Abnormal Uterine Bleeding Kelly Menge, DO, FACOOG

Objectives

u  Review what is normal bleeding and what is not normal

u  Discuss various etiologies of uterine bleeding

u  What to expect during a work-up

u  Review management options

Why do we care?

u  May reveal structural or systemic pathology.

u  Has an impact of quality of life.

When is it normal to start and stop periods?

u  Menarche

u  Average age = 12 years old

u  Menopause

u  Average age = 51 years old

Normal Cycle

u  28 days +/- 7 days

u  Occurs at regular intervals

u  Volume of blood </= 80mL

u  Duration 4-6 days

Abnormal Uterine Bleeding Definitions

u  Menstrual flow outside of normal volume, duration, regularity, or frequency

u  Heavy Menstrual Bleeding

u  Intermenstrual Bleeding

Sources of Abnormal Uterine Bleeding

Anatomic Source

u  Polyp

u  Adenomyosis

u  Leiomyoma

u  Malignancy

Physiologic Source

u  Coagulopathy

u  Ovulatory

u  Endometrial

u  Iatrogenic

u  Not otherwise specified

POLYPS

Polyps

u  Endocervical / Cervical

u  Benign (malignant degeneration rare)

u  Intermenstrual bleeding / contact bleeding

u  Endometrial

u  Benign (malignant transformation 0.5%)

u  Possible increased risk of endometrial carcinoma

u  Heavy menstrual bleeding, spotting

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ADENOMYOSIS

Adenomyosis

u  Endometrial glands and stroma of the basalis layer of the endometrium into the myometrium

u  Heavy menstrual bleeding and dysmenorrhea

u  Uterus may be diffusely enlarged

www.fibroid.com

Adenomyosis RFA

LEIOMYOMA (FIBROIDS)

Leiomyoma (Fibroids)

u  Most common tumor in women

u  Smooth muscle cell tumors

u  Contain estrogen and progesterone receptors

u  Abnormal microvascular growth and abnormal function of vessels in the adjacent endometrium

wdavidstinsonmd.com

www.examiner.com

MALIGNANCY

Malignancy

u  Vaginal

u  Cervical

u  Uterine

u  Fallopian tube

u  Ovarian

gynecendoscopy.org

COAGULOPATHY

Coagulopathy

u  Up to 20% of adolescent females who require hospitalization for heavy bleeding will have a coagulopathy

u  Von Willebrand’s disease

u  Platelet deficiency

u  Leukemia

u  Liver disease

OVULATORY DYSFUNCTION

Ovulatory Dysfunction

u  Anovulation

u  Continuous estradiol production without corpus luteum formation and progesterone production

u  Proliferative endometrium, may outgrow blood supply with variable necrosis

u  No uniform slough of basilis layer

u  Excessive bleeding

u  Postmenarchal / premenopausal

u  PCOS

u  Endocrinopathies

u  Thyroid disorders

u  Hyperprolactinemia

Ovulatory Dysfunction - Amenorrhea

u  Pregnancy

u  Obesity

u  Anorexia, mental stress

ENDOMETRIAL SOURCE

Endometrial

u  Endometritis – Infection / inflammation of the lining of the uterus

u  Prolonged menses or intermenstrual spotting

u  Chlamydia trachomatis

IATROGENIC

Iatrogenic

u  Medication related (Breakthrough Bleeding)

u  IUD

u  Oral/ Injectable Hormones

u  Psychotropics (eg TCAs)

u  Impact dopamine metabolism by reducing serotonin uptake

u  Reduced inhibition of prolactin disrupts H-P-O axis leading to anovulation

u  Anticonvulsants

u  Antibiotics

u  Procedure induced

WORK UP – PATIENT HISTORY

Medical History

u  Menstrual bleeding patterns

u  Frequency

u  Duration

u  Flow

u  Pain

u  Other issues with bleeding…

u  Postpartum hemorrhage

u  Surgical hemorrhage

u  Epistaxis (bloody nose)

u  Family history of bleeding disorders, cancer

Medical History

u  Meds

u  Coumadin

u  Lovenox

u  NSAIDs

u  Hormones

u  Psychotropics

u  Ginkgo, Ginseng, Motherwort

PHYSICAL EXAM

Physical Exam

u  Evidence of PCOS

u  Obesity, hirsutism

u  Evidence of Unopposed Estrogen

u  Obesity

u  Thyroid enlargement

u  Bruising, petechiae

u  Speculum

u  Lacerations, polyps, cervical cancer

u  Bimanual

u  Uterine enlargement, fibroids, ovarian masses

EVALUATION

Labs

u  Pregnancy testing

u  Pap smear

u  Chlamydia testing

u  Endometrial Biopsy

u  CBC, PT/PTT/INR, TSH, Prolactin, Liver Function

u  Testing for von Willebrands Disease

u  Ristocetin cofactor activity, Factor VIII, von Willebrand factor antigen

Imaging

u  Pelvic US

u  Saline infused sonohysterogram

u  MRI?

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Hysteroscopy

u  Further evaluate the cavity

u  Diagnostic and potentially curative when done with a dilation & curettage or polypectomy / myomectomy

u  Not curative for ovulatory dysfunctions

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Age Related Considerations

u  Adolescents

u  Immature Hypothalamic-Pituitary-Ovarian Axis

u  Coagulopathy

u  Hormonal Contraceptives

u  Pregnancy

Age Related Considerations

u  Adulthood

u  Pregnancy

u  Structural lesions

u  Ovulatory dysfunction

u  Hormonal contraceptives

u  Cancer

Age Related Considerations

u  Postmenopausal

u  Atrophy

u  Hyperplasia / Cancer

u  Meds

MANAGEMENT

Management

u  Weight loss

u  Birth Control Pills –continuous use may help

u  IV Estrogen

u  Progestins

u  Provera, Nexplanon, Mirena

u  Lysteda (prevent fibrin degradation)

u  Operative Hysteroscopy

u  Hysterectomy

u  Interventional Radiology – Uterine Artery Embolization, MRI-Guided Focused US Surgery

QUESTIONS?

References

u  De Silva, NK. Abnormal uterine bleeding in adolescents: Evaluation and approach to diagnosis. In: UpToDate, Torchia, MM (Ed), UpToDate, 2016.

u  Diagnosis of Abnormal Uterine Bleeding In Reproductive-Aged Women, ACOG Practice Bulletin #128, July 2012.

u  Kaunitz, AM. Approach to abnormal uterine bleeding in nonpregnant reproductive-age women. In: UpToDate, Falk, SJ (Ed), UpToDate, 2016.

u  Management of Abnormal Uterine Bleeding Associated With Ovulatory Dysfunction, ACOG Practice Bulletin #136, July 2013

u  Management of Acute Abnormal Uterine Bleeding In Nonpregnant Reproductive-Aged Women, ACOG Committee Opinion, #557, April 2013

u  FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. International Journal of Gynecology and Obstetrics 113, 2011, 3-13.