abnormal uterine bleeding tony hoang, md. abnormal uterine bleeding aub accounts for approx. 70% of...
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ABNORMAL UTERINE BLEEDINGT O N Y H OA N G , M D
ABNORMAL UTERINE BLEEDING
• AUB accounts for approx. 70% of all gyn visits in the peri-menopause & post-menopausal years
• Menstrual disorders accounts for 20% of all gyn visits• 2 millions visits per year
• Growing popularity of Bio-Identical hormones use
WHAT IS NORMAL BLEEDING
• AGE OF THE PATIENT (NON-PREGNANT)• ADOLESCENCE• REPRODUCTIVE• MENOPAUSAL
• FLOW• FREQUENCY• DURATION
NORMAL BLEEDING
• FLOW (5 days)• 30 ml – 80 ml of bleeding
• FREQUENCY• Every 21-35 days
• DURATION• Bleeding for 2 – 8 days
TERMINOLOGY
• MENORRHAGIA – heavy menstrual bleeding
• METRORRHAGIA – bleeding btwn periods
• MENOMETRORRHAGIA - combo
• OLIGOMENORRHEA – bleeding less frequent than 35 days
• POLYMENORRHEA – bleeding more often than 21 day
• AMENORRHEA – cessation of periods for 6 months
INITIAL EVALUATION
• HISTORY
• MENSTRUAL • BLEEDING PATTERNS• ASSOCIATED PAIN SYMPTOMS• SEVERITY• FAMILY HSTORY (20%)
• PAST OR PRESENT ILLNESSES
• USE OF MEDICATIONS / Herbal Products (Ginkgo Biloba/Ginseng/ motherwort)
• USE OF BIRTH CONTROL METHODS (IUDs / IMPLANTS / INJECTIONS)
• WEIGHT, EATING HABITS, EXERCISE, STRESS LEVEL
• PAP HISTORY
UNDERLYING BLEEDING DISORDER
• SCREEN• QUESTION ABOUT BLEEDING AT MENARCHE• HEMORRHAGE (ONE OF THE FOLLOWING)• POSTPARTUM• POST SURGICAL• BLEEDING ASSOC. WITH DENTAL WORK
• HEMORRHAGE (TWO OF THE FOLLOWING)• BRUISING ONE OR TWO TIMES PER MONTH• EPISTAXIS ONE OR TWO TIMES PER MONTH• FREQUENT GUM BLEEDING• FAMILY HISTORY
MENSTRUAL CYCLE DIARY
INITIAL EVALUATION
INITIAL EVALUATION
DIFFERENTIAL DIAGNOSIS
• PREGNANCY / MISCARRIAGE / ECTOPIC• ENDOMETRIAL POLYPS• ENDOMETRIAL ATROPHY• FIBROIDS• ADENOMYOSIS• OVULATORY• ANOVULATORY• BIRTH CONTROL SIDE EFFECT (IMPLANTS/IUD)• INFECTION (ENDOMETRITIS)• BLOOD CLOTTING DISORDERS• ENDOMETRIAL HYPERPLASIA • UTERINE CANCERS• PCOS• IATROGENIC• NOT YET CLASSIFIED
DIFFERENTIAL DIAGNOSIS
• PREGNANCY / MISCARRIAGE / ECTOPIC• ENDOMETRIAL POLYPS• ENDOMETRIAL ATROPHY• FIBROIDS• ADENOMYOSIS• OVULATORY• ANOVULATORY• BIRTH CONTROL SIDE EFFECT (IMPLANTS/IUD)• INFECTION (ENDOMETRITIS)• BLOOD CLOTTING DISORDERS• ENDOMETRIAL HYPERPLASIA • UTERINE CANCERS• PCOS• IATROGENIC• NOT YET CLASSIFIED
PALM-COEIN
WHAT TO ORDER
• HCG test• CBC• vWF (IF INDICATED)• Ristocetin cofactor (IF INDICATED)• PT/INR/PTT (IF INDICATED)• TSH• CHLAMYDIA
WORK UP TOOLS
• TRANSVAGINAL ULTRASOUND• SALINE INFUSION SONOHYSTEROGRAPHY• MRI• HYSTEROSCOPY• PAP SMEAR• ENDOMETRIAL BIOPSY• 45 YRS OR OLDER• OR RISK FACTORS: PCOS; OBESITY; FAILED RX;
PERSISTENT
TREATMENT
• MEDICATIONS• HORMONAL• NON-HORMONAL
• SURGICAL OPTIONS• DILATATION & CURETTAGE• HYSTEROSCOPIC RESECTION• UTERINE ARTERIAL EMBOLIZATION• MYOMECTOMY• ENDOMETRIAL ABLATION• HYSTERECTOMY
MEDICATION
• HORMONAL• OCP’S (Monophasic 35 mcg pills)• 4 X 4 - 3 X 3 – 2 X 2 – 1X1 THEN STOP FOR ONE WEEK – RESUME• 3 pills for Seven days• OCP Q 6 HRS (48 HRS)• ESTROGENS (CEE) 25-40 mg IV Q 4-6hrs• PROGESTINS • PROVERA 10 mg PO Q 4 hrs or 20 mg PO TID x 7 days• PROVERA 60 -120 mg PO x 1 then 20 mg Daily x 9 days• NORETHRINDRONE 5-10 mg PO Q 4hrs
• DMPA• MIRENA IUD
• NON-HORMAL• MOTRIN 800 mg PO TID x 5 days• TRANEXAMIC ACID 500 mg – 1.3 gm PO TID x 5 days (FDA warning)• DOXYCYCLINE 100 mg PO X 10 DAYS• MEFEPREX 100 mg
SURGICAL
• UTERINE ARTERY EMBOLIZATOIN / UFE• DILATATION & CURETTAGE• HYSTEROSCOPIC RESECTION / SYMPHION• ABLATION• HTA / NOVASURE / MEA / HER OPTION / THERMACHOICE
• HYSTERECTOMY• SUPRACERVICAL• MYOMECTOMY• LAVH• LTH• TVH• TAH
UTERINE ARTERY EMBOLIZATION
• COMPLETE CHILD BEARING• CATHERIZATION VIA FEMORAL ARTERY• IV CONTRAST • PVA (POLYVINYL ALCOHOL) • 1- 3 HRS PROCEDURE TIME• 6 HRS POST PROCEDURE BEDREST• POST OP PAIN 6-12 HRS (POSSIBLE SEVERAL MONTHS)• MAY REDUCE FIBROID BY 50%• 20% RETREATMENT OR REQUIRED SURGERY• S/E: INFECTION; PREMATURE MENOPAUSE;
PERSISTENT PAIN; SCAR TISSUE; AMENORRHEA
ABLATIONS
• HTA• MIA• NOVASURE• HER OPTION• THERMACHOICE
MEA
HER OPTION
THERMACHOICE
NOVASURE
HYDROTHERMAL
OBAMACARE??
“A HAPPY WIFE IS A HAPPY LIFE…”