Transcript Rule Out Pregnancy

Managing Menstrual Abnormalities
Jan Shepherd, MD, FACOG
Objectives
• Identify common causes of menstrual
abnormalities and discuss their pathophysiology.
• Describe office, laboratory, and additional
evaluation of menstrual abnormalities.
• Identify management options for acute and
chronic abnormal uterine bleeding.
The Normal Menstrual Period
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Blood loss < 80 cc
(average 30-35 cc)
Duration of flow 2-7 days (average 4 days)
Cycle length 21-35 days (average 29 days)
Mid-cycle spotting can occur with ovulation, but
other bleeding between periods is abnormal
Consider using menstrual calendar to evaluate
Abnormal Uterine Bleeding (AUB)
• Any change in menstrual period
– Flow (menorrhagia)
– Duration
– Frequency (polymenorrhea)
– Bleeding between cycles (metrorrhagia)
• 20 million office visits/year
• 25% of visits to women’s health practitioners
Causes of Abnormal Uterine Bleeding
• Complications of Pregnancy
– Miscarriage/Retained tissue
– Ectopic pregnancy
– Trophoblastic disease (e.g. molar pregnancy)
• Pelvic Pathology
– Vaginal/Vulvar
– Cervical – infection, polyp, dysplasia/Ca
– Uterine – endometrial polyps, hyperplasia/Ca
Uterine Fibroids (Leiomyomata)
• Occur in 20-40% of
reproductive-aged
women
• Rule out other causes!
• Diagnosis based on
physical exam
• Ultrasound for
– Rule out submucous
– Uncertain adnexal status
– Worrisome interval growth
Coagulation Disorders
• Inherited coagulopathy is the cause of AUB
in 18% of Caucasian and 7% of AfricanAmerican women
• Most commonly presents in adolescence
• Von Willebrand’s disease is the #1etiology
– Occurs in ~1% of Caucasians
– Order coagulation screen and Von Willebrand’s
factor (ristocetin cofactor assay) or PFA-100
– Consider referral to hematologist
Common Medical Causes of AUB
• Endocrinopathies
– Thyroid most common
• Systemic diseases
– Blood dyscrasias (e.g. leukemia, ITP)
– Liver or kidney disease
• Medications
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Hormones, including contraception, HRT, corticosteroids
Psychotropic drugs
Anticoagulants
Herbs and botanicals – esp. soy, ginseng, ginkgo
Dysfunctional Uterine Bleeding (DUB)
• No anatomic, systemic or iatrogenic cause
• Presumed disruption in normal ovarian function
– Usually anovulation (“Anovulatory bleeding”)
• Continuous estrogen exposure causes excessive
endometrial proliferation; no progesterone to control
and stabilize this growth  uncoordinated shedding
• DUB usually irregular cycles, heavy, and long duration
• Unopposed estrogen can lead to endometrial Ca
The Normal Menstrual Cycle
Common Etiologies for DUB
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Perimenarche or perimenopause
Obesity
Stress (emotional or physical)
Other hormone imbalance (esp. PCOS)
Checklist for
Making the Diagnosis in AUB
Important Elements in History of AUB
• Onset
– Gradual vs. sudden
– Perimenarche, perimenopause
– Temporal associations (postcoital, postpill, postpartum)
• Characteristics
– Volume
– Duration
• Is she ovulating?
– Regularity? Variability?
– Menstrual cramps? PMS?
– History of infertility
Associated Symptoms
• Systemic symptoms
– Weight gain or loss
– Fatigue, N&V
– Fever
• Symptoms of endocrinopathy
– Androgen Excess
– Thyroid
– Pituitary
• Symptoms of coagulopathy
Additional Focused History
• Gynecologic history
– Pap tests and annual exams
– Past pelvic surgeries or problems
• Past Medical History
– Medical illnesses
– Surgeries
– Medications
• Family History
– Menstrual Abnormalities
– Coagulopathies
– Gynecologic cancers
Checklist for Physical Exam for AUB
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Bruising, petechiae
Low or high BMI
Hirsutism or acne (Hyperandrogenism)
Acanthosis nigricans
Enlarged thyroid or thyroid nodule
Galactorrhea
Complete pelvic exam
Checklist for Laboratory Evaluation of AUB
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Rule Out Pregnancy
CBC
TSH
Coagulation profile if indicated (esp teenager)
Chem screen if indicated
17OHP, Testosterone, and DHEAS if
indicated
Additional Testing
• Endometrial Biopsy (esp if DUB suspected)
– > 35 years old
– obese, diabetic, hypertensive
– PCOS
• Findings
– Proliferative vs secretory endometrium (is she ovulating?)
