Download Abnormal Uterine Bleeding

Sonnie Kim-Ashchi, MD. FACOG
Patient No 1
Emily is 14 years old,
started her first menses
last year, irregular at the
beginning , now regular
monthly. But she reports
heavy bleeding that
soaks through her
uniform. And very “
inconvenient” to have
heavy bleeding during
her soccer/
lacrosse/crew practices.
Patient No2.
Laura is 26 years old
trying to get pregnant
for last 2 years. She has 4
to 5 periods a year. She is
getting more hair in her
face and darker in back
of her neck.
She is getting nervous
about her future fertility.
Patient No. 3
Mrs. Robinson is 50
years old. Her last
period was 6 months
ago. Now bleeding
heavily for 10 days
passing clots.
Patient No. 4
 Mrs. Hopkins is 70 years
old. She has been
postmenopausal since her
early 50’s. She noticed pink
spotting about three
months ago. At that time,
she was too embarrassed to
her PCP during her routine
checkup. But now,
spotting changed to heavy
bright red bleeding.
Abnormal Uterine Bleeding Associated with
Ovulatory Dysfunction ( AUB-O)
 The most common cause for gyn visits and referrals.
 Ovulatory dysfunction presents with heavy irregular
uterine bleeding due to the effects of chronic
unopposed estrogen on the endometrium.
 Acute AUB
 Chronic AUB- topic today
Causes of Anovulation
Physiologic
Pathologic
 Adolescence
 Hypothalamic dysfunction
 Pregnancy
 Lactation
 Perimenopause
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(secondary to anorexia nervosa)
Hyperprolactinemia
Primary pituitary disease
Premature ovarian failure
Thyroid disease
Hyper androgenic
anovulation(PCOS, CAH, or
Androgen-producing tumor)
Iatrogenic(secondary to
radiation or chemotherapy)
Medication
Causes of AUB by FIGO and ACOG
PALM-Structural Causes
COEIN-Nonstructural causes
 Polyp and Pregnancy
 Coagulopathy
 Adenomyosis
 Ovulatory dysfunction
 Leiomyoma
 Endometrial
 Malignancy and hyperplasia
 Iatrogenic
 Not yet classified
International Federation of Gynecology and Obstetrics ( FIGO)
American College of Ob/Gyn ( ACOG)
Age-Based Consideration in
Differential Diagnosis 13-18 Years
 Differential diagnosis is similar to other age groups
except endometrial hyperplasia and malignancy.
 1. Anovulation; Hypothalamic immaturity ( 90%)
 2.Stree-exercise-induced
 3. Obesity
 4. Coagulation disorder like Von Willebrand disease
5. Pregnancy, sexual trauma, STD regardless of her
“reported “ sexual history
6. Look for PCOS such as acne, hirsutism,
Age-Based Consideration in
Differential Diagnosis; 19-39 Years
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PCOS is one of the most common causes in this group.
Anovulation
Obesity is comorbid condition.
Endocrine disorder eg. hypothyroidism
Pregnancy
Polyp, fibroids, adenomyosis
Medication related esp. OCP
Infection
Premalignant or malignant endometrial pathology must be
considered for high risk patients especially medical
management is not successful.
Age-Based Considerations in differential diagnosis
;40 Years to Menopause
 Most likely normal perimenopausal changes with irregular
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sometimes heavy menses
Anovulation-unppopsed estrogen and hyperplasia
Mean age of menopause is 52 years.
The average duration of the menopausal transition is 4
years.
Polyp, fibroid, adenomyosis
Hyperplasia or cancer
Pregnancy must be excluded.
Definition of Menopause-cessation of menses for 12
consecutive months, NOT blood hormone tests
Age-Based Considerations in differential
diagnosis; Menopause and on
1.Vaginal atrophy
2.Cancer/polyp
3. Estrogen therapy
Basic information about your
patients via,,,,
History
Physical Exam
 Pertinent medical and surgical
 General—signs of systemic
history-- Surgery-related
bleeding? Bleeding after dental
work? Bruising easily? Frequent
nose bleeding or gum
bleeding? Family history of
bleeding?
 Medication– anticoagulant?
Chemo agents?
 Detailed gyn history-menarche?
Current bleeding frequency,
interval, duration, related
symptoms such as vaginal
discharge, pain, LMP
illness, ecchymosis,
thyromegaly, signs of
hyperandrogenism such as
hirsutism, acne, male pattern
balding. Acanthosis nigricans
 Pelvic exam including
speculum exam and
bimanual exam to look for
genital trauma, cervical
tumor, uterine enlargement.
Based on patient’s history and
physical examination,,,,
Laboratory Testing
Imaging
 Urine pregnancy test
 Complete Blood Counts and
 Transvaginal or
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platelets
TSH
If indicated, von Willebrandristocetin cofactor activity, vW
factor antigen and Factor VIII,
Liver Function Test.
Pap smear
Endometrial biopsy if older
than 45 years or “ high risk”
patients
transabdominal ultrasound
 Sonohysterogram
 Hysteroscopy
Treatment approach to guide
therapy for AUB-O
 The choice of treatment is according to the goals of
therapy
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√ Age group, 13 ? 25? 50? 75?
√ To stop acute bleeding?
√ To avoid future irregular heavy bleeding?
√ Need for contraception?
√ Need for comorbidity such as anemia
√ Need for surgical treatment? Only when medical
therapy fails, is contraindicated, is not tolerated by the
patient, or the patient has intracavitary lesions.
