Abnormal uterine Bleeding

Dr Stanford Wong / Dr Tereza Indrielle

Learning Objectives

• definitions• assessment• Diagnosis• FIGO PALM-COEIN classification• treatment

Definition (2009)*

• “Any variation from the normal menstrual cycle, and includes changes in regularity and frequency of menses, in duration of flow, or in amount of blood loss.”

*Reference: I.S. Fraser, H.O.D. Critchley, M. Broder, M. G. Munro, 2011, “The FIGO Recommendations on Terminologies and Definition for Normal and Abnormal uterine Bleeding” Seminars in Reproductive Medicine Sep;29(5), Page 383-390

Normal variance

• Regularity: 18-24 days

• Frequency: 24-38 days

• Duration: 3-8 days

Subdivision

Categories based on:

• Volume of menstruation(Normal, Heavy, Light)

• Regularity (Regular, Irregular, Absent)• Frequency (Normal, Frequent, Infrequent)• Duration (Normal, Prolonged, Shortened)• Chronicity (Acute, Chronic)• Timing related to reproductive status

(Inter-menstrual, Pre-menstrual, Break-through)

Abbreviations

• HMB (Heavy Menstrual Bleeding)• Excessive menstrual blood loss which interferes with

the woman’s life• HPMB (Heavy, Prolonged Menstrual Bleeding)

• As above + exceeding 8 days in duration

• AUB (Abnormal Uterine Bleeding)• Acute AUB: require immediate intervention to

prevent further blood loss• Chronic AUB: presentation for most of the last 6

months

Abbreviations

• IMB (Inter-menstrual Bleeding)

• PCB Post-coital bleeding (post-intercourse)

• PMB (Post-menopausal Bleeding)• Bleeding occuring more than 1 year after the last

period

Frequency

• Amenorrhoea• No bleeding in a 90 days period• Primary / secondary

• Oligomenorrhea >38 days • Polymenorrhea <24 days

Clinical Assessment

• Clinical history:

• PC and HPC:• Associating symptoms

(Eg. Vaginal discharge, Pelvic pain or pressure)• Sexual and reproductive history• Symptoms suggestive of anaemia• Symptoms suggestive of systemic causes of bleeding• Impact on social and sexual functioning, and quality of

life

• PMH, PSH

Drug History

• Especially medications that can associate with AUB:• Anticoagulants• Hormone Contraceptives• Tamoxifen• Antidepressants• Anti-psychotics• Corticosteroids• Herbal (Eg. Ginseng, Danshen , Chasteberry)

Family History

• Inherited coagulation disorders• Poly-cystic Ovarian Syndrome• Endometrial cancer• Colonic cancer (especially HNPCC)

• Woman with HNPCC have lifetime risk:• 40-60% for Endometrial cancer, Colorectal cancer • 12% for ovarian cancer

Risk factors for endometrial cancer*• Age• Obesity (BMI > 30kg/m2)• Nulliparity• Personal history of

• PCOS• Diabetes Mellitus• Hereditary Non-Polyposis Colorectal Cancer

*Reference: Timothy Rowe (Editor in Chief), May 2013, “ Abnormal Uterine Bleeding in Pre-Menopausal Women”, Journal of Obstetrics and Gynaecology Canada, Volume 35, Number 5

Investigate vs. Treat quickly?

• NICE:• If cancer not suspected start

treatment before investigations (apart form Mirena)

Gynaecological examination

• Inspection• Bimanual examination• Rectal examination

• If suspected for PR bleed

• Bedside tests:• Cervical smear• High vaginal swabs, Endocervical swabs

Investigation• Pregnancy test or Serum βHCG

• Blood tests:• Full Blood Counts• Others: clotting profile, thyroid function test etc.

• Imaging – TV scan

• Pathology/Histology – pipelle and hysteroscopy!

FIGO Classification(PALM-COEIN)

• Structural causes:• Polyps• Adenomyosis• Leiomyomas

(Submucosal, Others)• Malignancy and

Hyperplasia

• Non-structural:• Coagulopathy• Ovulatory dysfunction• Endometrial• Iatrogenic• Not yet specified

Structural Investigations

• Trans-vaginal Ultrasound (First line)

• If appropriate:• Hysteroscopy• Saline infusion sonography• MRI• Dilation and Curettage• Endometrial biopsy

Red Flags• Suspicious features of gynaecological cancer:

• Post-coital bleeding, PMB• Persistent IMB

• >45 years old with treatment failure• While on HRT or Tamoxifen

• Pelvic Mass• Enlarged Uterus (>10 weeks on clinical assessment or >10cm uterine

cavity length on USS)

• Moderate/Severe anaemia on usually benign pathology• Failure of medical treatment (patient’s own assessment)

• >3 months of drug treatment• >6 months on IUS

First Line Treatments(NICE Recommendation)• Tranexamic acid / Mefenamic acid• Combined oral contraceptives• Norethisterone

• Levonorgestrel-releasing intra-uterine system (LNG-IUS)

