Abnormal uterine bleeding
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Transcript Abnormal uterine bleeding
Nancy E Fay MD FACOG
Division of Reproductive Medicine
Definition-AUB
Any bleeding that is not regular cyclic menstrual flow
Intermenstrual spotting
Post coital bleeding
Excessively heavy bleeding
Unpredictable bleeding
PALM-COIEN Classification
PALM-Structural causes
Polyp (AUB-P)
Adenomyosis (AUB-A)
Leiomyoma (AUB-L)
Sub mucosal
Intramural
Malignancy/hyperplasia(AUB-M)
PALM-COEIN Classification
COEIN: Nonstructural causes
Coagulopathy (AUB-C)
Ovulatory dysfunction (AUB-O)
Endometrial (AUB-E)
Iatrogenic (AUB-I)
Not yet classified (AUB-N)
Physiology of
the menstrual
cycle
Proliferative or follicular
phase
Endometrium
Height starts <5
mm to <15 mm
Mitotic growth
of tubular glands
response to rising
estrogen
Follicular
phase
*Primordial follicles
develop
INDEPENDENT of FSH
Estradiol promotes FSH
receptors
Ends with LH surgeand
meiosis of dominant
follicle
Secretory or luteal phase
Endometrium
Stromal height fixed, becomes edematous
Glands tortuous, sub nuclear vacuoles
Arteries spiral
Endometrium stratified into basalis 25%,
spongiosa 50% and outer compacta 25%
Endometrial biopsy to date endometrium; luteal
insufficiency. Timed progesterone alternative
Secretory or luteal phase
Ovary
LH surge causes reduction division of oocyte
Growth of granulosa cells in size, #’s and
metabolic activity
Day 8 capillary growth and progesterone peak
If no HCG to stimulate, follicular atresia begins
*Progesterone suppresses new follicular growth
Luteal or
secretory
phase
Menstrual phase
Steroid withdrawal causes lysosomal instability
releasing prostaglandin synthetase, proteases and
collagenases
High thromboxane A2 results in vasospasm and
ischemic necrosis of the endometrium at the level of
basalis layer
Endometrial healing by rising estrogen from new
follicles with estradiol mediated growth
Adolescent development
Average development
Breast bud 9.8 yrs
Pubic hair 10.5 yrs
Maximal growth velocity 11.4 yrs
Menarche at 12.8 yrs
Adult pubic hair by 13.4 yrs
Adult breast by 14.6 yrs
Adolescent development
55% of cycles first year are anovulatory
Usually at least 15 months from menarche to achieve 10
cycles
Normal fertile adults have 1-2 anovulatory and 10-12
cycles per year
Adolescent menstrual pattern ends 2-3 yrs after
menarche
Tanner
Stages
Adolescent AUB, persistent
10% with menorrhagia will have coagulopathy
Most common are ITP, Von Willebrand’s,
Glanzmann's, Thalassemia major and Fanconi’s
anemia
Tests: INR, PTT, bleeding time, platelet count and
VonWillebrand’s screen
Other terms
Polymenorrhea; frequent cycles <18 days
Metrorrhagia; intermittent intermenstrual bleeding
Menorrhagia; regular but excessively heavy flow
Menometrorrhagia; irregular, frequent, heavy and
light bleeding
Hypomenorrhea; light flow at regular intervals
Oligomenorrhea; irregular, infrequent cycles >45 days
apart, ovulatory or anovulatory
Average menses
Estrogen + progesterone withdrawal
5 day flow (2-8 normal)
Volume loss 30 cc (>80 cc abnormal)
Average cycle range 21-35 days
Menstrual
cycle
Mature follicle 2-2.5
cm size
Corpus luteum
complex cyst 1-3 cm
size
Endometrial height
range 3-14 mm
Causes of anovulation (AUB-O)
Physiologic: adolescence, perimenopause, lactation
and pregnancy
Pathologic
Hyperandrogenic
Hypothalamic
Thyroid disease
Primary pituitary
Premature ovarian failure
Medications/herbal supplements
History the most important
Qualify and quantify bleeding: type of protection,
frequency of change saturation, clotting
Establish current complaint and find out what ‘normal’
menses usually are like OFF any hormonal
contraceptives (many women don’t think of hormonal
contraceptives as a medication)
Other symptoms such as cramping, dyspareunia
Evaluate use of medications prescriptive as well as
OTC and herbal supplements
Pregnancy
ALWAYS
check HCG
Polycystic ovary syndrome
Affects 1 in 9 women
Most common cause of anovulation
Diagnosis, Oligo or anovulation with one of:
Evidence of androgen excess
Polycystic ovary
Begins in teen years or early twenties
Multifactorial inheritance associated with insulin
resistance and metabolic syndrome. Family history of
type II DM
PCOS
Need to treat proactively with OCP’s, cyclic
progesterone to decrease their risk of endometrial
cancer from unopposed estrogen
For fertility purposes, use of insulin sensitizers
(metformin) may decrease insulin resistance enough
to allow ovulation along with low carb diet and
exercise. Ideal body weight the goal. Otherwise
ovulation induction needed to conceive.
