Download Abnormal Uterine Bleeding

Abnormal Uterine Bleeding
Benjie B. Mills, MD
Division Director, Pediatric & Adolescent Gynecology
Medical Director of Gynecology, GHS OB/GYN Center
Associate Professor of Clinical Obstetrics & Gynecology
University of South Carolina School of Medicine Greenville
Disclosures
• I have nothing to disclose
• This presentation will discuss off-label use of
medications
Objectives
• Describe etiologies, work up, and clinical course of
abnormal uterine bleeding
• Formulate a patient-centered and evidence-based
treatment plan
• Focus on issues of particular importance to the
PCP such as prevention, therapeutic lifestyle
changes, health maintenance, and when to refer
to a specialist
Etiologies
Abnormal Uterine Bleeding
Heavy Menstrual Bleeding (AUB-HMB)
Intermenstrual Menstrual Bleeding (AUB-IMB)
PALM: Structural
COEIN: Non-Structural
Polyp (AUB-P)
Coagulopathy (AUB-C)
Adenomyosis (AUB-A)
Ovulatory Dysfunction (AUB-O)
Leiomyoma (AUB-L)
Endometrial (AUB-E)
Malignancy & Hyperplasia (AUB-M)
Iatrogenic (AUB-I)
Not Yet Classified (AUB-N)
Structural
• Polyps
Structural
• Adenomyosis
Structural
• Leiomyomata
Structural
• Malignancy and Hyperplasia
Coagulopathy
• Inherited and acquired
• Occurs in up to 20% of patients with HMB
• Indications for evaluation
– Heavy menstrual bleeding since menarche, or
– Postpartum hemorrhage, excessive surgical bleeding
or bleeding with dental work, or
– Any two of the following
•
•
•
•
Bruising 1-2 times per month
Epistaxis 1-2 times per month
Frequent gum bleeding
Family history of bleeding symptoms
Ovulatory Dysfunction
• Encompasses amenorrhea to frequent
irregular menses and in between
– Hypothalamic hypogonadotropic hypogonadism
– Thyroid dysfunction
– Hyperprolactinemia
– Hyperandrogenemia/PCOS
– Premature ovarian insufficiency
– Idiopathic anovulation
– Chronic illness
Endometrial Abnormalities
•
•
•
•
Abnormal endometrial angiogenesis
Prostaglandin production
Vasoconstriction
Increased fibrinolysis
Iatrogenic
• Contraceptives
–
–
–
–
OCPs, contraceptive patch or ring
DepoProvera (DMPA)
Contraceptive implant (Nexplanon)
Intrauterine device
• Hormonal (levonorgestrel IUD, Mirena, Skyla)
• Non-hormonal (Paragard, copper T)
• Other medications
– Antipsychotics
– Anticoagulants
– Other
Evaluation
Evaluation: History
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•
•
•
•
•
•
Age of menarche
Menstrual bleeding pattern
Severity of bleeding (clots or flooding)
Pain
Medical history
Surgical history
Family history of bleeding disorders, PCOS,
diabetes …
Medications
•
•
•
•
•
•
•
Anticoagulants
Hormonal medications
NSAIDs
Antipsychotics
Ginkgo
Ginseng
Motherwort
Physical Exam
• Abnormalities of weight
• Skin
–
–
–
–
Acanthosis nigricans
Hirsutism
Pallor
Petechiae or ecchymoses
• Thyroid
• Abdomen
• Pelvic
Laboratory Testing
•
•
•
•
Pregnancy test
STD testing if indicated
CBC with diff
TSH
Laboratory Testing
• Bleeding disorder
– PT/PTT/INR
– Platelet function screen
– Fibrinogen
• Hyperandrogenism/PCOS
– Testosterone, free and total
– DHEAS
– 17 hydroxyprogesterone
– HgbA1C, lipids, CMP
Laboratory Testing
• Amenorrhea/Oligomenorrhea
– Prolactin
– FSH/LH
– Estradiol
Imaging and Tissue Sampling
• Ultrasound
– Transvaginal
– Transabdominal
• MRI
– Müllerian
anomalies
– Fibroid mapping
– Adenomyosis
• Saline infusion
sonogram
– Cavity assessment
– Endometrial biopsy
• Hysteroscopy
• Endometrial biopsy
Differential Diagnosis by Age
Category
Ages 13-18 Years
• Pregnancy – UCG
– TV Ultrasound for positive UCG and bleeding
and/or pain
• Pelvic infection
– GC and chlamydia NAATs
– Trichomonas or cervicitis
– PID
Ages 13-18 Years
• Anovulation – immaturity or dysregulation of the
hypothalamic-pituitary-ovarian axis
– Irregular cycle length
