1 vaginal bleeding in the perimenopause (age 35-50) ralph anderson, m.d., f.a.c.o.g., f.r.c.s. (c)...

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Vaginal Bleeding in the Perimenopause

(Age 35-50)

Ralph Anderson, M.D., F.A.C.O.G., F.R.C.S. (C)Chairman and Professor

Department of Obstetrics and GynecologyUniversity of North Texas Health Sciences Center

Fort Worth, Texas

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Classification of Abnormal Uterine Bleeding

• Menorrhagia: heavy bleeding; loss of more than 80 mL of blood and/or increased duration of flow (> 7 days) at regular intervals.

• Menometrorrhagia: increased loss or duration of bleeding occurring at irregular intervals.

• A 40-year-old female presents with irregular bleeding over the past year.

• Menstrual history• 1st period age 15• Bleeding q 25-28 x 3-5 days until 1 year ago • Now bleeding is heavy and very irregular (menometorrhagia)

• Gen Px normal• Pelvic – no abnormalities• Hb – 9.5 Hct 28

• What is the first step in the management?• Pregnancy test

• Pregnancy Related Complications• Threatened abortion• Incomplete abortion• Complete abortion• Missed abortion• Trophoblastic disease

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• A 40-year-old female presents with irregular bleeding over the past year.• Menstrual history

• 1st period age 15

• Bleeding q 25-28 x 3-5 days until 1 year ago

• Now bleeding is heavy and very irregular (menometorrhagia)

• Gen Px normal• Pelvic – no abnormalities• Hb – 9.5 Hct 28

• What is the first step in the management?

• Pregnancy test negative• What is the next step in the management?• Endometrial biopsy

• Proliferative endometrium

• Ultrasound• Normal uterus, tubes and ovaries

• What is the likely diagnosis?• Anovulatory cycles

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• Menometorrhagia (Heavy bleeding at Irregular Intervals)

• Excessive estrogen production and domination• Anovulatory cycles• Polycystic ovaries• Obesity

• Hypothalamic Dysfunction• Anorexia• Exercise 5

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Management of Perimenopausal Patient with Menometorragia Due to Anovulatory Cycles

1. Observation

2. Oral contraceptives

3. Oral progesterone• Provera 5mg daily• Provera 5mg for 14 days of each month

4. Depoprovera

5. Progesterone IUD

6. D&C

7. Hysterectomy7

Management of Perimenopausal Patient with Menometorragia Due to Anovulatory Cycles

1. Observation

2. Oral contraceptives

3. Oral progesterone• Provera 5mg daily• Provera 5mg for 14 days of each month

4. Depoprovera

5. Progesterone IUD

6. D&C

7. Hysterectomy8

• A 43-year-old g3p3 female presents with a history of having had heavy normal periods her entire life until 1 year ago when they began to be heavier and have progressively become heavier until now she bleeds heavily for 9-10 days and uses approximately 8 pad 1 day.

• General Physical Examination normal• Pelvic examination

• Uterus enlarged to 8 week size

• Hb 9.2 Hct 26• Pregnancy test negative• Endometrial biopsy shows secretory endometrium with no

evidence of hyperplasia or malignancy.• What is the next step in the management?

• Transvaginal ultrasound

• Saline Infusion Transvaginal ultrasound 9

Heavy Bleeding with Regular Menstrual Cycles(Menorrhagia)

• Benign gynecologic disease• Endometrial polyp• Fibroids• Adenomyosis

• Neoplasm of uterus• Hyperplasia • Cancer

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Benign Conditions of the Uterus

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• A 43-year-old g3p3 female presents with a history of having had heavy normal periods her entire life until 1 year ago when they began to be heavier and have progressively become heavier until now she bleeds heavily for 9-10 days and uses approximately 8 pad 1 day.

• General Physical Examination normal

• Pelvic examination

• Uterus enlarged to 8 week size

• Hb 9.2 Hct 26

• Pregnancy test negative

• Endometrial biopsy shows adenomatous hyperplasia with atypia.

• What is the managementA. D&C

B. Progesterone IUD

C. Provera or Megace

D. Hysterectomy12

Hyperplasia of Endometrium

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• Oral progesterone• Progesterone IUD (Mirena)

• D&C• Hysterectomy andBilateral salpingooophorectomy

1% risk of cancer 1-3% risk of cancer 15-20% risk of cancer

Cancer of the Endometrium

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• A 43-year-old g3p3 female presents with a history of having had heavy normal periods her entire life until 1 year ago when they began to be heavier and have progressively become heavier until now she bleeds heavily for 9-10 days and uses approximately 8 pad 1 day.

• General Physical Examination normal• Pelvic reveals a normal size uterus and no pelvic

pathology.• Hb 9.2 Hct 26• Pregnancy test negative• Endometrial biopsy reveals secretory endometrium• Transvaginal ultrasound reveals normal uterus and

ovaries.

• What are your thoughts? 15

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• In a reproductive age woman with menorrhagia or menometorrhagia not related to• Pregnancy• Benign uterine pathology• Hyperplasia or cancer

• Think of Systemic Disorders• Endocrine

• Hyperthyroidism• Liver Disease• Renal Disease• Obesity

• Hypothalamic Disorders• Anorexia• Exercise

Abnormal Uterine BleedingMedications Associated with Menorrhagia

•Antidepressants•Antipsychotics

• Interferes with stimulatory and inhibitory nervous impulses that control hypothalamic function resulting in anovulation and abnormal uterine bleeding

•Anabolic steroids• Amenorrhea or irregular vaginal bleeding due to the androgenic effects

of the steroids.

•Aspirin and other prostaglandin synthase inhibitors inhibit platelet function•Heparin and warfarin interferes with clotting mechanisms.•Digoxin•Propranolol•Corticosteroids 17

Iatrogenic Causes of Menorrhagia and Menometorrhagia in the Perimenopausal Female

• Oral contraceptives

• Depot medroxyprogesterone acetate

• Post menopausal therapy

• Anticoagulants

• Herbal supplements

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Vaginal Bleeding in the Perimenopause(35-50)

• Pregnancy Related Problems• Heavy bleeding at Irregular Intervals

• Anovulatory cycles

• Heavy bleeding with Regular Menstrual Cycles• Benign gynecologic disease• Polyp ∙Fibroids ∙ Adenomyosis• Neoplasm of the uterus

• Hyperplasia ∙Cancer

• Metabolic Disorders• Hypothyroidism ∙Renal ∙Cirrhosis ∙Obesity

• Medications associated with Menorrhagia• Antidepressants ∙Antipsychotics ∙ Aspirin

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Vaginal Bleeding in the Perimenopause (35-50)

• Pregnancy Related Problems• Heavy bleeding at Irregular Intervals

• Anovulatory cycles

• Heavy bleeding with Regular Menstrual Cycles• Benign gynecologic disease• Polyp ∙Fibroids ∙ Adenomyosis• Neoplasm of the uterus

• Hyperplasia ∙Cancer

• Metabolic Disorders• Hypothyroidism ∙Renal ∙Cirrhosis ∙Obesity

• Medications associated with Menorrhagia• Antidepressants ∙Antipsychotics ∙ Aspirin

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