– Simple or complex hyperplasia +/- atypia, endometrial ca
– Chronic endometritis
– Atrophic endometrium
– Insufficient for diagnosis  needs further testing
Additional Testing
• Transvaginal Ultrasonography
– Measure endometrial stripe (< 5 mm reassuring)
– Rule out endometrial pathology, fibroids, ovarian
pathology
• Saline Installation - Sonohysterography
– Useful in further evaluating intracavitary
abnormalities
– Superior to TVS alone
Saline Installation Sonography
Additional Testing
• Hysteroscopy with directed biopsy
– Definitive diagnosis
– Excision of endometrial polyps, submucous fibroids
• MRI
– Can further characterize pelvic and intrauterine
lesions, e.g. adenomyosis vs fibroids, penetration
depth of fibroids
Endometrial Polyps
Slide courtesy of Linda Darlene Bradley, MD.
Am Fam Physician 2004;69:1915-26.
Management of AUB
Management of Acute AUB/DUB
• Can be a life-threatening emergency
– Monitor Vital signs
– IV fluids
– Type and Crossmatch
• Estrogen - 25 mg IV q 4-6 hrs x 24 hrs
or 10-20 mg po in 4 divided doses over 24 hrs
• 30-35 μg OCP, Norethindrone acetate 5 mg,
or Medroxyprogesterone acetate 20 mg
tid x 7, tapering to qd x 3-6 weeks
Management of Chronic AUB/DUB
• General Health Measures
– weight control
– stress reduction
– iron supplements
• NSAIDS (Antiprostaglandins) – blood loss  50-80%
• NEW – Tranexamic acid – superior to NSAIDS
– Blocks plasminogen/plasmin  prevents breakdown of
fibrinogen  preserves fibrin matrix  stabilizes clots
– Two 650 mg tabs tid x 5 days per cycle
– Contraindicated with thrombophilia and with OCPs
Management of Chronic AUB/DUB
• Progestins (control bleeding & prevent endometrial Ca)
– Oral contraceptives, if not contraindicated
– Cyclic progestins (days 5-26)
• Norethindrone acetate
• Medroxyprogesterone acetate
– Progestin-only contraception
• Progestin-only pills
• Depo Provera
– Levonorgestrel IUC
• Endometrial Ablation
LNG IUS vs Endometrial Ablation
Year 1
Year11
Year
YearYear 1
Year 2
Recent Meta-analysis 
Efficacy of LNG IUS 
Endometrial Ablation
up to 2 years after
treatment
Year 3
Obstet Gynecol 2009;113:1104-16.
Global Endometrial Ablation
• Indication
– Idiopathic menorrhagia (pathology ruled out) in
premenopausal woman who has completed childbearing and
failed hormonal therapy
• Contraindications
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Pregnancy or desire for future pregnancy
Premalignant endometrial changes or endometrial carcinoma
History of classical C-section or transmural myomectomy
Uterine anomaly
Untreated PID, hydrosalpinx
Considerations for Endometrial Ablation
• Patient expectations
– Does she understand she will still need contraception?
– Will she be satisfied with reduced flow?
• 23% amenorrhea1
– 16% will need further treatment within 5 years1
• 20-40% in other series
– Highest failure rate1
• Age < 45
• Parity > 5
1. Obstet Gynecol 2009;113:97-106.
Comparison of Methods
Obstet Gynecol 2006;108:990-1003.
Case
• A 14-year-old Caucasian female is brought in by
her mother because she has been having
periods every 2 weeks for the past 3 months.
Currently she has been bleeding for 2 days, is
filling a pad every 3 hours, and flooding the bed
overnight. Periods began at age 13 but were
initially 3 months apart and not as heavy.
