objectives abnormal uterine bleeding abnormal uterine ... · • discuss the evaluation for aub ......
TRANSCRIPT
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Abnormal Uterine Bleeding
Rachel Maassen MD, MBA Department of ObGyn
University of Iowa Hospitals and Clinics
• Describe the normal menstrual cycle • Describe 2011 shift in terminology for
Abnormal Uterine bleeding • Discuss etiology for Abnormal Uterine
Bleeding • Discuss the evaluation for AUB • Describe therapeutic options for AUB
Objectives
Characteristics of the Normal Menstrual Cycle
Average Range Abnormal
Cycle length 28 d 21-35 d <21 or > 35 d
Duration 4 d 1-8 d > 7 d
Blood loss 35 mL 20-80 mL > 80 mL
The endometrium • Follicular/Proliferative phase(1-13)
– Estrogen stimulates rapid growth, regeneration of glandular stumps
– Maximum thickness at the end of this phase
• Luteal/Secretory phase(14-28) – CL development and progesterone
production – Inhibition of further endometrial
thickening – Microvasculature differentiates (spiral
arterioles)
Menstruation • CL involutes and progesterone falls • Vasoconstriction causes ischemia and
hemorrhage • Release of PGE2 alpha • Hemostasis
– Platelet plugs – Vasoconstriction – Regeneration of the functional layer
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Etiology/Terminology
Evaluation: History
• Gynecologic History – Menstrual history
• Frequency, Volume, Duration
– Sexual history -pregnancy, STD?
– Gyn Surgery – Contraceptives – Risk for endometrial cancer
History • Medical History
– Bleeding disorder • Up to 13% von Willebrand disease • Up to 20% coagulation disorder
– Signs or symptoms of Thyroid disorder
– Systemic Disease – Medications/Herbal remedies
Screen for Bleeding disorder
• HMB since menarche • One of the following:
– Postpartum hemorrhage – Surgery related bleeding – Bleeding with dental work
• Two or more of the following: – Bruising 1-2 times per month – Epistaxis 1-2 times per month – Frequent gum bleeding – Family history of bleeding symptoms
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Evaluation: Physical Exam
• Signs of hyperandrogenism (PCOS)
• Signs of a bleeding disorder • Pelvic
– Is the blood from the uterus? • Lacerations, cervical lesions
– Uterine size – Enlarged ovaries?
Evaluation: Testing
Labs to consider • HCG!!! • CBC (+ iron studies for HMB) • TSH/Prolactin • Cervical cultures • In office endometrial biopsy
• Unopposed estrogen any age • >45 irregular bleeding
• Ultrasound +/- SIS
Ultrasonography with saline infusion
Additional testing: + screen for bleeding disorder
• Coags: PTT, PT, INR, fibrinogen* (w active bleeding)
• Von Willebrand factor antigen • Ristocetin cofactor assay • Factor VIII • LFTs
Treatment depends upon type of AUB
• Structural Causes (PALM) – Polyp/Leiomyoma
• Gynecology referral
– Adenomyosis • Consider Mirena IUD vs hormonal
suppression – Malignancy/Hyperplasia
• Gynecology referral • Progestins
Treatment: Nonstructural causes
• Ovulatory • Coagulopathy AUB-C
• Refer to hematology/gynecology • Endometrial: see AUB-O • Iatrogenic: stop intervention or
tolerate AUB • Ovulatory Dysfunction AUB-O
• Amenorrhea • PCOS
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Ovulatory Dysfunction AUB-O
• Treat medically not surgically – Progestins
• Provera, Norethindrone • Nexplanon • Mirena IUD • Depo provera
– Combined hormonal contraceptive • Pills • Transdermal patch • Ring http://www.cdc.gov/reproductivehealth/unintendedpregnancy/usmec.htm
Age appropriate treatments for AUB-O/E
• 13-18 – low dose ocps(20-35 mcg of ethinyl
estradiol • 19 to 39/40 to menopause
– low dose ocps(20-35 mcg of ethinyl estradiol
– Progestins – Mirena IUD – Surgical Intervention
Surgical Intervention (if all else fails)
• Endometrial ablation – Risk of endometrial cancer
• Not first line for AUB-O – Long-term complications – Continued need for contraception
• Hysterectomy
Case #1
• 45 G2P0 LMP 21 days ago • Regular 28-30d cycles lasting 7-10
d mild cramps • 6 mo ago began 25-32d cycles
severe cramps, heavy flow. • No weight change • Condoms for contraception,
manogamous • No meds, no medical history
Exam
• 130/88, P=100, 150lbs, Ht 5’6
• Appears pale • Normal pelvic
Labs
• Labs: Hbg 9.0, Hct 27%, HCG negative.
• Endometrial biopsy: normal secretory endometrium
• Ultrasound: Heterogeneous endometrium, 1.4cm irregular lining. SIS shows polyp, normal ovaries.
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Diagnosis/Treatment
• AUB-P • Hysteroscopic polypectomy • Iron supplementation • Consider OCPS, vs
Norethindrone, vs Mirena IUD • Ablation candidate if fails
above
Case #2
• 19 G0 with bleeding or spotting almost daily for the past 4 months
• Menarche age 12, irregular for 2 years. Now Q29 days
• 3 lifetime partners, no history of STDs
Exam
• 125/70, P75, BMI 21 • General: NAD • Pelvic: copious discharge,
mild CMT
Testing
• Urine pregnancy test: Negative
• Wet prep: trichamonads • Cultures: CT +
Diagnosis/Treatment
• AUB-E • Azithromycin 1g, + treat
partner.
Case #3 • 32 G3P3 with irregular and heavy
bleeding since delivery of last child 3 years ago
• PMHX: Gestational Diabetes • No past surgical or pertinent family
history. Non smoker • Husband has vasectomy • Gained 30lbs with each pregnancy
without getting back to pre-pregnancy weight
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Exam
• 140/90, P 95, BMI 45 • General: Obese, mild
hirsutism under chin and on abdomen
• Pelvic: Normal
Testing
• Urine pregnancy test negative • H/H: 8/26 , normal platelets • TVUS: Thickened endometrial
stripe, no fibroids. PCOS ovaries
• Endometrial biopsy: Simple Hyperplasia without atypia
Diagnosis/Treatment
• Iron supplementation • Cycle suppression vs Mirena
IUD • Evaluation for metabolic
syndrome vs referral to Internal Medicine/Family Medicine
Take home points • Normal menstrual cycle is 21-35 days,
<80cc of flow, lasting <8days • The terminology for Menorrhagia/AUB
has changed to PALM-COEIN • Etiology varies by age, may be structural
or non-structural, Ovulatory vs Ovulary Dysfunction
• Screen for bleeding disorders
Take Home
• Treatment varies by etiology and age – If negative bleeding disorder screen and non
structural can use progestins or combined oral contraceptives per CDC guidelines http://www.cdc.gov/reproductivehealth/unintendedpregnancy/usmec.htm
– Surgery is last resort. – Ablation is relatively contraindicated in AUB-O
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References • ACOG Practice Bulletin Number 81, May 2007.
Endometrial Ablation • ACOG Practice Bulletin Number 128, July 2012.
Diagnosis of Abnormal Bleeding in Reproductive-Aged Women
• ACOG Practice Bulletin Number 136, July 2013. Management of Abnormal Uterine Bleeding Associated with Ovulatory Dysfunction
• ACOG Committee Opinion Number 557, April 2013 Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women
• Munro at al. 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