Transcript Clinical Diagnosis & Management of Abnormal Uterine Bleeding

Normal &
Abnormal
Uterine
Bleeding
Suzanne Bush, MD, FACOG
Clinical Associate Professor
FSU College of Medicine
Objectives





Recognize the characteristics of Normal
Menstrual Bleeding (The LMP as the fourth vital
sign!)
Describe the etiologies of Abnormal Uterine
Bleeding (AUB.)
Understand etiologies of AUB with respect to
the life stages of women.
Understand the diagnostic tools to identify the
etiology of the AUB.
State the medical & surgical options available
in primary care and gynecology settings.
Case One
 22
year old G0P0 presents for well woman
care. She is concerned about her periods
being irregular. She describes her cycles
as coming the 18th of one month & the
16th the next month. She never knows
when it is coming.
 How
would you counsel this patient?
Normal Menstruation
 The
Menstrual Cycle
In the normal menstrual cycle, orderly cyclic
hormone production and parallel proliferation of
the uterine lining prepare for implantation of the
embryo.
Berek & Novak’s Gynecology, 2012, p.145
Normal Menstruation
 “The
menstrual cycle starts with the first day of
bleeding of one period and ends with the first
day of the next. In most women, the cycle last
about 28 days. Cycles that are shorter or longer
by 7 days are normal.”
ACOG Website: FAQ095
The Normal Menstrual Period
 Blood
loss < 80 ml
(average 30-35 ml)
 Duration of flow 2-7 days
(average 4 days)
 Cycle length 21 - 35 days
(average 29 days)
(28 days +/- 7 days}
Phases of the Menstrual Cycle
Reproductive Cycle
 Follicular

Begins with Menses ends with luteinizing (LH) hormone
surge
 Ovulation

Begins with LH surge and ends with ovulation
 Luteal

(30-36 hours)
(14 days)
Begins with the end of the LH surge and ends with
onset of menses
The Normal Menstrual Cycle
Another Way of looking at it
M. Manting; DUB LECTURE 2008
Phases of the Menstrual Cycle
Endometrium
 Proliferative

Begins with menses and ends at ovulation
 Secretory

Begins at ovulation and ends with menses
The Normal Menstrual Cycle
Another Way of looking at it
M. Manting; DUB LECTURE 2008
Regulation:
Hypothalamic Pituitary Axis
 Hypothalamus
is the
pulse generator
mediated through
GnRH
 GnRH
cannot be
directly measured
 Negative
Feedback
Regulation of The Ovary
2 Cell Theory
 Theca
Cell
 Granulosa
Cell
Case One
 22
year old G0P0 presents for well woman
care. She is concerned about her periods
being irregular. She describes her cycles
as coming the 18th of one month & the
16th the next month. She never knows
when it is coming.
 How
would you counsel this patient?
How would you counsel this
patient?
Abnormal Uterine Bleeding
(AUB)

Definition:
 Any
change in
menstrual
period
Flow
Duration
Frequency
Bleeding
between
cycles
 Prevalence:
 20
million office
visits/year
 25% of visits to
gynecologists
Old Terminology
 Menorrhagia
 Dysmenorrhea
 Metrorrhagia
 Amenorrhea
 Menometrorrhagia
 Oligomenorrhea
 Polymenorrhea
 Hypomenorrhea
New Terminology
 Heavy


Menstrual Bleeding
Acute
Chronic
 Intermenstrual
Bleeding
History for AUB
 HPI
Onset
Quantity :
Spotting or heavy
daily or intermittent
Duration
History for AUB
 Associated
Symptoms
 Pain
 Dysmenorrhea
 Menstrual
Changes
 Timing
 Flow (clots)
 Frequency
 Fever/chills
 Changes
in hair/
body
 Bruising/bleeding
 Rectal/urethral
bleeding
 Nausea/vomiting
Gender Specific History
 Menstrual
 Contraception
 Gynecologic
 Obstetric
 Sexual
 Genital
Infections
Other Important Details