FIGO and ACOG recommends
 Abnormal Uterine Bleeding, NOT Dysfunctional
Uterine bleeding, DUB which was used in the past for
the bleeding with no systemic or structural cause.
DUB
Treatment for AUB-O
Progestin Therapy
 Medroxyprogesterone
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acetate( Provera)
Megestrol acetate (Megace)
Norethindrone
acetate(Aygestin)
Depo Medroxyprogesterone
acetate (Depo Provera)
Implanon/Nexaplanon
Levonorgestrel-releasing
intrauterine device ( Mirena
or Skyla or Liletta)
Treatment for AUB-O
Progesterone and Estrogen combination therapy
 Oral contraceptives (Monophasic vs. Triphasic vs.
combination extended cycle)
 Transdermal patches
 Vaginal rings
Surgical Management of AUB-O,
ONLY IF medical managements fail
 Hysteroscopy
 Dilatation and Curettage
 Endometrial ablation
 Hysterectomy
Patient No 1
Emily is 14 years old,
started her first menses
last year, irregular at the
beginning , now regular
monthly. But she reports
heavy bleeding that soaks
through her uniform. And
very “ inconvenient” to
have heavy bleeding during
her soccer/
lacrosse/swimming
practices.
 Lab tests- urine hCG, CBC,
TSH, vWd factor
 Treatment – Iron supplements
and/or Low dose OCP or
Progesterone IUD ( Skyla)
 Consider CONTINOUS
combined hormonal
contraceptives e.g., Seasonale,
Seasonique.
 4 periods a year
Patient No2.
Laura is 34 years old
Gravida 0, having
noncyclic menses, 4
to 5 periods a year.
She is not sure
about her fertility.
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Any hyper androgenic signs?
Obesity?
Labs-CBC, TSH, Fasting Prolactin
Pelvic ultrasound
Endometrial biopsy for high risk
patients for hyperplasia or even cancer
 Fertility desired? If yes, induce
ovulation. If not, OCP or
Levonorgestrel IUD (Mirena or Liletta)
whose benefit includes reduction of
endometrial cancer.
 Weight Loss and Exercise
Patient No. 3
Mrs. Robinson is 50 years
old, last period was 6
months ago. Now bleeding
heavily for 10 days passing
clots. Very frustrated.
 Need to rule out endometrial
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hyperplasia and cancer with
EMB!
Labs- B HCG, CBC, TSH,
Prolactin
Pelvic ultrasound
Treatment- low dose OCP, cyclic
progestin therapy, Mirena IUD
or endometrial ablation.
Remember perimenopausal
women can get pregnant!!
Patient No. 4
 Mrs. Hopkins is 70 years
old. She has been
postmenopausal since
her early 50’s. She
noticed pink spotting
about three months ago.
At that time, she was
embarrassed to see her
gynecologist. But now
spotting changed to
heavy bright red
bleeding.
 EMDOMETRIAL
BIOPSY!!
 Transvaginal ultrasound
especially endometrial
stripe
When is EMB indicated?
§ Purpose of EMB is to rule out hyperplasia and cancer.
§ Incidences of endometrial cancer in different age groups
Younger than 20; 0.2 in 100, 000
Age 20-34; 1.6%
Age 35-44; 6.2%, the incidence increases with aging,
Age 70-74; 88 cases per 100,ooo
§ EMB is indicated for patients older than 45 years with AUB-O
§ Also indicated younger than 45,
1.if medical management failed and systemic diseases such as
leukemia or liver disease were ruled out in young patients.
2.patients with h/o unopposed estrogen exposure such as obesity
(BMI greater than 30) and PCOS, chronic anovulation, h/o breast
cancer, Tamoxifen use, family h/o endometrial cancer.
Surgical management for AUB-O
ONLY IF medical managements fail
 Saline infused sonohysterogram
 Hysteroscopy
 Dilation and Curettage
 Endometrial ablation
 Hysterectomy
Surgical management for AUB-O
Hysteroscopy and Dilation and Curettage
 Saline infusion sonohysteroscopy
Surgical management for AUB
Endometrial ablation
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“ Hysterectomy Alternative”
Can be done in the office,= Just copay for the office visit
Resectoscopic endometrial ablation since 1937
Global nonresectoscopic ablation
Freeze-Cryotherapy
Radiofrequency electricity-Novasure
Heated fluid- Thermachoice, HydroThermAblator
Microwave-Microsulis
Treatment Goal is to “ normalize “ menses ( 70 to 90 % patient satisfaction
rate) , NOT amenorrhea.
Prerequisites -uterus less than 10 cm, no cavitary lesion, adequate
contraception after the procedure
 Patient must be counseled about the risks of masking endometrial cancer in
the future.
 Post ablation Asherman syndrome, synechiae, endometrial distortion/stricture
Surgical management for AUB
Endometrial Ablation
Resectoscopic ablation
Therma Choice
Hydro ThermAblator)
Novasure
MicroSulis
Surgical management for AUB;
Hysterectomy
ONLY indicated for medical management failure or
patient’s desire for definitive treatment.
daVinci robot assisted total
hysterectomy
Advantages for the patients
*Minimally invasive.
*Less painful.
*less blood loss, about 50 cc.
*Less infection.
*Less hospitalization days.
*More cosmetically appealing.
*Quicker recovery.
*Faster return to normal life/work.
Advantages for the surgeons
*Much improved 3 D visualization
*Less complication
*Less ergonomically challenging,, Less tiring
Single Site Entry
Last Note,,Health apps for Patients
Objective data collection instead of “ I bleed a lot”
Thank you
Questions about Abnormal
Uterine Bleeding?