·:{iC0Fp'16ACOFP 53rd Annual Convention & Scientific Seminars

Dysfunctional Uterine Bleeding

Michele Tartaglia, DO

3/17/2016

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Michele Tartaglia, DO, FACOOG, CSAssistant Professor and Residency Program Director

Rowan University School of Osteopathic Medicine

Department of Obstetrics & Gynecology

1. Define normal and abnormal uterine bleeding (AUB)

2. Describe a patterns based approach to AUB

3. Understand the diagnostic modalities commonly used in the workup of AUB

4. Describe the different options for both the medical and surgical management of AUB

Objectives

No financial disclosures to report

Financial Disclosure

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Entire talk based on one article with some evidence based updating and commentary from me

I’m not the only author of this talk!!!

Misc. Disclosure

• Authors = 2 family docs and 2 gynecologists

• MEDLINE search for algorithms for clinical management AUB

• Also examined care of 100 random women in university gyn clinic

• Then honed own clinically based algorithm

• Noticed that gyns usually immediately group all AUB patients into one of 4 groups

JABFM Article

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1. Severe acute bleeding

2. Irregular bleeding

3. Menorrhagia

4. Abnormal bleeding associated with contraceptive use

• Oral contraceptives

• Depo-medroxyprogesterone

• Intrauterine devices

JABFM Article

Normal interval is 21-35 days

Normal duration is 1-7 days

Gyn textbook answer – two to eight days

Normal amount is less than 1 pad or tampon every 3 hours

Normal Uterine Bleeding

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Severe Acute Bleeding

Bleeding that requires more than one pad/tampon

per hour

AND/OR

Vital signs indicating hypovolemia

Severe Acute Bleeding

Common causes:

Adolescents – coagulopathy (vonWillebrand disease, leukemia)

Fibroids – especially submucosal

People on anticoagulants

Obesity – anovulatory cycles and adenomyosis

Trauma

Tailor your lab workup to the individual patient

Ultrasound NOT as helpful in the adolescent

Severe Acute Bleeding

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Severe Acute Bleeding

“Cycle Provera” – consider starting high dose (10mg BID-TID) with taper then standard dose (10mg qHS x 10-21 days) next two cycles

Alternative medical therapies

Tranexamic acid

Antifibrinolytic agent

Not studied for acute AUB

IV and PO options

Foley catheter placed into uterus

Tamponade

26F with 30mL saline – case reports proving efficacy

Desmopressin or recombinant Factor VIII in patients with vonWillebrand disease

Severe Acute Bleeding

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Surgical options

D&C

Endometrial Ablation

Uterine artery embolization

Hysterectomy

Severe Acute Bleeding

Severe Acute BleedingSummary

Irregular Bleeding

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Includes:

Metrorrhagia

Menometrorrhagia

Oligomenorrhea

Prolonged bleeding

Intermenstrual bleeding

Any other irregular pattern

Irregular Bleeding

Not every patient needs evaluation!

Adolescent in the first 2 yr after menarche immaturity HPO axis

However may request intervention

Perimenopausal patient Some shortening or lengthening of the cycle is expected

Repeated cycles outside the normal range or other AUB requires endometrial biopsy

Reproductive age woman Some spotting just before, just after, or at ovulation can

be normal

However, ANY midcycle bleeding in an older patient should be worked up

Irregular Bleeding

HCG, TSH, prolactin

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Paper: Age >35 with irregular bleeding REQUIRE biopsy

ACOG

>45yo as first line test

<45yo if hx unopposed estrogen (PCOS, obesity), failed medical management, persistent AUB

Sensitivity of EMB in studies that use hysterectomy: 68%, used D&C: 78%

Samples an average of 4% of the endometrium

Still a good test – just consider further eval if no response to therapy in the face of a normal EMB

Endometrial Biopsy

Identify polyps, fibroids, very thick EMS

EMS < 5mm = VERY low likelihood of endometrial hyperplasia or carcinoma

Large meta-analysis: intrauterine abnormalities found in 46.6% of women with AUB

Try to schedule day 4-6 of cycle (EMS thin)

Proliferative phase EMS usually 4-8mm

Secretory phase EMS usually 8-14mm

Saline infusion sonohysterography even more accurate

Transvaginal Ultrasound

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Chronic endometritis – treat w doxy 100mg BID x 10d

Medications – eg. TCAs, corticosteriods, antipsychotics

Systemic disease – liver or kidney failure, thyroid d/o

Hyperandrogenic syndromes

PCOS

Congenital adrenal hyperplasia

Androgen secreting tumors

Hyperprolactinemia

Systemic Causes

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Menorrhagia

Heavy but regular, cyclic bleeding

Blood loss greater than 80mL per cycle or patient perception of very heavy bleeding

Large clots

Iron deficiency anemia

If the bleeding lasts > 12 days (arbitrary set by authors) follow irregular bleeding algorithm

Menorrhagia

Up to 20% of women have an underlying bleeding

disorder – MUST SCREEN YES answer to any of the following is a +screen

HMB since menarche

One of the following: PP hemorrhage

Surgery related bleeding

Bleeding assoc w dental work

Two or more of the following: Bruising 1-2x a month

Epistaxis 1-2x a month

Frequent gum bleeding

Family hx bleeding symptoms

Menorrhagia

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Oral antifibrinolytic FDA approved for treatment of

HMB of greater than 80mL per cycle

Few case reports of arterial and venous thrombosis

NO REPORTS of VTE

Contraindicated in those w hx or high risk VTE

No data on use with COCs - contraindicated

Reduces blood loss by 40-65%

TID dosing only on days of heaviest bleeding – max 5 days

Tranexamic Acid

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AUB from Hormonal Contraception

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• Ely JW, Kennedy CM, Clark EC, Bowdler NC. Abnormal Uterine Bleeding: a

management algorithm. J Am Board Fam Med. 2006. 19(6):590-602.• ACOG Practice Bulletin Number 557. Management of Acute Abnormal

Uterine Bleeding in Nonpregnant Reproductive-Aged Women. April 2013 (Reaffirmed 2015).

• ACOG Practice Bulletin Number 128. Diagnosis of Abnormal Uterine Bleeding in Reproductive Aged Women. July 2012 (Reaffirmed 2014).

• ACOG Practice Bulletin Number 136. Management of Abnormal Uterine Bleeding Associated with Ovulatory Dysfunction. July 2013 (Reaffirmed 2015).

• Curtis M, Overholt S, Hopkins M. Glass’ Office Gynecology. 6th Edition. Lippincott Williams & Wilkins. 2006.

• Lysteda (package insert). Parsippany, NJ: Ferring Pharmaceuticals Inc.; Rev 10/2013.

• Kost A, Pitney C. Tranexamic Acid (Lysteda) for Cyclic Heavy Menstrual Bleeding. American Family Physician. Volume 84, Number 8. October 15, 2011.

References

Enjoy Puerto Rico!!!!

Michele Tartaglia, DO, FACOOG, CS

tartagmi@rowan.edu