Family History



Anyone else?
Von Willebrand's
PCOS

PMH

Chronic conditions




PSH
Nutrition and
exercise



Weight changes
Exercise habits
diet





Liver disease
Kidney disease
Anemia
Drugs /medications
Psychiatric
medications
Thyroid Disorders
Blood thinners
Case Two
 48
year old G2P2, S/P Bilateral Tubal
Ligation 14 years ago, presents to your
office with RLQ pain of 3 months duration.
LMP 5 weeks ago has had many years of
irregular menses thought to be PCOS.
 Ultrasound shows an 8 cm adnexal cyst
with CA 125 normal.
Differential Diagnosis Of AUB
Structural:
PALM-COEIN
(Non Gravid Women)
Life
Pre-menarche
Menarche
Reproductive
Post-Menopause
Cycles:
Anatomic:
“Bottoms Up”
Pregnancy
Age is Not
An Issue!
Never
Forget
Pregnancy
PROVE IT!
Assumptions can
lead to death
PALM-COEIN
 FIGO
Classification System (PALM-COEIN)
for causes of AUB in non gravid women of
reproductive age
 Structural
vs. Non-Structural
 Developed
to create a universally
accepted nomenclature
PALM
Structural Causes
P- Polyp (AUB-P)
A- Adenomyosis (AUB-A)
L- Leiomyoma (AUB-L)
Submucosal myoma (AUB-LSM)
Other myoma (AUB-LO)
M- Malignancy & hyperplasia (AUB-M)
COEIN
Non-Structural Causes
C- Coagulopathy (AUB-C)
O-Ovulatory dysfunction (AUB-O)
E- Endometrial (AUB-E)
I- Iatrogenic (AUB-I)
N- Not yet classified (AUB-N
AUB-O
 Abnormal
Uterine Bleeding with ovulatory
dysfunction
 Heavy, irregular bleeding
Causes of Anovulation:
Physiologic
 Adolescence
 Menopause
 Lactation
 Pregnancy
Transition
Causes of Anovulation
Pathologic
 Hyperandrogenic
anovulation (e.g.,
PCOS, CAH, or
androgenproducing tumors)
 Hypothalamic
dysfunction
 Hyperprolactinemi
a
 Thyroid
disease
 Pituitary disease
 Premature ovarian
failure
 Iatrogenic
(Chemo)
 Medications
Case #2
 28
yo nulliparous female presents with
history of heavy menstrual bleeding. On
further questioning she states that she has
always bled heavy and irregularly since
menarche @ age 12. She is always
anemic & tired.
 Her physical exam is noted for a BMI of
47. There is no hirsutism, acne or skin
changes.
Case # 3
 42
year old G3P3 who goes is in your civic
group presents with heavy, cyclic uterine
bleeding. You note spider angioma
across her chest & down her arms. She
has a slightly protuberant abdomen. Her
husband had a vasectomy 7 years ago.
The next step in evaluating
her heavy uterine bleeding:
Liver Disease
 Patients
known to have liver disease manifest
additional symptomatology because of
abnormal hepatic function.
 Evaluate
patients for spider angioma, palmar
erythema, splenomegaly, ascites, jaundice, and
asterixis.
Coagulation Disorders
Coagulation Disorders
Inherited
von Willibrand's
hemophilia
Acquired
ITP
leukemia
Rule out
von Willebrand's
in any girl who
requires
transfusion for excessive
bleeding
when first
starting periods
Drug Induced
coumadin/heparin
aspirin
Bleeding from
ther Sites
 GI

Neoplasia or hemorrhoids
 GU


Urethral caruncle or diverticulum
Renal lithiasis or hemorrhagic cystitis
 GYN


Labia, cervix, or vagina
Trauma, infection, or
neoplasia
Remember
Hemoccult
& Urinalysis
Differential Diagnosis
of AUB: Life Cycles
 Pre-Menarche
 Menarche
 Reproductive
 Postmenopausal
Etiology
of AUB
Life Cycles
Approach
Premenarchal
•E2 withdrawal
@birth
•Foreign Body
•Sarcoma
•Ovarian Tumor
•Trauma
Menarche
•Coagulation
Defects
•Hypothalamic
Immaturity
•Psychogenic
Reproductive
•Pregnancy
•Anovulation
•Endogenous
•Exogenous
•Anatomic
PostMenopausal
•Carcinoma
•Vaginal Atrophy
•E2 Replacement
•Anatomic
Differential Diagnosis of AUB:
Structural
 “Bottoms





Vulva
Vagina
Cervix
Ovary
Brain
Up”
 Contiguous
Anatomy


GU
GI
 Non-Pelvic


Etiology
Endogenous
Iatrogenic
Vulvar
 Infections
 HPV
 Atrophy
 Benign
Lesions
 Cancerous lesions
 Dermatologic Causes
PHYSICAL EXAM: INSPECTION IS IMPORTANT
Vagina
 Malignancy


Carcinoma
Sarcoma
:
 Laceration/trauma
 Infections
 Atrophic
 Foreign
 Granulomatous



bodies
Diaphragm, Pessary
Tampon
other
changes
tissue


formed after surgery
post hysterectomy
Physical Exam: Inspection is important
Cervix
 Neoplasia



