abnormal uterine bleeding (aub)...references • williams gynecology. 3rd edition. ch8, abnormal...
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Abnormal Uterine Bleeding (AUB)
Stephanie Getz, DO, FACOOGMetro Health – University of
Michigan Health
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Objectives• AUB History• AUB Terminology, Work up and Diagnosis –
PALM COEIN• Individual Management
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Disclosure• I have nothing to disclose.
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AUB HistoryWilliam Cullen (late 1700s)- Physics Professor at U of Edinburgh- Translated medical texts from Latin into English- Coined term menorrhagia- “to burst forth monthly”
Graves (1935)- Coined term “dysfunctional uterine bleeding”
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AUB HistoryProblems with terminology
- No standardization- Difficulty documenting symptoms- No consensus re: use of diagnostic techniques
and medical/surgical therapies- Inability to design and interpret basic clinical
research- Inability to conduct multi-center/multi-national
clinical trials
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FIGOMenstrual Disorders Committee (MDC)- Standing committee since 2012- Published the FIGO AUB Classification System used today- Published in International Journal of Gynecology and Obstetrics
(IJGO)
“P.A.L.M C.O.E.I.N.”
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Obsolete Terminology (MDC)Menorrhagia Hypermenorrhea
Metrorrhagia Menometrorrhagia
DUB Polymenorrhea
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NORMAL MENSTRUATIONFrequency: every 21 - 35 daysRegularity: no more than 7-9 days varianceDuration: no more than 8 daysVolume:
research → </= 80ml/cycleclinical → quality of life
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ABNORMAL UTERINE BLEEDING● ANY variation from normal menses +● Intermenstrual Bleeding● Subtypes:
ACUTE AUB CHRONIC AUB
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ACUTE AUB
● Reproductive-age, non-gravid women only● Isolated episode● Requires immediate intervention to prevent
further blood loss
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CHRONIC AUB
● Bleeding from uterine body (corpus) only● Abnormal frequency, duration and/or
volume● Must be present for at least the majority of
the past 6 months
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MENSTRUAL FREQUENCY● Normal = 21 - 35 days● Frequent Uterine Bleeding = period occurs
more often than every 21 days● Infrequent Uterine Bleeding = period occurs
less often than every 35 days● Secondary Amenorrhea = regular cycles
followed by no bleeding >/= 6 months
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MENSTRUAL VOLUME● Definition has 2 subtypes: clinical and
research-based
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CLINICAL MENSTRUAL VOLUME● Perception of increased daily/monthly flow● Interferes with patient’s sense of well-being:
PhysicalSocialEmotionalMaterial
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MENSTRUAL VOLUME for RESEARCH
● Normal </= 80 ml/cycle● Abnormal > 80 ml/cycle
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INTERMENSTRUAL BLEEDING (IMB)
● AUB that occurs between well-defined cycles● Impossible to apply to women with irregular
or frequent menses
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IMB - Uterine CausesPolyps: endometrial / endocervicalAdenomyosisLeiomyomas: mainly submucosalHyperplasia or Malignancy:
EIN - Endometrial Intraepithelial NeoplasiaEndometrial AdenocarcinomaSarcomaEndocervical Adenocarcinoma
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UTERINE IMB cont.
Ovulatory DisordersEndometrial Disorders
- Disorders of local hemostasis- Endometritis- Other
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UTERINE IMB cont.Iatrogenic: - Anticoagulants- Gonadal Steroid Drugs or Precursors- Devices (ie IUD)- Other
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UTERINE IMB cont.Not Otherwise Classified:
- AV Malformations- Cesarean Scar Bleeding- Endometriosis- Other
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CYCLIC UTERINE IMB
MID-CYCLE - small amt of detectable bleeding arising from uterine cavity around mid-cycle● Common (9% have detectable cause; 90% have occult)● Physiologic - mid-cycle drop in E2
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CYCLIC IMB cont.PRE or POST-Menstrual - typically cyclic and light
FOLLICULAR -------------ll-----------------LUTEALEndometriosis -------------------------------------------------->Polyp -------------------------------------------------------------->Structural Lesions ---------------------------------------------->
Luteal Phase Defect --->
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ACYCLIC IMB● No cyclic pattern● Not predictable● Typically benign (cervicitis, polyp etc)● Can rarely indicate malignancy
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NON-UTERINE IMB ● ENDOCERVICAL
Cervicitis - acute or chronicPolypsMalignancy
● VAGINA / VULVATraumaNeoplasiaInfection
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P.A.L.M. C.O.E.I.N● Standardized way to classify AUB● P.A.L.M. -
structural entitiesVisible with imaging or with histopathology
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P.A.L.M. C.O.E.I.N.
