Abnormal Uterine Bleeding: Not just OCPs or hysterectomy anymore

1. Abnormal Uterine Bleeding:Not just OCPs or hysterectomyanymore Tony Ogburn MD Professor, Dept. of Ob/Gyn University of New Mexico

2. Objectives • Discuss the classification of abnormal uterine bleeding • Understand the evaluation of abnormal uterine bleeding in reproductive aged women • List the non surgical treatment options of abnormal uterine bleeding • Discuss the indications for surgical management for abnormal uterine bleeding

3. Disclosures • Nexplanon trainer – no disclosure • IUD devotee…

4. A lot of confusing terms!

5. Common Terminology

6. A new classification systemPALM - COEIN • Initial conference – 2005 • Wide participation of stakeholders • FIGO, ACOG, FDA, Researchers, Journals • Focused on terminology, defining needs and resources • Follow-up conference – 2009 • Nomenclature and classification systems • Approved by FIGO - 2011 • Useful for clincians, researchers, and educators • Provides a tool for structured history, evaluation

7. Nomenclature • Acute AUB • “an episode of bleeding in a woman of reproductive age, who is not pregnant, that, in the opinion of the provider, is of sufficient quantity to require immediate intervention to prevent further blood loss.” • Chronic AUB • “bleeding from the uterine corpus that is abnormal in duration, volume, and/or frequency and has been present for the majority of the last 6 months.”

8. Suggested “norms”

9. PALM-COEIN • 4 categories that are defined by visually objective structural criteria (PALM) • Polyp • Adenomyosis • Leiomyoma • Malignancy and hyperplasia • 4 criteria that are unrelated to structural anomalies (COEI) • Coagulopathy • Ovulatory dysfunction • Endometrial • Iatrogenic • 1 criterion that is reserved for entities that are not yet classified (N).

10. Causes of AUBStructural abnormalities (PALM) • Polyps – AUB-P • endocervical or endometrial • Detected by ultrasound or sonohysterography • Often irregular, light bleeding

11. Structural abnormalities (PALM) • Adenomyosis –AUB-A • Controversial as a cause of bleeding • Diagnosed with ultrasound, MRI, pathology

12. Structural abnormalities (PALM) • Leiomyoma – AUB-L • Submucous • Intramural • Subserosal • Diagnosed with exam, ultrasound, MRI, CT • Heavy, regular bleeding

13. Structural abnormalities (PALM) • Malignancy and hyperplasia – AUB-M • Diagnosed by biopsy • Irregular bleeding

14. Non Structural Causes - COEI • Coagulopathy • Usually suspected based on history • Von Willebrands most common • Heavy, regular bleeding • Ovulation disorders • Suspected on history • Variable cycle length • Can be confirmed with laboratory testing • Wide range of bleeding patterns – usually irregular

15. Causes of AUB • Anovulatory • Most common cause of AUB • Many reasons for anovulation • Unknown • PCOS • Stress, weight change, exercise • Endocrine • Thyroid, PRL • Secreting tumors

16. Non Structural Causes - COEI • Endometrial • A diagnosis of exclusion • A wastebasket… • Iatrogenic • Hormone Use • IUD, implant

17. Not Yet Classified - N • “Other entities that may or may not contribute to or cause AUB but have not been identified or have been poorly defined, inadequately examined, and/or are extremely rare”

18. Evaluation • History • Acute • Stable? • Chronic • Characterize bleeding pattern • Examination • Is it from the uterus?! • Laboratory studies • Pregnancy test • Hct/CBC • Other labs only if indicated – e.g. • TSH/PRL • Iron studies • Labs for disorders of hemostasis

19. Evaluation • Other diagnostic procedures • EMB • Consider in all patients over 45 or refractory bleeding • Pipelle vs. D&C • Ultrasound • Sonohysterogram • Hysteroscopy

20. Endometrial biopsy

21. Ultrasound - Abdominal or transvaginal - Inexpensive and readily available in most of the world

22. Sonohysterogram • Inject small amount of fluid in uterine cavity • Transvaginal ultrasound • Endometrial thickness and evaluation of intrauterine structures

23. Hysteroscopy Expensive Can be used for treatment

24. MRI • Very expensive • Not readily available • Rarely needed!

25. Treatment • Acute or chronic? • If you find something in your evaluation • Treat it! • Thyroid disease, cervical polyp, pregnancy, etc. • Structural – consider referral early on • Surgery, embolization, hormonal Rx • Often left with no obvious cause • Now what?

