Transcript Abnormal Uterine Bleeding

Abnormal Uterine
Bleeding
District 1 ACOG Medical Student
Education Module 2011
What is normal uterine bleeding?
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Age of patient
Frequency
Duration
Flow
What is normal uterine bleeding?
• Frequency of menses
– 21 days (0.5%) to 35 days (0.9%)
• Age 25, 40% are between 25 and 28 days
• Age 25-35, 60% are between 25 and 28 days
• Teens and women over 40’s cycles may be longer
apart
Munster K et al, Br J Obstet Gynaecology
What is normal uterine bleeding?
• Duration of menses
– 2 days to 8 days
• Usually 4-6 days
Hallberg L et al, Acta Obstet Gynecology Scandinavica
What is normal uterine bleeding?
• Flow/amount of menses
– Normal volume of menstrual blood loss is
30 cc
Hallberg L et al, Acta Obstet Gynecology Scandinavica
Traditional terminologies
• Menorrhagia
– Regular intervals, excessive menstrual blood
loss
• amount >80mL
• Metrorrhagia
– Irregular intervals, excessive flow and duration
• Oligomenorrhea
– Interval longer than 35 days
• Polymenorrhea
– Interval less than 21 days
Cohen BJB et al, Obstetrical and Gynecologic Survey
Differential diagnosis
• Pregnancy related complications
– ectopic, inevitable
Differential diagnosis
• Disease of the cervix
– Polyp, ectropian, dysplasia, invasive
cancer
Differential diagnosis
• Disease of the uterus
– Infection: endometritis
– Endometrial polyp, adenomyosis, hyperplasia,
adenocarcinoma
– Fibroids
• One third of patients with symptoms
– Correlation between the severity of the bleeding and
the area of endometrial surface
» Sehgal N, et al American Journal of Surgery
– Histologic abnormalities of the endometrium, ranging
from atrophy to hyperplasia
» Deligdish, et al Journal of Clinical Pathology
– Endometrial venule ectasia
» Faulkner RL American J of Obstetrics and Gynecology; Farrer-Brown G, et
al Journal of Obstetrics and Gynaecology Br Common W
Differential diagnosis
• Disease of the ovary
– Germ cell tumors
• Choriocarcinomas
• Embryonal carcinoma
– Sex cord-stromal tumors
• Granulosa cell tumors(1-2% of all ovarian
tumors)
– Peak incidence between 50 and 55 years of age
Differential diagnosis
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Thyroid disease
Prolactinomas
Coagulation defects
Renal, liver failure
Differential diagnosis
• Trauma
• Foreign bodies
Differential diagnosis
• Dysfunctional uterine bleeding
– Anovulatory cycles
• Loss of normal regulatory mechanism
– Immaturity
– Dysfunction
» Psychiatric medications, stress, anxiety,
exercise, rapid weight loss, anorexia nervosa
• Ovarian failure
• Obesity
• PCOS
Evaluation
• History and physical
• Labs
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Pregnancy test
CBC
TSH
Prolactin
(Liver function tests)
(Coagulation panels)
(Androgen profile)
• Testosterone, DHEAS, Hydroxyprogesterone
Evaluation (cont)
• Cytopathology
– Pap
– Endometrial biopsy
• Imaging studies
• Surgical
– D&C hysteroscopy
Treatments
• Medical therapy
– Hormonal
• Progestin, estrogen (IV), combination OCPs
• GnRH agonist
• Surgical therapy
– D&C
– Endometrial ablation
– Myomectomy/hysterectomy
• Radiologic therapy
– Uterine artery embolization (UAE)
Anovulatory Bleeding:
Adolescents (13-18 years)
• Anovulatory bleeding may be normal
physiologic process, with ovulatory cycles
not established until 1-2 yrs after
menarche (immature HPG axis)
• Screen for coagulation disorders (PT/PTT,
plts)
• May be caused by leukemia, ITP,
hypersplenism
• Consider endometrial bx in adolescents
with 2-3 year history of untreated
anovulatory bleeding, especially if obese
Anovulatory Bleeding:
Management in Adolescents
• High dose estrogen therapy for acute
bleeding episodes (promotes rapid
endometrial growth to cover denuded
endometrial surfaces): conjugated equine
estrogens PO up to 10 mg/d in 4 divided doses
or IV 25 mg q 4 hrs for 24 hrs
• Treat pts with blood dyscrasias for their
specific diseases, r/o leukemia
• Prevent recurrent anovulatory bleeding with:
• cyclic progestin (i.e. Provera)
or
• low dose (≤ 35 μg ethinyl estradiol) oral contraceptive
– suppresses ovarian and adrenal androgen production and
increases SHBG  decreasing bioavailable androgens
Anovulatory Bleeding:
Reproductive Age (19-39 years)
• Anovulatory bleeding not considered physiologic,
evaluation required
• 6-10% of women have hyperandrogenic chronic
anovulation (i.e. PCOS), characterized by noncyclic
bleeding, hirsutism, obesity (BMI ≥ 25)
– Underlying biochemical abnormalities: noncyclic estrogen
production, elevated serum testosterone, hypersecretion of
LH, hyperinsulinemia.
