Management of Abnormal Uterine Bleedingin Perimenopausal Women

Dr.Fariha FarooqAssoc.Prof.Obs & Gynae

Akhtar Saeed Medical & Dental College

Perimenopause

• Perimenopause (around menopause) is a transition phase, begins several years before menopause.

• Estrogen levels gradually decline.

• Irregular menstrual periods, hot flashes, vaginal dryness, sleep disturbances, and mood swings are common, normal signs of perimenopause.

Perimenopause

Menstrual Cycle

Anovulatory Bleeding

• Corpus luteum is not produced– Ovary fails to secrete progesterone– Continuous, unopposed E stimulation of

endometrium:• Endometrial proliferation without P-induced

differentiation / stabilization– Endometrium becomes excessively

vascular without stromal support fragility and irregular endometrial bleeding

New FIGO Nomenclature & classification of AUB

Suggested “normal limits” for uterine bleeding in the mid-reproductive years

Abnormal Uterine Bleeding New Terminology by FIGO

Term HMB (Heavy mentrual bleeding) has replaced the term Menorrhagia:

Bleeding that occurs at regular intervals, loss of ≥ 80 mL blood per

DUB has been replaced by BEO(Bleeding of Endometrial origin)

Terminology abandoned by FIGO Munro et al. Int J Gynecol Obstet 2011; 113: 3-13

FIGO 2015

FIGO- PALM-COEIN classification

Causes of heavy menstrual bleeding

‘PALM’(structural abnormalities)-Polyp–Adenomyosis

–Leiomyoma

–Malignancy and hyperplasia

‘COEIN’(non-structural abnormalities)–Coagulopathy

–Ovulatory dysfunction

–Endometrial

–Iatrogenic

–Not yet classified

ENDOMETRIAL POLYP

AdenomyosisTVS

Adenomyosis

Fibroid Uterus

Submucous Fibroid

Invasive cervical cancer

Carcinoma endometrium

PCOS

Anovulatory Bleeding:Later Reproductive Age (40-Menopause)

• Incidence of anovulatory bleeding increases due to declining ovarian function.

• Incidence of endometrial CA in women 40-49 years: 36.2/100,000

• All women >40 yrs who present with suspected anovulatory bleeding merit endometrial bipsy.

Each case has 1 identified abnormality

>1 positive category

Diagnosis of Abnormal uterine bleeding

• Medical history• Physical examination• Laboratory tests• Imaging tests

• Age of onset of menses• Frequency/duration of menses• Quantity of flow,number of pads,passage of

clots and flooding• Intermenstrual bleeding• Postcoital bleeding• Dyspyerunia• Use of contraceptives/medication• Family history of menarche,

menopause,malignancy

AUB-History

AUB-History

• Pelvic Pain• Postcoital pain• Vaginal Discharge• Excessive bruising/bleeding from other

sites• History of post partum haemorrhage• Family history of bleeding problems• Urinary symptoms• Weight change ,heat or cold intolerance • Stress

Physical examination

• General examination• Abdominal examination• Vaginal / per speculum and pelvic B/M

examinations

Examination

• GPE Assess for obesity, hirsutism, stigmata of

thyroid disease (hypothyroidism associated with anovulation), signs of hyperprolactinemia (visual field testing, galactorrhea)

• ABDOMINAL EXAMINATION Abdominal masses

• CBC,Coagulation screen– Assays for thyroid hormone

• HVS,endocervical swab,Pap smear• Pelvic ultrasound

– Abdominal/Transvaginal Ultrasonography (TVS)– Sonohysterography,saline infusion

• Endometrial biopsy– Endometrial sampling by Pipelle– Hysteroscopy– Dilation and Curettage (D&C)

Biopsy should be performed as first line test(ACOG)• Aged >45 years • Irregular or intermenstrual bleeding

CT scan and MRI(special circumstances))

Laboratory and Imaging Tests

Transvaginal ultrasound

Saline infused sonohysterography

Sonohysterogram

Hysteroscopy

Evaluating endometrial cavity

Hysteroscopy “Gold standard” for endometrial assessment• Office procedure• Thorough, direct inspection of endometrial cavity• Directed biopsy or treatment possible (e.g., polyp

excision)

Drugs for HMB• NSAID’s• Tranexamic acid• COCP’s

– YAZ– Diane-35– Meliane

• Progyluton/Climen• Oral Progestogens• Mirena• Danazol/GNRH analoges

Progyluton

Composition

•Composed of estradiol-17 valerate and cyproterone acetate

* Presented in calendar packs of 21 tablets each

* First 11 tablets contain estrogen only; the other 10 contain both hormones

Climen

Contraindications of HRT

• PREVIOUS THROMBOEMBOLIC DISEASE• IMPAIRED LFT/ LIVER DISEASE• CARCINOMA BREAST• CARCINOMA ENDOMETRIUM• FIBROIDS &ENDOMETRIOSIS(relative)

HYPERTENTION,DIABETES,CARDIO-VASCULAR DISEASE ARE NOT C/I

Oral Progestogens

• Norethisterone acetate(Primolute N)

• Dose is 5-10mg three times a day from day 6 to 26 of the cycle

The levonogestrel intrauterine system (LNG-IUS),

Mirena

What is Mirena® used for?Indications:

–Contraception

–Treatment of heavy menstrual bleeding (idiopathic menorrhagia)

–Protection from endometrial hyperplasia during oestrogen replacement therapy

Endometrial effects with Mirena®

Before Mirena®

Endometrial changes

OvulationMenstruation

Reducedmenstruation

After Mirena®

Ovulation

Surgical treatment

Endometrial ablation•First-generation:

– Rollerball– Transcervical resection of the endometrium

•Second-generation:– Impedance-controlled bipolar radiofrequency– Balloon thermal– Microwave– Free-fluid thermal

Surgical treatment

• Uterine artery embolization(UAE)• Hysteroscopic myomectomy• Myomectomy• Hysterectomy

– Abdominal– Vaginal– Laparoscopic

Uterine artery embolization for Fibroids

• Defintion:Post menopausual bleeding is defined as: vaginal bleeding after the menopause in women who are not taking HRT.

• Aetiology:• Atrophic vaginitis • Endometerial polyp• Endometerial hyperplasia • Endometerial carcinoma• Cervical carcinoma

Post menopausal bleeding

MANAGEMENT OF PMBDiagnosis Management Atrophic vaginitis Topical oestrogen cream, oestrogen pessaries or

estringTM oestrogen ring pessary.

Cervical polyp Remove via speculum examination using polyp forceps

Endometrial polyp Remove under direct visualization at hysteroscopy

Simple hyperplasia

Progestogens: oral preparation or LNG-IUS (Mirena)

Complex hyperplasia

Progestogens: oral preparation or LNG-IUS (Mirena)

Atypical hyperplasia

Total abdominal hysterectomy as significant risk of progression to malignancy.

Endometrial cancer

Total abdominal hysterectomy + BSO + Washings ± adjuvant therapy.

QUESTIONS?