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Abnormal Uterine Bleeding: Causes & Treatment

Get insights on different types of abnormal uterine bleeding, from menorrhagia to DUB, in various life stages. Learn about related medical conditions and effective therapies. Stay informed for optimal health management.

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Abnormal Uterine Bleeding: Causes & Treatment

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  1. Abnormal Uterine Bleeding Douglas Brown M.D.

  2. GYNOSPEAK • Dysfunctional Uterine Bleeding – non-menstrual bleeding due to failure of ovulation • May be frequent e.g. every 2 weeks • May be infrequent e.g. every 6 months • Generally heavier than menses

  3. More Gynospeak • Menorrhagia – heavy menstrual bleeding • Menometrorrhagia – heavy irregular bleeding – may be DUB or organic • Midcycle bleeding – periovulatory bleeding, usually light, lasting 1-5 days • Premenstrual bleeding – spotting or light bleeding 2-7 days prior to menses, leading into menses

  4. Even More Gynospeak • Breakthrough bleeding (BTB) – irregular bleeding associated with exogenous hormone use such as OCPs ot HRT • Oligomenorrhea – infrequent menses, generally less often than every 6 weeks • Postmenopausal bleeding – occurs afer 1 year following cessation of menses

  5. Adolescent • Expect DUB with the first several “periods” as the hypothalamus matures • Regular menses may take a year to develop • DUB more likely to be chronic in obese teens (?genetic?) Watch for PCO • Watch for amenorrhea in athletic teens • Consider OCPs, calcium supplement

  6. Adolescent Menorrhagia • Distinguish menorrhagia from DUB • 15-20% of teens requiring transfusion will have a coagulation disorder • Von Willebrand’s is most common • If VW test other women in family

  7. Isolated Early or Late Menses • Most common etiology is stress • Change in environment • Short term corticosteroid use • Exclude pregnancy with home test or serum HCG • The Holiday Rule

  8. Meds and Medical conditions • Hyper and hypo thyroidism • Chronic renal or endocrine disease • Endometriosis • Hyperprolactinemia due to CNS or pituitary disease • Phenothiazenes • Metoclopromide • Tricyclics

  9. Postcoital Bleeding • Cervical lesion – polyp, cancer, ectropion • Vaginal atrophy • Endometritis • Unstable or atrophic endometrium due to OCs, HRT or Depoprovera • Endometrial polyp or myoma • Have a low threshold for endometrial biopsy

  10. Bleeding with Contraception • BTB with OCs – change pills – increase estrogen, change progestin • Depoprovera or minipill – add estrogen until bleeding stops • Paraguard copper IUD –irregular bleeding, menorrhagia – may be endometritis • Mirena levonorgestrel IUD – may cause 2-4 months irregular bleeding, then hypomenorrhea or amenorrhea

  11. DUB • Due to anovulation • Distinguish from oligomenorrhea • Risk is endometrial hyperplasia or Ca • Consider endometrial biopsy (later) • If chronic evaluate for PCO • Draw fasting glucose and insulin

  12. DUB Acute therapy • IV premarin 25mg q 4-6 hrs – vasospasm • Monophasic OCs “OCP Taper” – qid for 4 days, tid for 3 days, bid for 2 days, daily for remainder of two packs • MPA (provera,cycrin) – 10 mg 2-3x/day for 2 weeks

  13. DUB long term therapy • OCPs • Withdrawal with progestin for 10-14 days every 6-8 weeks • Use provera 10 mg, prometrium 100 mg, aygestin 2.5 – 5 mg

  14. Menorrhagia • Myoma • Polyp • Coagulation Disorder • “Humoral” • Idiopathic

  15. Uterine Myoma • Menorrhagia is most common symptom • Look for intramural or submucous myomas • Interruption of contractile hemostasis • Dx with ultrasound • Smell any fish?

  16. Therapy for Myomas • Continuous OCPs • GnRH agonists e.g Lupron • Myomectomy/Hysterectomy • Operative hysteroscopy • Uterine artery embolization • Post-DUBYA – Mifepristone 50 mg/day

  17. Humoral Menorrhagia • Diagnosis of exclusion • Consider coagulopathy workup – 10% • Diff Dx: VWDz, thrombocytopenia,TTP, ITP,vasculitis, liver disease • Desmopressin nasal spray for VW Dz

  18. Medical Therapy • NSAIDs – Ibuprofen, Naproxen, Mefenamic acid (meclomen, ponstel) • OCPs – consider continuous regimen • Depoprovera • Iron replacement • Endometrial ablation – Rollerball, Novasure (mesh), Thermachoice (balloon), MEA (microwave)

  19. Perimenopause • Oligomenorrhea if you’re lucky • Anovulatory biweekly “menorrhagia” if you’re not • Therapy – low dose OCPs or higher dose HRT such as Activella or FemHRT • Don’t forget space-occupying disease

  20. Postmenopause • All postmenopausal bleeding is cancer until proven otherwise • 90% of BTB due to atrophy • Prove it with endometrial Bx or TV U/S • On U/S endometrial “stripe” should be less than 5 mm • BTB common in new start HRT • Obese patients may require withdrawal

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