– h/o rapidly progressing hirsutism with virilization suggests
tumor
• Lab testing: HCG, TSH, fasting serum prolactin
– If androgen-producing tumor is suspected, serum DHEAS
and testosterone levels
– If POF suspected, serum FSH
• Chronic anovulation resulting from hypothalamic
dysfunction (dx’d by low FSH level) may be due to
excessive psychologic stress, exercise, or weight loss
Anovulatory Bleeding:
Reproductive Age (19-39
yrs)
When is endometrial evaluation indicated?
• Sharp increase in incidence of endometrial
CA from 2.3/100,000 ages 30-34 yrs 
6.1/100,000 ages 35-39 yrs
• Therefore, endometrial bx to exclude CA
is indicated in any woman > 35 yrs old with
suspected anovulatory bleeding
• Pts 19-35 who don’t respond to medical
therapy or have prolonged periods of
unopposed estrogen 2/2 anovulation merit
endometrial bx
Anovulatory Bleeding:
Reproductive Age (19-39
yrs)
Medical therapies
• Can be treated safely with either cyclic progestin
or OCPs, similar to adolescents.
• Estrogen-containing OCPs
– relatively contraindicated in women with HTN or DM
– contraindicated for women > 35 who smoke or have h/o
thromboembolic dz
• If pregnancy is desired, ovulation induction with
clomid is initial tx of choice
– Can induce withdrawal bleed with progestin (i.e.
provera), followed by initiation of therapy with
Clomid, 50 mg/d for 5 days, starting b/t days 3
and 5 of menstrual cycle
Anovulatory Bleeding:
Later Reproductive Age (40Menopause)
• Incidence of anovulatory bleeding
increases toward end of reproductive
years
• In perimenopausal women, onset of
anovulatory cycles is due to declining
ovarian function.
• Can initiate hormone therapy for cycle
control
When is endometrial evaluation indicated?
• Incidence of endometrial CA in women 4049 years: 36.2/100,000
• All women > 40 yrs who present with
suspected anovulatory bleeding merit
Anovulatory Bleeding:
Later Reproductive Age (40Menopause)
Medical therapy
• Cyclic progestin, low-dose OCPs, or
cyclic HRT are all options
• Women with hot flashes secondary to
decreased estrogen production can have
symptomatic relief with ERT in
combination with continuous or cyclic
progestin
Anovulatory Bleeding:
Later Reproductive Age (40-Menopause)
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Surgical therapy
Surgical options include: hysterectomy and
endometrial ablation
Surgical tx only indicated when medical mgmt has
failed and childbearing complete
Some studies suggest hysterectomy may have higher
long-term satisfaction than ablation
Endometrial ablation: NovaSure, thermal balloon
– YAG laser and rollerball less widely-used currently
– 45% of women achieve amenorrhea after YAG laser or
resectoscope. 12 month post-op satisfaction is 90%. Only
15% of women achieve amenorrhea after thermal balloon
ablation, and 1 yr satisfaction rate still 90%
– Long-term satisfaction with ablation may be lower:
• in 3-year f/u study, 8.5% of women who had undergone ablation
were re-ablated, an additional 8.5% had hyst
• In a 5-year follow up study, 34% of women who underwent
ablation later had a hyst.