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
• 16 year old G0P0 presents because 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?
A. Oral combined contraception pills will regulate her
cycles
B. She needs to do 3 months of a menstrual diary using
an App on her smartphone
C. She probably has a luteal phase defect and needs
progesterone days 15-25.
D. She has normal cycles and needs reassurance.
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 lasts 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 (variable)
• Begins with Menses & ends with luteinizing (LH) hormone
surge
• Ovulation (30-36 hours)
• Begins with LH surge and ends with ovulation
• Luteal (14 days)
• Begins with the end of the LH surge and ends with onset of
menses
Phases of the Menstrual Cycle
Endometrium
• Proliferative
• Begins with menses and ends at ovulation
• Secretory
• Begins at ovulation and ends with menses
Case Two
• A 25 year old G0P0 just moved to the area and desires a
pregnancy. She has irregular menses. She was told by
her previous doctor that she has polycystic ovarian
syndrome (PCOS) and does not ovulate. She has results
of a day 21 endometrial biopsy that shows “Secretory
Endometrium.” What can you tell this patient?
What can you tell this patient?
• The biopsy confirms anovulation
• The biopsy was done on the wrong day
• The biopsy confirms ovulation.
• This patient does not have PCOS
Compare
Phases of the
Reproductive Cycle
• Follicular
Phases of the
Endometrium
• Proliferative
• Ovulatory
• Secretory
• Luteal
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
Loop
Regulation of The Ovary
2 Cell Theory
• Theca Cell
• Granulosa Cell
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
Munro MG, FIGO Classification of AUB 2011
Clinical dimensions of menstruation and the
menstrual cycle
Descriptive terms
Normal limits (5th to 95th percentiles)
Frequency of menses (days)
Frequent
<24
Normal
24–38
Infrequent
>38
Absent
No
Regular
2–20 days
Irregular
>20 days
Prolonged
>8.0 days
Normal
4.5–8.0 days
Shortened
<4.5 days
Heavy
>80
Normal
5–80
Light
<5
Regularity of menses (cycle to cycle variation over
12 months)
Duration of flow (days)
Volume of monthly blood loss (mL)
History for AUB
• HPI
• Onset
• Quantity :
• Spotting or heavy
• daily or intermittent
• Duration
Ask lots of
questions!
History for AUB
• Associated Symptoms
•
•
•
•
•
Pain
Nausea
Fatigue
Headache
Mastalgia
• Gender Specific
• Menstrual
• Contraception
• Gynecologic
• Obstetric
• Sexual
• Genital Infections
Other Important Details
• Family History
• Anyone else?
• Von Willebrand's
• PCOS
• PSH
• Nutrition and exercise
• Weight changes
• Exercise habits
• Diet
• PMH
• Chronic conditions
• Liver disease
• Kidney disease
• Anemia
• Drugs /medications
• Psychiatric
medications
• Thyroid Disorders
• Blood thinners
Case Three
• 48 year old G2P2, S/P Bilateral Tubal Ligation 14 years
ago, referred from her primary care office with RLQ pain
of 3 months duration. LMP 5 weeks ago has had many
years of irregular menses thought to be menopause
transition.
• Ultrasound shows an 8 cm adnexal cyst
with CA 125
normal.
The next step is:
• Get her on the schedule for surgery
• MRI
• Order Follicle Stimulating hormone(FSH)
• Urine Pregnancy Test
• Estradiol
Pregnancy
Age is not an
issue!
Assumption
can lead to
death
Never forget
pregnancy
Prove it!
Differential Diagnosis Of AUB
• Structural:
PALM-COEIN
(Non Gravid Women)
• Life Cycles:
Pre-menarche
Menarche
Reproductive
Post-Menopause
• Anatomic:
“Bottoms Up”
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)
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)
Case Four
• 42 year old G3P3 who 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, and
her pregnancy test is negative.
The best next step in evaluating her
heavy uterine bleeding:
• Fasting Blood Glucose
• Thyroid Stimulating Hormone
• Liver Function Test
• Follicle Stimulating Hormone
• Estradiol
What FIGO nomenclature would you use
to label her AUB?
• AUB-C
• AUB-O
• AUB-E
• AUB-I
• AUB-N
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.
Differential
Diagnosis
of AUB
Pre-menarche
•E2 withdrawal
@birth
•Foreign Body
•Sarcoma
•Ovarian Tumor
•Trauma
Etiology
of AUB
Life Cycles
Approach
Menarche
•Coagulation
Defects
•Hypothalamic
Immaturity
•Psychogenic
Reproductive
•Pregnancy
•Anovulation
•Endogenous
•Exogenous
•Anatomic
PostMenopausal
•Carcinoma
•Vaginal Atrophy
•E2 Replacement
•Anatomic
Differential Diagnosis of AUB:
Anatomical
• “Bottoms Up”
• Vulva
• Vagina
• Cervix
• Ovary
• Brain
• Contiguous Anatomy
• GU
• GI
• Non-Pelvic Etiology
• Endogenous
• Iatrogenic
EVALUATION OF AUB
Pregnant?
NO
YES
Evaluate for
complications
IUP, SAB, Ectopic
Structural (PALM)
VS.
Non-Structural (COEIN)
Acute * Sub-Acute * Chronic
AUB
Initial Assessment
• History & Physical
• Vital Signs
• Shock Signs
• Laboratory
• Pregnancy Test
• Complete Blood Count
Evaluation
Evaluation of the Uterus &
Endometrium
• Endometrial Biopsy
• Transvaginal &/or
abdominal Ultrasound
(TVS/AUS)
• Saline Sono-hysteroscopy
(SIS)
• Hysteroscopy
Endometrial Biopsy (EMB)
• Evaluation of the
Endometrium
• Pipelle
TVS & SIS
TVS
SIS
Evaluation
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
• Parenteral estrogens
• Anti-fibrinolytics
• Androgens
• Anti-prostiglandin
• GnRH agonists
• Progestins
• Anti-progestational
• Estrogen +
progestins (OCP)
agents
Surgical Approach
Minimally Invasive Surgery
• Intrauterine Device (IUD)
with progesterone
• Dilation & Curettage
Major Surgery
• Myomectomy
• Total Abdominal
Hysterectomy (TAH)
• Total Vaginal Hysterectomy
(TVH)
• Laparoscopic Hysterectomy
• LSH (laparoscopic supra-
• Endometrial Ablation
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?
The Best Next Step?
• Oxygen & IV Fluids
• Type and Cross 2 units of blood
• Order a pelvic ultrasound
• Order TSH, CBC, Coagulation panel
• IV Conjugated Equine Estrogen
• Consent for surgery
Management
Chronic,
Stable AUB
Acute AUB
• Can be a life-threatening
emergency
• Combined Oral
• Monitor vital signs, Start
oxygen
• IV fluids (wide bore IV
catheter)
• Type and Cross 2-4 units of
blood
• IV Estrogen
• IM Progesterone
• NSAIDS (Anti-prostaglandins
vs. Anti-fibrinolytics)
• Emergency D&C
•
•
•
•
Contraception
AUB-O progestin therapy
Levonorgestrel IUD
Endometrial sampling is
indicated prior to starting
hormones in older women
Medical failures have the
surgical options
Clinical Pearls
Never
Forget
Pregnancy!
PROVE IT!
Age is
Not an Issue!
Assumptions Can
Lead to Death!
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