Patient and her mother deny any past medical
problems and state she is not sexually active.
Adolescent
• Pregnancy test!
• Rule out coagulation disorder
– Order CBC,coag screen and Von Willebrand’s
panel (vWF, ristocetin cofactor, PFA-100, etc.)
• OCP or Norethindrone acetate 5 mg tid x 7,
tapering to qd x 3 weeks
• Consider maintenance OCP
Case
• A 36-year-old Caucasian female g2p2 presents
c/o bleeding constantly for over a month. The
flow has varied but now fills about 5 pads per
day. Her periods have been increasingly
irregular, heavy, and long for the past few years.
PE reveals BMI of 36, bp 140/86, pelvic exam
difficult to evaluate but no gross abnormalities
noted. Bright red blood seen flowing from
cervical os. How will you manage this patient?
Obesity-Related AUB
• Pregnancy test!
• Estrogen excess  Consider endometrial biopsy
• Norethindrone acetate 5 mg tid x 7, tapering to
qd x 3 weeks
• Consider Mirena IUC
• Consider maintenance progestin therapy:
medroxyprogesterone acetate 5-10 mg or
norethindrone acetate 5 mg cycle days 5-26
Case
• A 49-year-old AA woman g2p2 presents c/o
almost continuous bleeding for the past month.
Her menses have been becoming further apart
(LMP 3 months ago), heavier, and longer, but
this is the worst so far. She has been having
some hot flashes lately but otherwise feels well.
She was told in the past that she had uterine
fibroids and is currently taking medication for
hypertension. Her BMI is 28.
Perimenopausal Woman
• Pregnancy test!
• Consider endometrial biopsy
• Norethindrone acetate 5 mg tid x 7,
tapering to qd x 3 weeks
• Consider
– Maintenance OCP, if not contraindicated
– Maintenance progestin therapy
– Levonorgestrel IUC
COCPs for Perimenopause
• Benefits
– Regulation of menses
– Symptom relief
– Maintenance of bone density
• Risks
– Safe for nonsmokers with no CV risk factors
– Incidence of VTE increases at age 40
• Exercise caution with high risk, esp. obesity
IUCs for Perimenopausal Women
• Among perimenopausal women who are bleeding
normally or less frequently, either the Copper IUC or
the levonorgestrel IUC is acceptable
• Among women who are bleeding abnormally
– Preinsertion endometrial evaluation is recommended
– If no intrauterine pathology, hormone-releasing IUDs
may help control bleeding and prevent endometrial
hyperplasia
Innovative Management of Fibroids
• Medical
– GnRH agonists/antagonists
– Aromatase inhibitors (anastrozole, letrozole)
– Anti-progesterone (mifepristone)
• Interventional
– Endometrial Ablation
– Endoscopic myomectomy
• Hysteroscopy
• Laparoscopy
– Radiologic management
• Uterine artery embolization
• MRI-guided focused ultrasound (ExAblate)
Amenorrhea/Oligomenorrhea
Definitions
• Primary Amenorrhea – no spontaneous uterine
bleeding by the age of 16
• Secondary Amenorrhea – absence of menses
for 6 months or more
• Oligomenorrhea – menstrual cycle > 35 days
Causes of Primary Amenorrhea
• Hypothalamic/Pituitary
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Constitutional
Systemic Illness
Extreme physical, nutritional, or emotional stress
PCOS
• Ovarian
– Gonadal dysgenesis (esp Turner’s Syndrome)
• Anatomic
– Mullerian anamolies or agenesis (e.g. absent vagina)
– Imperforate hymen
Causes of Secondary Amenorrhea
• Pregnancy or Breast-Feeding
• Hypothalamic
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Extreme physical, emotional, or nutritional stress
Systemic illness
PCOS
Obesity
Perimenarche, perimenopause
• Pituitary
– Hyperprolactinemia
• Ovarian
– Premature ovarian failure
• Uterine
– Iatrogenic
Evaluation of
Amenorrhea/Oligomenorrhea
• Rule Out Pregnancy
• Complete H and P with focus on Weight,
Hirsutism, Galactorrhea
• TSH, Prolactin
• FSH, LH
• Testosterone, DHEAS (if indicated)
* Treat based on etiology