Treatment Potential Unwanted Outcomes

LNG-IUS

Common

5% Risk of expulsion over 5 years (most likely with the first menses after insertion)Irregular Bleeding (usually <6 months)Hormone related (minor and transient)- Eg. Breast tenderness, acne, headache

Uncommon Amenorrhoea

Rare Uterine perforation at time of insertion

Tranexamic Acid Uncommon Indigestion, Diarrhoea, Headaches

NSAIDsCommon Indigestion, Diarrhoea

Rare Asthma exacerbation, Peptic ulcer disease

Combined oral contraceptive

Common Mood changes, Headache, Nausea, fluid retention, Breast tenderness

Very Rare DVT, Stroke, Ischaemic heart disease

Treatment Potential Unwanted Outcomes

Oral Progesterone

Common Weight gain, Irregular bleeding, Amenorrhoea, PMS

Rare Depression

Injected Progesterone

Common Weight gain, Ireegular bleeding, Amenorrhoea, PMS

UncommonReduced bone mineral density(Largely recovered when treatment discontinued)

GnRH Analogue

Common Menopausal-like symptoms

Uncommon Osteoporosis (Particular >6 months use)

Surgical - ablation

Dilation and curettage• No longer recommended as a therapeutic treatment

Potentially fertility sparing…• Uterine artery embolisation

• Should be first line for patient presented with large fibroid (>3cm), present with HMB and other significant symptoms

• Myomectomy

Oophorectomy or Not?

• Patient wants it• FHx of gynae cancer• Adds extra risks to the procedure

• NOT recommended for healthy ovaries!

Treatment Potential Unwanted Outcomes

Endometrial ablation

Common Vaginal discharge, Worsen dysmenorrhoea, Need for additional surgery

Uncommon Infection

Rare Perforation (very rare with second generation technique)

Uterine artery embolisation

Common Persistent vaginal discharge, Post-embolisation syndrome

Uncommon Need for additional surgery, Premature ovarian failure, Haematoma

Rare Haemorrhage, Tissue necrosis, Speticaemia

MyometectomyUncommon Adhesion, Need for additional surgery,

Recurrence, Perforation, Infection

Rare Haemorrhage

Treatment Potential Unwanted Outcomes

Hysterectomy

Common Infection

Uncommon Intra-operative haemorrhage, Damage to abdominal organs, Urinary dysfunction

Rare Thrombosis

Very Rare Death

Oophorectomy at time of hysterectomy

Common Menopausal-like symptoms

MOCK EXAM!

*Reference: BMJ Learning “Heavy menstrual bleeding in secondary care - in association with NICE” - http://learning.bmj.com/learning/module-intro/heavy-menstrual-bleeding-secondary-care.html?locale=en_GB&moduleId=6055070

40 year old with HMB. When you take a further history, she tells you that she also has some bleeding after sex. examination of her vagina and cervix:

•What is the diagnosis? 1. Normal examination2. Bacterial Vaginosis3. Vaginal cancer4. Cervical Polyp

Cervical polyp

• Other causes of PCB• Endometrial polyps• Vaginal cancer• Cervical cancer• Trauma

Levonorgestrel releasing intrauterine system

First line treatment, >12 months provision of symptomatic relief and contraception

• 26 year old• Menorrhagia + dysmenorrhea• no regular medication• no children • no plans to have any until after her

husband finishes his qualifications in 18 months' time.

Endometrial ablationNext step after failure of medical treatment, Minimally invasive procedure

• 30 year old• tried Mirena, tranexamic acid, and

COCP• unable to tolerate NSAIDs

Uterine artery embolisation

Suitable for fibroid >3cm, Benefits of treatment without surgery

• A 40 year • heavy periods • 5 cm fibroid• wants to avoid surgery

Levonorgestrel releasing intrauterine system

First line treatment, suitable for both symptomatic relief and contraception,No need for oral tablets

• 35 year old• Menorrhagia• Doesn’t plan more children• No good with tablets

Reference• http://www.ladycarehealth.com/how-to-treat-dysfunctional-uterine-bleeding/• I.S. Fraser, H.O.D. Critchley, M. Broder, M. G. Munro, 2011, “The FIGO

Recommendations on Terminologies and Definition for Normal and Abnormal uterine Bleeding” Seminars in Reproductive Medicine Sep;29(5), Page 383-390

• NICE clinical guideline 44, “Heavy menstrual Bleeding” January 2007• Timothy Rowe (Editor in Chief), May 2013, “ Abnormal Uterine Bleeding in Pre-

Menopausal Women”, Journal of Obstetrics and Gynaecology Canada, Volume 35, Number 5

• http://www.hopkinsmedicine.org/healthlibrary/test_procedures/gynecology/dilation_and_curettage_d_and_c_92,p07772/

• “Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women”, American College of Obstetricians and Gynaecologists Committee Opinion No. 557, Obstet Gynaecol 2013: 121:891-6

• BMJ Learning “Heavy menstrual bleeding in secondary care - in association with NICE” - http://learning.bmj.com/learning/module-intro/heavy-menstrual-bleeding-secondary-care.html?locale=en_GB&moduleId=6055070

THANK YOU!Any questions?