26. Treatment - Acute • Unstable? • High dose hormones vs D&C • IV estrogen – 25 mg IV q 4-6 hours • Stable • Oral meds • Monophasic OCPs – One TID for seven days, then daily for at least one cycle • Medroxyprogesterone(Provera) – 20 mg TID for seven days, then daily for at least three weeks • Tranexamic acid (Lysteda) – 1.3 mg TID for five days

27. Treatment - ChronicConsiderations • Etiology and severity of bleeding (eg, anemia, interference with daily activities) • Associated symptoms (eg, pelvic pain, infertility) • Contraceptive needs or plans for future pregnancy • Contraindications to hormonal or other medications • Medical comorbidities • Patient preferences regarding medical versus surgical and short-term versus long-term therapy

28. Treatment Options • Non-surgical – usually the first line of treatment • Expectant management • NSAIDs • Reduce blood loss by ~50% • Antifibrinolytic agents - Tranexemic acid (Lysteda) • Expensive • Hormonal methods • Combination methods • Reduce blood loss by ~50% • Regulate cycles in ~85% • Levonorgestrel IUD • Reduce blood loss by ~85% • Less effective at regulating cycles but usually not an issue • Cyclic progestin • Most appropriate for anovulatory bleeding if other methods contraindicated • GnRH agonists (leuprolide) • Expensive for long term use but good for pre-procedure preparation

29. Levonorgestrel IUD • FDA approved for treatment of abnormal bleeding • More effective than OCPs, oral progestins, Depo-Provera, NSAIDs • Cost effective • Few side effects • Reduces blood loss by up to 97% • Takes 3-6 months for optimal effect

30. Combination Methods • OCPs • Use monophasic at least for first three months • Use 30-35 of estrogen • Continuous vs. cyclic • Patch/Rings • No good trials about efficacy for this indication

31. Other? • Depo Provera • Implant

32. Surgical Treatment • Two main approaches • Global endometrial ablation • Hysterectomy • Future pregnancy contraindicated/impossible

33. Global Endometrial Ablation • Outpatient procedure • Excellent safety profile • A variety of methods • Balloon – Thermachoice • Radiofrequency electricity – Novasure • Freezing – Her Option • Circulating hot water – HTA • Unclear which, if any, is best! • All have about 80% “success” • Less in younger patients… • Equal to IUD in efficacy

34. Thermachoice • Eight minute cycle • Lots of cramping during procedure

35. HTA - 10 minute cycle - Vaginal burns an early issue

36. Her Option - Takes a long time…

37. Novasure 1-2 minutes Have to dilate cervix more We have it at CRH!!!

38. Hysterectomy • Random facts… • 100% effective for AUB • A significant minority of women with “conservative” management end up with a hyst eventually • Satisfaction rates are very high • Major complications do happen • Expensive

39. Questions ?

40. Maria • 32 yo G2P2 with post – coital spotting for several months • History completely unremarkable

41. Cora • 37 yo with longstanding history of regular, heavy menses now bleeding heavily for 16 days. Passed out at home and brought in by ambulance.

42. Erica • 62 yopostmenopausal for 11 years with spotting for several months

43. Stephanie • 24 yo G0 with very heavy menses and cramping increasing over one year

44. Jane • 42 yo G3P3 presents with heavy, regular bleeding for 9-12 months. • Bleeds 2-3 weeks each month with large clots and cramps.

45. Sara • 46 yo G2P2 with heavy, irregular menses for two years. Now increasing in frequency and flow • Previous C/S X 2