9/25/15

1

Abnormal Uterine Bleeding

Rachel Maassen MD, MBA Department of ObGyn

University of Iowa Hospitals and Clinics

•  Describe the normal menstrual cycle •  Describe 2011 shift in terminology for

Abnormal Uterine bleeding •  Discuss etiology for Abnormal Uterine

Bleeding •  Discuss the evaluation for AUB •  Describe therapeutic options for AUB

Objectives

Characteristics of the Normal Menstrual Cycle

Average Range Abnormal

Cycle length 28 d 21-35 d <21 or > 35 d

Duration 4 d 1-8 d > 7 d

Blood loss 35 mL 20-80 mL > 80 mL

The endometrium •  Follicular/Proliferative phase(1-13)

–  Estrogen stimulates rapid growth, regeneration of glandular stumps

–  Maximum thickness at the end of this phase

•  Luteal/Secretory phase(14-28) –  CL development and progesterone

production –  Inhibition of further endometrial

thickening –  Microvasculature differentiates (spiral

arterioles)

Menstruation •  CL involutes and progesterone falls •  Vasoconstriction causes ischemia and

hemorrhage •  Release of PGE2 alpha •  Hemostasis

–  Platelet plugs –  Vasoconstriction –  Regeneration of the functional layer

9/25/15

2

Etiology/Terminology

Evaluation: History

•  Gynecologic History – Menstrual history

•  Frequency, Volume, Duration

– Sexual history -pregnancy, STD?

– Gyn Surgery – Contraceptives – Risk for endometrial cancer

History •  Medical History

– Bleeding disorder •  Up to 13% von Willebrand disease •  Up to 20% coagulation disorder

– Signs or symptoms of Thyroid disorder

– Systemic Disease – Medications/Herbal remedies

Screen for Bleeding disorder

•  HMB since menarche •  One of the following:

–  Postpartum hemorrhage –  Surgery related bleeding –  Bleeding with dental work

•  Two or more of the following: –  Bruising 1-2 times per month –  Epistaxis 1-2 times per month –  Frequent gum bleeding –  Family history of bleeding symptoms

9/25/15

3

Evaluation: Physical Exam

•  Signs of hyperandrogenism (PCOS)

•  Signs of a bleeding disorder •  Pelvic

–  Is the blood from the uterus? •  Lacerations, cervical lesions

– Uterine size – Enlarged ovaries?

Evaluation: Testing

Labs to consider •  HCG!!! •  CBC (+ iron studies for HMB) •  TSH/Prolactin •  Cervical cultures •  In office endometrial biopsy

•  Unopposed estrogen any age •  >45 irregular bleeding

•  Ultrasound +/- SIS

Ultrasonography with saline infusion

Additional testing: + screen for bleeding disorder

•  Coags: PTT, PT, INR, fibrinogen* (w active bleeding)

•  Von Willebrand factor antigen •  Ristocetin cofactor assay •  Factor VIII •  LFTs

Treatment depends upon type of AUB

•  Structural Causes (PALM) – Polyp/Leiomyoma

•  Gynecology referral

– Adenomyosis •  Consider Mirena IUD vs hormonal

suppression – Malignancy/Hyperplasia

•  Gynecology referral •  Progestins

Treatment: Nonstructural causes

•  Ovulatory •  Coagulopathy AUB-C

•  Refer to hematology/gynecology •  Endometrial: see AUB-O •  Iatrogenic: stop intervention or

tolerate AUB •  Ovulatory Dysfunction AUB-O

•  Amenorrhea •  PCOS

9/25/15

4

Ovulatory Dysfunction AUB-O

•  Treat medically not surgically –  Progestins

•  Provera, Norethindrone •  Nexplanon •  Mirena IUD •  Depo provera

–  Combined hormonal contraceptive •  Pills •  Transdermal patch •  Ring http://www.cdc.gov/reproductivehealth/unintendedpregnancy/usmec.htm

