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ABNORMAL UTERINE BLEEDING

ABNORMAL UTERINE BLEEDING. Terminology / Classification. OLD Dysfunctional uterine bleeding (DUB) Menometrorrhagia (MMR) Oligomenorrhea NEW (introduced by FIGO in 2011) – PALM-COEIN P olyp A denomyosis L eiomyoma M alignancy C oagulopathy O vulatory dysfunction E ndometrial

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ABNORMAL UTERINE BLEEDING

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  1. ABNORMAL UTERINE BLEEDING

  2. Terminology / Classification • OLD • Dysfunctional uterine bleeding (DUB) • Menometrorrhagia (MMR) • Oligomenorrhea • NEW (introduced by FIGO in 2011) – PALM-COEIN • Polyp • Adenomyosis • Leiomyoma • Malignancy • Coagulopathy • Ovulatory dysfunction • Endometrial • Iatrogenic • Not yet classified

  3. Uterine Fibroids • Most common pelvic tumor in women • > 80 % by age 50 in black (American, African, and Caribbean) women • 70 % by age 50 in white women • Benign • Monoclonal – arise from a single muscle cell • Symptoms: • Abnormal uterine bleeding • Prolonged, heavy menses • Pelvic pain and pressure • Reproductive dysfunction

  4. Uterine Fibroids – Risk Factors • Race • Black > White • Greater size • Earlier onset • Early menarche (< 10 yrs old) • Parity • Lower risk if 1 or more pregnancies beyond 20 wks • Hormonal contraception • Possible increased risk if early exposure to combined OC (13-16 yrs old) • Long-acting progestin-only contraceptives (DP, Nexplanon) – protective • Red meat • Alcohol, especially beer • Smoking • Decreases risk through an unknown mechanism • Caffeine • NOT a risk factor

  5. Fibroids – Clinical Manifestations • Majority – NO SYMPTOMS • Bleeding • Heavy, prolonged menses • NOT intermenstrual bleeding • Pain / pressure • Dysmenorrhea (painful menses) – likely due to increased bleeding/clots • Dyspareunia (painful intercourse) • Degeneration – ischemia due to insufficient blood supply • Reproductive difficulties • Other (rare) – ectopic hormone production • Polycythemia – from autonomous production of erythropoietin • Hyperprolactinemia • Hypercalcemia – from autonomous production of PTHrP

  6. Uterine Fibroids - Diagnosis • Pelvic examination • Enlarged uterus • Irregular contour • Tender • Imaging • Pelvic U/S – fastest, cheapest, very sensitive (95-100%) • MRI – the best modality to visualize size and location of all fibroids, expensive • CT – not used in evaluation of pelvic organs

  7. Fibroids – Natural History • Premenopausal women • Variable growth • Some regression occurs • Overall, increase in size • Growth during pregnancy • Postpartum regression • Postmenopausal women • Most, but not all, will experience shrinkage

  8. Fibroids - Treatment • Major goal – relief of symptoms • Type and severity of symptoms • Pain, bleeding, both, other • Size and location • Patient age • Reproductive history and plans

  9. Fibroids - Treatment • Expectant management • Really?? Doing nothing?? • Medical therapy • Seems to be effective for bleeding primarily • Hormone therapy • Combined or progestin-only • GnRH agonists (Lupron) • Significant reduction in size – 30-60 % • Amenorrhea – correction of anemia • Short duration of therapy, 3-6 months, typically preoperative • Rapid resumption of bleeding and uterine size once stopped

  10. Fibroids - Treatment • Hormone therapy (cont’d) • Antiprogesting (PRM’s – progestin receptor modulators) – i.e. Mifepristone (RU-486) • Effective – reduce uterine volume by 26-74 % • Amenorrhea comparable to Lupron • Regrowth occurs slowly after cessation of therapy • May cause pseudo-hyperplasia of endometrium • Not approved by the FDA for use in treatment of fibroids • Antifibrinolytic agents • Lysteda (Tranexamic acid) • Approved for heavy menstrual flow, but useful for fibroids as well • NSAIDs • For pain only • No effect on bleeding

  11. Fibroids – Surgical Treatment • Mainstay of therapy for fibroids • Hysterectomy • Abdominal, Vaginal, Laparoscopic (Robotic) • Definitive treatment • Myomectomy • Abdominal, Laparoscopic • Uterine artery or uterine fibroid embolization • Minimally invasive, fast recovery time • Only useful for bleeding • For women who are not planning future pregnancy • Endometrial ablation • Minimally invasive, fast recovery time • Only useful for bleeding • For women who are not planning future pregnancy

  12. Endometrial Polyps • Frequently asymptomatic • One of the most common reasons for AUB • Premenopausal AND postmenopausal • Single or multiple polyps can occur • Incidence increases with age • RISK FACTOR: endogenous or exogenous estrogen • PCOS • Obesity • Tamoxifen therapy

  13. Endometrial Polyps • Majority (95%) are benign • Removal via hysteroscopy is both diagnostic and therapeutic • Recurrence is rare

  14. Adenomyosis • Presence of endometrial glands within the uterine wall • NOT an invasion of endometrial lining • Causes uterine enlargement and pain/bleeding • Heavy menstrual bleeding • Painful menstruation • Benign • Affects 20% of women • Histologically present in up to 65% of women • Similar to ENDOMETRIOSIS (endometrial implants outside the uterus) • More common in parous women

  15. Adenomyosis - Treatment • Hormonal • Combined E/P or P-only • Effective only during use • Recurrence after cessation of therapy • Surgical • Hysterectomy – definitive • Endometrial ablation – variable success due to unpredictable thickness • UAE – appears to be somewhat successful

  16. Ovulatory Dysfunction • Oligoovulation or anovulation • Unpredictable menstrual pattern • Absent menstruation • Prolonged bleeding • Immaturity at the onset of menarche or perimenopause • Polycystic ovary syndrome (PCOS) • Thyroid dysfunction • Genetic conditions • Medications • Other

  17. PCOS • Important cause of menstrual dysfunction • Unclear etiology • Complex genetic trait similar to cardiovascular disease or type 2 diabetes • Interaction of multiple genetic and environmental factors • Prevalence 6.5 – 10 % in women of reproductive age regardless of race • Syndrome with multiple etiologies and variable clinical presentation • Key features: • Oligo- or anovulation, causing menstrual dysfunction • Hyperandrogenism – excess androgens, i.e. testosterone • Polycystic ovaries on U/S • Insulin resistance • Obesity

  18. PCOS - Risks • Cardiovascular disease • Obesity • Dyslipidemia • Endometrial hyperplasia • Type 2 diabetes • Non-alcoholic steatohepatitis (NASH) • Mood disorders • Anxiety/depression • Eating disorders

  19. PCOS - Treatment • Lifestyle changes • Diet and exercise for overweight women with PCOS • Even 5-10% reduction in body weight can restore ovulation • Response is variable and unpredictable • More effective for insulin resistance and hyperandrogenism than meds • Combined E/P contraceptives – mainstay of treatment • Establish normal menstrual pattern • Lower serum testosterone levels • Endometrial protection • Metformin • Restores ovulatory function in 30-50% of women with PCOS • Statins for dyslipidemia • Ovulation induction for those desiring pregnancy • Clomiphene

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