Milder cases of PCOS ovulatory, low progesterone, and
have a higher risk of miscarriage
PCOS
Associated with
thyroid
dysfunction.
Hirsutism treated
with
spironolactone
and OCP’s
Endometrial
biopsy? When
needed?
Hypothalamic dysfunction
Hyper or hypothyroidism
Age factor in screening >35 hypo
Hyperprolactinemia
Amenorrhea or hypomenorrhea 2/3
Galactorrhea present in 1/3
Infertility with normal menses
Need repeat >48 hrs apart to confirm
Level >50 need to consider MRI of sella
Hypothalamic dysfunction
CNS suppression, low FSH and LH
Stress most common cause
Anorexia
Athletic
Lower suppression higher estradiol, more suppression
hypoestrogenic
Rare congenital absence of LH or mutation in
gonadotropins or GnRH (the latter primary
amenorrhea)
Coagulation disorder
Most common causes are ITP, VonWillebrand’s,
Glanzman’s, Thallasemia major or Fanconi’s anemia
Test for bleeding time, INR, PTT, platelet count and
VonWillebrand’s screen
Remember if severely anemic testing skewed
In adolescents 10% will have coagulopathy
Usually ovulatory cycles with severe menorrhagia
Tranexamic acid may be of benefit for some
Chromosome disorders
Suspect if initial normal cycles then irregular or
amenorrhea and evidence of diminished reserve
<25 y/o Turner mosaic more likely
Later 20’s to early mid 30’s diminished reserve
associated with Fragile X pre-mutation or on the older
end BRCA 1 mutation
If mutation and some reserve left consider ART
options: gamete freezing, IVF with PGD
Otherwise fertility with donor eggs and use of HRT or
OCP’s as replacement therapy till 50
Anatomic
causes of
AUB
Endometrial
polyp
Sub mucus
fibroid
Ovarian
masses
Endomctrioma
Hormone
secreting
tumors
PID
Malignancies
Endometrial cancer
What age should you biopsy to rule out?
Endometrial hyperplasia
Simple
Complex adenomatous
Atypical complex
Ovarian
Treatment of AUB
Anatomic causes treat and usually bleeding controlled.
If not likely hormone issue
Thyroid dysfunction treatment will resolve AUB once
normal functions after 2 months
Hyperprolactinemia treat with cabergoline or
bromocriptine. When prolactin normal, normal
menses in 2 cycles
If unable to treat cause then cyclic progestins or
hormonal contraceptives best treatment.
Treatment of hemorrhage
Usually at extremes of menstrual ages
Rule out pregnancy, trauma, coagulopathy; replace
blood products as needed
Endometrial biopsy depending on age and history
High dose IV conjugated estrogen 25 mg Q4-6 hrs till
bleeding slows then switch to oral estrogen and
progestin. Give for 3 weeks then withdrawal.
Antiemetics
Oral high dose E+P an option if stable
Cycle with hormonal contraceptives 2 months