A focus on the evaluation and management of AUB

Dr. Devon AmbroseASA 2014

Disclosures

Faculty:- Dr. Devon Ambrose RCPSC

Relationships with commercial interests:

- Grants/Research Support: nil- Speakers Bureau/ Honoraria: nil- Consulting Fees: nil- Other: Tache Obstetrical Group

Objectives

• How to evaluate AUB

• 7 steps

• How to treat AUB

• New medication

• Fibristal for fibroids

Classification

PALM - COEIN

Munro et al, Int J Gynaecol Obstet 2011; 113: 3

Classification

PALM - COEIN

Munro et al, Int J Gynaecol Obstet 2011; 113: 3

CoagulpathyOvulatoryEndometrialIatrogenicNot yet classified

PolypAdenomyosisLeiomyomaMalignancy/Hyperplasia

Evaluation7 steps

Evaluation

• Step 1: Confirm uterine source

Evaluation

• Step 2: Pregnancy test

Evaluation

• Step 3: Is ovulation occurring?

If not, will need an anovulation work-up

Evaluation

• Step 4: Description of cycle

PatternVolumeDysmenorrhea

Evaluation

• Step 5: Lab testsPregnancyAnemiaOvulation - TSH, PRL, T, DHEA-S, E2, LH,

FSH, P4

Coagulapathy

Evaluation

• Step 6: Ultrasound

Evaluation

• Step 7: Endometrial Biopsy

> Age 45> Age 35 with risk factors:

ObesityChronic anovulationFailed medical managementLynch syndrome, Tamoxifin use

ACOG Practice Bulletin 128. Obstet Gynecol 2012; 120(1): 197

Evaluation• Step 1: Confirm uterine source

• Step 2: Pregnancy test

• Step 3: Is ovulation occurring?

• Step 4: Description of cycle

• Step 5: Lab tests

• Step 6: Ultrasound

• Step 7: Endometrial Biopsy

Evaluation

PALM - COEINCoagulpathyOvulatoryEndometrialIatrogenicNot yet classified

PolypAdenomyosisLeiomyomaMalignancy/Hyperplasia

Treatment

PALM - COEINCoagulpathyOvulatoryEndometrialIatrogenicNot yet classified

PolypAdenomyosisLeiomyomaMalignancy/Hyperplasia

TreatmentPALM - COEIN

Treatment• AUB-L (Leiomyoma)

• First-step medical treatment options:

• Tranexamic acid 1 gram po tid x 5days

• OCP

• Progesterone

• Mirena, Depot-Provera

PALM - COEIN

Treatment

• AUB-L (Leiomyoma)

• Next-step medical treatment options:

• Lupron 7.5 mg IM monthly

• Fibristal 5mg po od

PALM - COEIN

Treatment

• More information on Fibristal...

PALM - COEIN

Selective Progesterone Receptor Modulator

Dose: 5mg po od for 3 months

Treatment

• More information on Fibristal...

PALM - COEIN

Side Effects:- Headache 16%- Hot flushes 5%- Nausea, fatigue, breast tenderness

4%

(Hot flushes with Lupron 40%)

Treatment

• More information on Fibristal...

PALM - COEIN

Contraindications:- Pregnancy or Breast feeding- Cancer: breast, cervix, uterus,

ovarian

Treatment

• More information on Fibristal...

PALM - COEIN

Downsides:- Cost $1200 (approx)- Variable long-term benefit

PEARL II: Time to Control of Bleeding

(PBAC < 75)

0

20

40

60

80

100

0 10 20 30 40 50 60 70 80 90 100

Time (days)

Pa

tie

nts

(%

)

ulipristal acetate 5 mg

ulipristal acetate 10 mg

Leuprolide 3.75 mg

Donnez J, et al. N Engl J Med 2012;366:421-32

7 days 30 days30 days

Treatment

• AUB-L (Leiomyoma)

• Surgical treatments options:

• Uterine Fibroid Embolization

• Endometrial resection (submucosal)

• Hysterectomy

PALM - COEIN

Treatment• AUB-A (adenomyosis)

• OCP not as effective unless continuous

• Progesterone options:

• Mirena IUD

• Depot-Provera

• Provera 10mg po od-bid

PALM - COEIN

Treatment

• AUB-A (adenomyosis)

• Other options:

• Danazol 200-400mg po bid

• acne, hair loss, voice changes, lipids

PALM - COEIN

Treatment

• AUB-O (ovulatory dysfunction)

• OCP

• Mirena

• Cyclic Provera

• Endometrial Ablation

PALM - COEIN

Treatment SummaryPALM - COEIN

Adenomyosis

ProgesteroneC-OCP

Danazol

Hysterectomy

Leiomyoma

ProgesteroneOCP

CyclokapronLupronFibristal

HysterectomyEmbolizationResection

Anovulation

ProgesteroneOCP

Cyclic Progest

HysterectomyAblation

Treatment• AUB-P (polyp)

• Polypectomy

• Risk malignant transformation 0.8-8%

• menopausal

• persistent

• elevated BMI, hypertension

PALM - COEIN

Costa-Paiva et al. Menopause 2011; 18(12): 1278-82

Treatment

• AUB-M (malignancy or hyperplasia)

• referral for surgery or high dose Progesterone if Non-atypical hyperplasia

PALM - COEIN

Treatment

• AUB - C (Coagulapathy)

• OCP

• Cyclokapron

• Mirena IUD

• Endometrial Ablation

• Consider DDAVP for VWD

PALM - COEIN

Treatment

• AUB-E (Endometritis)

• rare cause

• antibiotics

PALM - COEIN

Treatment

• AUB-I (Iatrogenic)

• often estrogen containing treatments are contraindicated

• consider Mirena, Endometrial Ablation

PALM - COEIN