estrogen (25mg IV Q 4 hours)  then give progestins • PO Estrogen (2.5 mg po Q 4-6 hours for 14 – 21 days)  then give progestins • Note: Once bleeding stops give progestins for 7-10 days

  26. Treatment of AUB • GnRH Agonist (Lupron) • Useful for leiomyomas, ovulatory and anovulatory bleeding • Induces amenorrhea and can shrink uterine volume by 40-60% • Note: Gonadotropin “flare” may induce bleeding and/or cramping >14 days after starting therapy

  27. Treatment of AUB • Tranexamic Acid (TXA/Lysteda) • Inhibits fibrinolysis • Reserved for severe heavy menstrual bleeding and postpartum hemorrhage • 1300mg PO TID for 5 days at start of menses • Contraindication in VTE history

  28. Treatment of AUB:Supplement to anemia • Iron • Average woman ingests enough dietary iron to replace menstrual blood loss up to 60 mL per month. • Oral iron replacement can be sufficient at 325mg every other day with less side effects

  29. Treatment of AUB • Surgical treatment • Endometrial Ablation • Hysterectomy • (Note: In acute setting dilation and curettage may be useful until to stop bleeding)

  30. Treatment of AUB • Endometrial ablation • 90% of patients are satisfied at 12 months • 50% amenorrhea at 12 months • At 5 years, 80% had no further surgery and 90 % had not had a hysterectomy • *Mirena IUD and novasure had similar patient satisfaction scores at 3 years

  31. Treatment of AUB • Hysterectomy • Most common surgical treatment for AUB • 550,000 hysterectomies performed each year in U.S. • 40% performed for AUB • 50% of uterine specimens show no uterine abnormality

  32. Questions?

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