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Normal & Abnormal Uterine Bleeding Suzanne Bush, MD, FACOG Clinical Associate Professor FSU College of Medicine Objectives Recognize the characteristics of Normal Menstrual Bleeding (The LMP as the fourth vital sign!) Describe the etiologies of Abnormal Uterine Bleeding (AUB.) Understand etiologies of AUB with respect to the life stages of women. Understand the diagnostic tools to identify the etiology of the AUB. State the medical & surgical options available in primary care and gynecology settings. Case One 22 year old G0P0 presents for well woman care. She is concerned about her periods being irregular. She describes her cycles as coming the 18th of one month & the 16th the next month. She never knows when it is coming. How would you counsel this patient? Normal Menstruation The Menstrual Cycle In the normal menstrual cycle, orderly cyclic hormone production and parallel proliferation of the uterine lining prepare for implantation of the embryo. Berek & Novak’s Gynecology, 2012, p.145 Normal Menstruation “The menstrual cycle starts with the first day of bleeding of one period and ends with the first day of the next. In most women, the cycle last about 28 days. Cycles that are shorter or longer by 7 days are normal.” ACOG Website: FAQ095 The Normal Menstrual Period Blood loss < 80 ml (average 30-35 ml) Duration of flow 2-7 days (average 4 days) Cycle length 21 - 35 days (average 29 days) (28 days +/- 7 days} Phases of the Menstrual Cycle Reproductive Cycle Follicular Begins with Menses ends with luteinizing (LH) hormone surge Ovulation Begins with LH surge and ends with ovulation Luteal (30-36 hours) (14 days) Begins with the end of the LH surge and ends with onset of menses The Normal Menstrual Cycle Another Way of looking at it M. Manting; DUB LECTURE 2008 Phases of the Menstrual Cycle Endometrium Proliferative Begins with menses and ends at ovulation Secretory Begins at ovulation and ends with menses The Normal Menstrual Cycle Another Way of looking at it M. Manting; DUB LECTURE 2008 Regulation: Hypothalamic Pituitary Axis Hypothalamus is the pulse generator mediated through GnRH GnRH cannot be directly measured Negative Feedback Regulation of The Ovary 2 Cell Theory Theca Cell Granulosa Cell Case One 22 year old G0P0 presents for well woman care. She is concerned about her periods being irregular. She describes her cycles as coming the 18th of one month & the 16th the next month. She never knows when it is coming. How would you counsel this patient? How would you counsel this patient? Abnormal Uterine Bleeding (AUB) Definition: Any change in menstrual period Flow Duration Frequency Bleeding between cycles Prevalence: 20 million office visits/year 25% of visits to gynecologists Old Terminology Menorrhagia Dysmenorrhea Metrorrhagia Amenorrhea Menometrorrhagia Oligomenorrhea Polymenorrhea Hypomenorrhea New Terminology Heavy Menstrual Bleeding Acute Chronic Intermenstrual Bleeding History for AUB HPI Onset Quantity : Spotting or heavy daily or intermittent Duration History for AUB Associated Symptoms Pain Dysmenorrhea Menstrual Changes Timing Flow (clots) Frequency Fever/chills Changes in hair/ body Bruising/bleeding Rectal/urethral bleeding Nausea/vomiting Gender Specific History Menstrual Contraception Gynecologic Obstetric Sexual Genital Infections Other Important Details Family History Anyone else? Von Willebrand's PCOS PMH Chronic conditions PSH Nutrition and exercise Weight changes Exercise habits diet Liver disease Kidney disease Anemia Drugs /medications Psychiatric medications Thyroid Disorders Blood thinners Case Two 48 year old G2P2, S/P Bilateral Tubal Ligation 