Cancer
Polyps
Myomas
Cervical Eversion (Ectropion)
 Infection



Cervicitis
Condyloma Acuminata
IMPORTANT:
Visualize the Cervix!
Uterus
 Myomas
Postmenopausal
Bleeding
is considered
endometrial cancer
until proven otherwise
 Polyps
 Endometrial
Hyperplasia
 Endometrial Carcinoma
 Atrophy
PHYSICAL EXAM: Bimanual Exam checks
enlargement
Postmenopausal
bleeding
is evaluated
by an
Endometrial
biopsy
Most PMB
Is due to
Atrophy
Ovary
 Anovulation
 PCOS
 Menopause
Transition
Pathophysiology
Etiologies Of AUB
 Estrogen
Withdrawal
 Estrogen
Breakthrough
 Progesterone
Withdrawal
Clinical Management of Abnormal Uterine Bleeding:
APGO Educational Series, May 2002, p. 8.
Initial Assessment of AUB
Acute
Sub-Acute
Chronic
Initial Assessment of AUB
 History


& Physical
Vital Signs
Shock Signs
 Laboratory


Pregnancy Test
Complete Blood Count
EVALUATION OF AUB
Pregnant?
YES
NO
Evaluate for
complications
Structural (PALM)
IUP, SAB, Ectopic
Non-Structural (COEIN)
VS.
Evaluation of AUB

Evaluation of the Endometrium

Endometrial Biopsy
 Transvaginal &/or abdominal Ultrasound (TVS/AUS)
 Saline Sono-hysterocopy (SIS)
 Hysteroscopy
Evaluation of the Uterus
 TVS
 SIS
 Hysteroscopy


Pregnancy test
Endometrial Biopsy (EMB)
 Evaluation
of the
Endometrium

Pipelle
Transvaginal Ultrasound
 To

assess for thickened endometrium
In 92% of abnormal endometrial biopsies,
ultrasound showed >5mm endometrium
 In
96% of endometrial cancer by biopsy
result, ultrasound showed >5mm
endometrium
 Therefore,
ultrasound measured
endometrium <5mm is likely benign uterine
condition
TVS & SIS
TVS
SIS
Hysteroscopy
MRI
 Precisely
localizes sub-mucosal fibroids
 MRI
is not superior to TVS & SIS in overall
diagnostic potential
Dueholm M, et al. Fertil Steril. 2001;76(2):350357
Treatment of AUB
 Observation
 Medical
 Minimally
invasive surgery
 Major surgery
Medical Management
 Iron
 Anti-fibrinolytics
 Progestins
 Estrogen
(OCP)
+ progestins
 Parenteral
estrogens
 Androgens
 GnRH agonists
 Anti-progestational
agents
Minimally Invasive Surgery
 Intrauterine
 Dilation
Device (IUD) with progesterone
& Curettage
 Endometrial
Ablation
Major Surgery
 Myomectomy
 Total
Abdominal Hysterectomy (TAH)
 Total Vaginal Hysterectomy (TVH)
 Laparoscopic Hysterectomy




LSH (laparoscopic supra-cervical)
TLH (total laparoscopic)
LAVH (laparoscopically assisted vaginal
hysterectomy)
Robotic (TLH or LSH)
Final Case
 32
year old G2P2002 presents to the ER
with 10 day history of heavy uterine
bleeding. She is pale and appears
frightened. Pulse is 120, BP is 90/60.
Hemoglobin is 6, Hematocrit is 18.
Pregnancy test is negative.
How do you manage this patient?
How would you manage
this patient?
Management of Acute AUB
 Can



 IV
be a life-threatening emergency
Monitor Vital signs, Start oxygen
IV fluids (wide bore IV catheter)
Type and Cross 2-4 units of blood
Estrogen
 IM Progesterone
 NSAIDS (Anti-prostaglandins vs. Antifibrinolytics)
 Emergency Dilatation and Curettage
(D&C)
Treatment in Chronic,
Stable AUB
 High
dose OCP’s to slow the bleeding
 Anovulatory Bleeding can be treated with
progesterone alone
 Endometrial sampling is indicated prior to
starting hormones in older women
Clinical Pearls
Never
Forget
Pregnancy!
Age is
Not an Issue!
Assumptions Can
Lead to Death!
PROVE IT!
References







ACOG Practice Bulletin No. 136, July 2013
Beckmann, et al., Obstetrics & Gynecology, 7th
ed., Chapters 37, 39
Clinical Management of Abnormal Uterine
Bleeding: APGO Educational Series, May 2002
Dueholm M, et al. Fertil Steril. 2001;76(2):350357
Fritz, MA, Speroff et al, Clinical and Gynecologic
Endocrinology and Infertility,
8th ed. 2011.
Manting M., AUB Lecture 2008
Munro, MG, et al, FIGO Classification System
(PALM-COEIN) for causes of AUB in non gravid
women of reproductive age. Int J Gynaecol
Obstet 2011; 113:3-13