● C.O.E.I.N. -NOT structural entitiesYou can’t “see” them
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“P” is for PolypsDefinition: localized epithelial tumors
Endometrial or EndocervicalFIGO: classify presence/absence if SEEN
Histopathology does NOT count!
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“A” is for AdenomyosisDefinition: presence of endometrial-type glands/stroma within myometriumDiagnosis: traditionally by histopath(after hyst)
MRI + TVUS (pre-hyst) - newRole in AUB: poorly understood and studies mixed
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“L” is for Leiomyoma Definition: benign tumors of smooth muscleHierarchy of Classification:
Primary - presence or absence only
Secondary - submucosal vs. non-submucosal
Tertiary - most specific/categorizes ALL in relation to EM
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“M” is for MalignancyDefinition: EM Hyperplasia w/ Atypia
EM AdenocarcinomaEM Stromal SarcomaLeiomyosarcoma
Classification: “AUB-M” then FIGO staging
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“C” is for CoagulopathyEncompasses: spectrum of Systemic Hemostasis Disorders
24% women with HMB will have coagulopathy
von Willebrand’s is most common
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How to pick up COAGULOPATHY
● Start with a screening history. ● Positive history includes 1 of following:
HMB since menarchePPHSurgical BleedingDental Bleeding
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COAGULOPATHY screen cont.
● Two or more of following:Bruising 1-2/monthEpistaxis 1-2/monthBleeding gums frequentFH Bleeding symptoms
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(+) Coagulopathy Screen● Consider further evaluation
● Hematology Consult
● Labs: vW factor + Ristocetin cofactor
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“O” is for Ovulatory Dys(fn)Includes: anovulation, oligo-ovulation, Luteal Phase Defects
Presentation: Irregular Bleeding + HMB
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An- and Oligo- ovulation
● Long-term exposure to E2
● Increased volume of proliferative EM
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Luteal Phase Defect
1. Early Recruitment of Follicle2. Follicle matures precociously3. Huge increase in E24. Increased menstrual volume
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Causes of Ov. Dysfunction
● Psychological stress● Weight loss/gain● Excessive exercise● Medications (effect dopamine metabolism)● Endocrine issues:
Hypothalamus → Pituitary → Ovaries
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“E” is for EndometriumPresentation: regular cycles + HMB +/- IMB
with no other identifiable cause Most common cause: Primary Disorder of EM(ie - disorder of mechanism regulating LOCAL hemostasis of EM)
No available test
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“I” is for IatrogenicCauses: Mechanical devices (IUDs)
Drugs:
Estrogens Progestins AndrogensSERMs SPRMs GnRHDopamine Prolactin Anti-coag.
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“N” is for Not Otherwise Classified● Poorly defined● Extremely rare
Examples: A-V MalformationsC-section scar (uterine isthmocele)
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Treatment• Treatment can vary based upon the cause of
bleeding• In many cases, a form of hormone therapy is
recommended and there are many different options/forms
• Wide variety of procedural treatments available as well, and again, dependent on the etiology
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References• Williams Gynecology. 3rd edition. Ch 8, Abnormal Uterine
Bleeding. 2016.• Diagnosis of Abnormal Uterine Bleeding in Reproductive-
Aged Women. ACOG Practice Bulletin #128, July 2006, Reaffirmed in 2016.
• Management of Abnormal Uterine Bleeding Associated with Ovulatory Dysfunction. ACOG Practice Bulletin, #136, July 2013, Reaffirmed in 2018.
• www.uptodate.com – Abnormal uterine bleeding in reproductive-aged women.
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THANK YOU!QUESTIONS?