Age appropriate treatments for AUB-O/E

•  13-18 –  low dose ocps(20-35 mcg of ethinyl

estradiol •  19 to 39/40 to menopause

–  low dose ocps(20-35 mcg of ethinyl estradiol

–  Progestins –  Mirena IUD –  Surgical Intervention

Surgical Intervention (if all else fails)

•  Endometrial ablation –  Risk of endometrial cancer

•  Not first line for AUB-O –  Long-term complications –  Continued need for contraception

•  Hysterectomy

Case #1

•  45 G2P0 LMP 21 days ago •  Regular 28-30d cycles lasting 7-10

d mild cramps •  6 mo ago began 25-32d cycles

severe cramps, heavy flow. •  No weight change •  Condoms for contraception,

manogamous •  No meds, no medical history

Exam

•  130/88, P=100, 150lbs, Ht 5’6

•  Appears pale •  Normal pelvic

Labs

•  Labs: Hbg 9.0, Hct 27%, HCG negative.

•  Endometrial biopsy: normal secretory endometrium

•  Ultrasound: Heterogeneous endometrium, 1.4cm irregular lining. SIS shows polyp, normal ovaries.

9/25/15

5

Diagnosis/Treatment

•  AUB-P •  Hysteroscopic polypectomy •  Iron supplementation •  Consider OCPS, vs

Norethindrone, vs Mirena IUD •  Ablation candidate if fails

above

Case #2

•  19 G0 with bleeding or spotting almost daily for the past 4 months

•  Menarche age 12, irregular for 2 years. Now Q29 days

•  3 lifetime partners, no history of STDs

Exam

•  125/70, P75, BMI 21 •  General: NAD •  Pelvic: copious discharge,

mild CMT

Testing

•  Urine pregnancy test: Negative

•  Wet prep: trichamonads •  Cultures: CT +

Diagnosis/Treatment

•  AUB-E •  Azithromycin 1g, + treat

partner.

Case #3 •  32 G3P3 with irregular and heavy

bleeding since delivery of last child 3 years ago

•  PMHX: Gestational Diabetes •  No past surgical or pertinent family

history. Non smoker •  Husband has vasectomy •  Gained 30lbs with each pregnancy

without getting back to pre-pregnancy weight

9/25/15

6

Exam

•  140/90, P 95, BMI 45 •  General: Obese, mild

hirsutism under chin and on abdomen

•  Pelvic: Normal

Testing

•  Urine pregnancy test negative •  H/H: 8/26 , normal platelets •  TVUS: Thickened endometrial

stripe, no fibroids. PCOS ovaries

•  Endometrial biopsy: Simple Hyperplasia without atypia

Diagnosis/Treatment

•  Iron supplementation •  Cycle suppression vs Mirena

IUD •  Evaluation for metabolic

syndrome vs referral to Internal Medicine/Family Medicine

Take home points •  Normal menstrual cycle is 21-35 days,

<80cc of flow, lasting <8days •  The terminology for Menorrhagia/AUB

has changed to PALM-COEIN •  Etiology varies by age, may be structural

or non-structural, Ovulatory vs Ovulary Dysfunction

•  Screen for bleeding disorders

Take Home

•  Treatment varies by etiology and age –  If negative bleeding disorder screen and non

structural can use progestins or combined oral contraceptives per CDC guidelines http://www.cdc.gov/reproductivehealth/unintendedpregnancy/usmec.htm

–  Surgery is last resort. –  Ablation is relatively contraindicated in AUB-O

9/25/15

7

References •  ACOG Practice Bulletin Number 81, May 2007.

Endometrial Ablation •  ACOG Practice Bulletin Number 128, July 2012.

Diagnosis of Abnormal Bleeding in Reproductive-Aged Women

•  ACOG Practice Bulletin Number 136, July 2013. Management of Abnormal Uterine Bleeding Associated with Ovulatory Dysfunction

•  ACOG Committee Opinion Number 557, April 2013 Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women

•  Munro at al. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. International Journal of Gynecology and Obstetrics 113 (2011)3-13