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