– Within 3 years of menarche (80% in a regular pattern)
– Plan:
• R/O pregnancy
• Cyclic medroxyprogesterone acetate 10 mg x 10 days per
month or OCPs if desires treatment
• TSH in patients with other symptoms of thyroid dysfunction
• Coagulopathy workup if heavy since menarche
• Assess for anemia if heavy or prolonged bleeding
Ages 13-18 Years
• Coagulopathies
– Prolonged, heavy menses
– May be irregular due to immature HPO axis
– Plan:
•
•
•
•
TSH
Bleeding disorder labs
Treat underlying condition
Treatment choices
– OCPs (increases factor secretion)
– Anti-fibrinolytics
– Menstrual suppression
Ages 13-18 Years
• Hormonal contraceptive use
– OCPs
Cycle 1
Extended
Cycle OCP
> 7 days
65%
42%
> 20 days
35%
15%
Cycles 1-4
28d Cyclic
OCP
Cycle 4
Cycles 10-13
> 7 days
38%
39%
> 20 days
6%
4%
Ages 13-18 Years
• Hormonal contraceptive use
– Etonogestrel implant
Bleeding Patterns
Definitions
%*
Infrequent
Less than three bleeding
and/or spotting episodes in 90
days (excluding amenorrhea)
33.6
Amenorrhea
No bleeding and/or spotting in
90 days
22.2
Prolonged
Any bleeding and/or spotting
episode lasting more than 14
days in 90 days
17.7
Frequent
More than 5 bleeding and/or
spotting episodes in 90 days
6.7
Ages 13-18 Years
• Hormonal contraceptive use
– Depo Medroxyprogesterone Acetate (DMPA)
• 54% with AUB at 1 year
• 46% with amenorrhea
• 25% discontinue because of AUB
Ages 19-39 Years
•
•
•
•
Pregnancy
Infection
Hormonal contraception
Structural abnormalities
– Fibroids
– Polyps
– Adenomyosis
Ages 19-39 Years
• Anovulation
– Polycystic ovarian syndrome is the most common
cause
– Chronic disease
– Idiopathic
– Premature ovarian insufficiency
• Endometrial hyperplasia and malignancy
(rare)
– Endometrial sampling in high risk patients
Ages 40 to Menopause
• Pregnancy
• Anovulation
– Physiologic when approaching menopause
– PCOS
• Structural abnormalities
• Endometrial hyperplasia and malignancy
Imaging & Tissue Sampling
Who gets imaging?
• Abnormal pelvic examination
• Unresponsive to initial treatment in a patient
with a normal pelvic exam
• Suspicion for structural abnormality
Which imaging is best?
• Transvaginal ultrasound (2D and 3D)
– Screening test
– Intracavitary pathology
• Sensitivity 56%
• Specificity 73%
– Endometrial thickness is not helpful
• Saline infusion sonography
– Superior at determining intracavitary pathology
– Global changes vs. specific lesions
• MRI is not recommended for evaluation of AUB
Who needs endometrial
sampling?
• Women > age 45 with AUB
• Women < age 45 with AUB and chronic
anovulation (unopposed estrogen)
– Obesity
– PCOS
– Endometrial cancers and hyperplasias can be
diagnosed in young patients at very high risk
Evidence-Based Evaluation
and Treatment Plans
Adolescent with AUB
(IMB or HMB)
History & Physical
Exam
Peripubertal
Anovulatory
Bleeding
Expectant
Management
Bleeding Disorder
Treat with
Cyclic MPA or
OCPs
Labs
Refer to Peds Gyn
Reproductive Age with HMB
History, Physical
Exam & Labs
Abnormal Pelvic
Exam
Ultrasound
Treat Abnormality
Normal Pelvic Exam
Treat:
OCPs
LngIUD
DMPA
Tranexamic acid
Treatment Success
No further workup
Treatment Failure
Ultrasound
Refer to OB/Gyn
Reproductive Age with IMB
History, Physical
Exam, Normal
Pelvic Exam & Labs
Short-term IMB
Long-standing IMB
Expectant
Management or
Treat:
OCPs
Cyclic MPA
EMB and Cavity
Evaluation
Refer to OB/Gyn
Treatment Failure
Needs Cavity Eval
Refer to OB/Gyn
Treatment Success
No further workup
Prevention
Prevention
• Maintain healthy weight
• Evaluate for PCOS if patient is 3 years postmenarche and having IMB
– Prevent hirsutism
– Prevent long-term morbidity of PCOS via education
and health maintenance
– Prevent psychologic sequelae
• Avoid use of DMPA for AUB
• Recognize patients at high-risk for hyperplasia or
malignancy