14 years ago, presents to your office with RLQ pain of 3 months duration. LMP 5 weeks ago has had many years of irregular menses thought to be PCOS. Ultrasound shows an 8 cm adnexal cyst with CA 125 normal. Differential Diagnosis Of AUB Structural: PALM-COEIN (Non Gravid Women) Life Pre-menarche Menarche Reproductive Post-Menopause Cycles: Anatomic: “Bottoms Up” Pregnancy Age is Not An Issue! Never Forget Pregnancy PROVE IT! Assumptions can lead to death PALM-COEIN FIGO Classification System (PALM-COEIN) for causes of AUB in non gravid women of reproductive age Structural vs. Non-Structural Developed to create a universally accepted nomenclature PALM Structural Causes P- Polyp (AUB-P) A- Adenomyosis (AUB-A) L- Leiomyoma (AUB-L) Submucosal myoma (AUB-LSM) Other myoma (AUB-LO) M- Malignancy & hyperplasia (AUB-M) COEIN Non-Structural Causes C- Coagulopathy (AUB-C) O-Ovulatory dysfunction (AUB-O) E- Endometrial (AUB-E) I- Iatrogenic (AUB-I) N- Not yet classified (AUB-N AUB-O Abnormal Uterine Bleeding with ovulatory dysfunction Heavy, irregular bleeding Causes of Anovulation: Physiologic Adolescence Menopause Lactation Pregnancy Transition Causes of Anovulation Pathologic Hyperandrogenic anovulation (e.g., PCOS, CAH, or androgenproducing tumors) Hypothalamic dysfunction Hyperprolactinemi a Thyroid disease Pituitary disease Premature ovarian failure Iatrogenic (Chemo) Medications Case #2 28 yo nulliparous female presents with history of heavy menstrual bleeding. On further questioning she states that she has always bled heavy and irregularly since menarche @ age 12. She is always anemic & tired. Her physical exam is noted for a BMI of 47. There is no hirsutism, acne or skin changes. Case # 3 42 year old G3P3 who goes is in your civic group presents with heavy, cyclic uterine bleeding. You note spider angioma across her chest & down her arms. She has a slightly protuberant abdomen. Her husband had a vasectomy 7 years ago. The next step in evaluating her heavy uterine bleeding: Liver Disease Patients known to have liver disease manifest additional symptomatology because of abnormal hepatic function. Evaluate patients for spider angioma, palmar erythema, splenomegaly, ascites, jaundice, and asterixis. Coagulation Disorders Coagulation Disorders Inherited von Willibrand's hemophilia Acquired ITP leukemia Rule out von Willebrand's in any girl who requires transfusion for excessive bleeding when first starting periods Drug Induced coumadin/heparin aspirin Bleeding from ther Sites GI Neoplasia or hemorrhoids GU Urethral caruncle or diverticulum Renal lithiasis or hemorrhagic cystitis GYN Labia, cervix, or vagina Trauma, infection, or neoplasia Remember Hemoccult & Urinalysis Differential Diagnosis of AUB: Life Cycles Pre-Menarche Menarche Reproductive Postmenopausal Etiology of AUB Life Cycles Approach Premenarchal •E2 withdrawal @birth •Foreign Body •Sarcoma •Ovarian Tumor •Trauma Menarche •Coagulation Defects •Hypothalamic Immaturity •Psychogenic Reproductive •Pregnancy •Anovulation •Endogenous •Exogenous •Anatomic PostMenopausal •Carcinoma •Vaginal Atrophy •E2 Replacement •Anatomic Differential Diagnosis of AUB: Structural “Bottoms Vulva Vagina Cervix Ovary Brain Up” Contiguous Anatomy GU GI Non-Pelvic Etiology Endogenous Iatrogenic Vulvar Infections HPV Atrophy Benign Lesions Cancerous lesions Dermatologic Causes PHYSICAL EXAM: INSPECTION IS IMPORTANT Vagina Malignancy Carcinoma Sarcoma : Laceration/trauma Infections Atrophic Foreign Granulomatous bodies Diaphragm, Pessary Tampon other changes tissue formed after surgery post hysterectomy Physical Exam: Inspection is important Cervix Neoplasia Cancer Polyps Myomas Cervical Eversion (Ectropion) Infection Cervicitis Condyloma Acuminata IMPORTANT: Visualize the Cervix! Uterus Myomas Postmenopausal Bleeding is considered endometrial cancer until proven otherwise Polyps Endometrial Hyperplasia Endometrial Carcinoma Atrophy PHYSICAL EXAM: Bimanual Exam checks enlargement Postmenopausal bleeding is evaluated by an Endometrial biopsy Most PMB Is due to Atrophy Ovary Anovulation PCOS Menopause Transition Pathophysiology Etiologies Of AUB Estrogen Withdrawal Estrogen Breakthrough Progesterone Withdrawal Clinical Management of Abnormal Uterine Bleeding: APGO Educational Series, May 2002, p. 8. Initial Assessment of AUB Acute Sub-Acute Chronic Initial Assessment of AUB History & Physical Vital Signs Shock Signs Laboratory Pregnancy Test Complete Blood Count EVALUATION OF AUB Pregnant? YES NO Evaluate for complications Structural (PALM) IUP, SAB, Ectopic Non-Structural (COEIN) VS. Evaluation of AUB Evaluation of the Endometrium Endometrial Biopsy Transvaginal &/or abdominal Ultrasound (TVS/AUS) Saline Sono-hysterocopy (SIS) Hysteroscopy Evaluation of the Uterus TVS SIS Hysteroscopy Pregnancy test Endometrial Biopsy (EMB) Evaluation of the Endometrium Pipelle Transvaginal Ultrasound To assess for thickened endometrium In 92% of abnormal endometrial biopsies, ultrasound showed >5mm endometrium In 96% of endometrial cancer by biopsy result, ultrasound showed >5mm endometrium Therefore, ultrasound measured endometrium <5mm is likely benign uterine condition TVS & SIS TVS SIS Hysteroscopy MRI Precisely localizes sub-mucosal fibroids MRI is not superior to TVS & SIS in overall diagnostic potential Dueholm M, et al. Fertil Steril. 2001;76(2):350357 Treatment of AUB Observation Medical Minimally invasive surgery Major surgery Medical Management Iron Anti-fibrinolytics Progestins Estrogen (OCP) + progestins Parenteral estrogens Androgens GnRH agonists Anti-progestational agents Minimally Invasive Surgery Intrauterine Dilation Device (IUD) with progesterone & Curettage Endometrial Ablation Major Surgery Myomectomy Total Abdominal Hysterectomy (TAH) Total Vaginal Hysterectomy (TVH) Laparoscopic Hysterectomy LSH (laparoscopic supra-cervical) TLH (total laparoscopic) LAVH (laparoscopically assisted vaginal hysterectomy) Robotic (TLH or LSH) Final Case 32 year old G2P2002 presents to the ER with 10 day history of heavy uterine bleeding. She is pale and appears frightened. Pulse is 120, BP is 90/60. Hemoglobin is 6, Hematocrit is 18. Pregnancy test is negative. How do you manage this patient? How would you manage this patient? Management of Acute AUB Can IV be a life-threatening emergency Monitor Vital signs, Start oxygen IV fluids (wide bore IV catheter) Type and Cross 2-4 units of blood Estrogen IM Progesterone NSAIDS (Anti-prostaglandins vs. Antifibrinolytics) Emergency Dilatation and Curettage (D&C) Treatment in Chronic, Stable AUB High dose OCP’s to slow the bleeding Anovulatory Bleeding can be treated with progesterone alone Endometrial sampling is indicated prior to starting hormones in older women Clinical Pearls Never Forget Pregnancy! Age is Not an Issue! Assumptions Can Lead to Death! PROVE IT! References ACOG Practice Bulletin No. 136, July 2013 Beckmann, et al., Obstetrics & Gynecology, 7th ed., Chapters 37, 39 Clinical Management of Abnormal Uterine Bleeding: APGO Educational Series, May 2002 Dueholm M, et al. Fertil Steril. 2001;76(2):350357 Fritz, MA, Speroff et al, Clinical and Gynecologic Endocrinology and Infertility, 8th ed. 2011. Manting M., AUB Lecture 2008 Munro, MG, et al, FIGO Classification System (PALM-COEIN) for causes of AUB in non gravid women of reproductive age. Int J Gynaecol Obstet 2011; 113:3-13