Transcript Abnormal Uterine Bleeding

Abnormal Uterine
Bleeding
John Bettler
UNM DFCM Resident School
February 1, 2017
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Audience texts JOHNBETTLER830 to 22333 to join the
session, then they text a response.
PollEv.com/johnbettler830
Objectives
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A.Discuss the classification of abnormal uterine
bleeding
B. Understand the evaluation of abnormal uterine
bleeding in reproductive aged women
C.List the non surgical treatment options of abnormal
uterine bleeding
D.Discuss the indications for surgical management for
abnormal uterine bleeding
Many terms
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Menorrhagia
Menometorrhagia
Hypermenorrhea
Polymenorrhea
Metrorrhagia
Oligomenorrhea
Amenorrhea
Nomenclature
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Acute AUB
“an episode of bleeding in a woman of reproductive age, who
is not pregnant, that, in the opinion of the provider, is of
sufficient quantity to require immediate intervention to prevent
further blood loss.”
Chronic AUB
“bleeding from the uterine corpus that is abnormal in duration,
volume, and/or frequency and has been present for the
majority of the last 6 months.”
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What’s normal bleeding?
What volume of blood is in a soaked,
regular-sized tampon or pad?
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A. 5 L
B. 10 mL
C. 5 mL
D. I don’t know, I’m a dude!
E. 1 mL
What’s normal?
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Character
Frequency of menses, d
Regularity of menses: cycle-tocycle variation over 12 months,
d
Duration of flow, d
Volume of monthly blood loss,
mL
Descriptive term
Normal limits
Frequent
<21
Normal
21-38
Infrequent
>38
Absent
Regular
Irregular
No Bleeding
Variation ± 2-20
Variation >20
Prolonged
Normal
Shortened
>8
3-8
<3
Heavy
Normal
Light
>80
5-80
<5
1 normally soaked “regular” product is approximately 5mL of blood, a “super” or
“maxi” size holds 10mL
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Etiology of AUB
We need a mneumonic!
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A.HELPERR
B. CHADSVASc
C.SIGECAPS
D.O BATMAN!
E. I GET SMASHED
F. ABCDEFGH
G.PPPPPPP
If I had a coin in my palm for every women with
AUB…
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Classification: PALM-COEIN
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Causes of AUB in nonpregnant reproductive-aged women
International Federation of Gynecology and Obstetrics, 2011
Structural causes (PALM)
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A.Polyps – AUB-P
◦ endocervical or
endometrial
B.Detected by ultrasound
or sonohysterography
C.Often irregular, light
bleeding
Structural causes (PALM)
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A.Adenomyosis –AUB-A
B. Controversial as a
cause of bleeding
C.Diagnosed with
ultrasound, MRI,
pathology
Structural causes (PALM)
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A.Leiomyoma – AUB-L
◦ Submucous
◦ Intramural
◦ Subserosal
B.Diagnosed with exam,
ultrasound, MRI, CT
C.Heavy, regular bleeding
Structural causes (PALM)
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A.Malignancy and
hyperplasia – AUB-M
B. Diagnosed by biopsy
C.Irregular bleeding
Non-structural causes COEIN
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Coagulopathies or bleeding disorders
Ovulatory dysfunction
Endometrial
Iatrogenic sources (medications, smoking)
Not yet classified
Causes of AUB - Anovulatory
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A.Most common cause
of AUB
B. Many reasons for
anovulation
1. Physiologic
2. PCOS
3. Stress, weight change,
exercise
4. Endocrine
◦ Thyroid, PRL
◦ Secreting tumors
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So She’s bleeding, now what?!?
Diagnosis: H&P
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A. History
1. Acute vs Chronic
2. Characterize bleeding pattern
3. Menstrual bleeding hx (incl. severity and assoc pain)
4. FamHx: AUB/ bleeding disorders
5. Meds: warfarin, heparin, NSAID, OCP, ginkgo, ginseng,
motherwort
B. Physical
1. PCOS: obesity, hirsutism, acne
2. Thyroid dysfunction: cold/heat intolerance, dry skin, lethargy,
proptosis
3. DM: acanthosis nigricans
4. Bleeding disorder: petechiae, pallor, signs of hypovolemia
5. Pelvic exam
◦ Is it from the uterus?!
Diagnosis: Labs and Imaging
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A. Labs
1.
2.
3.
4.
5.
Pregnancy test (Strong recommendation)
CBC (Strong recommendation)
Targeted screening for bleeding disorder (when indicated)
TSH
Gonorrhea/Chlamydia in high risk patients
B. Imaging:
1.
2.
3.
4.
TVUS
Sonohysterography
Hysteroscopy
MRI
C. Endometrial biopsy
Uterine Evaluation
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Practice bulletin no. 128: diagnosis of abnormal uterine bleeding in reproductive-aged
women. Obstet Gynecol. 2012 Jul;120(1):197-206. doi:
10.1097/AOG.0b013e318262e320.
Who should get an EMB?
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A.Women aged > 45 years as first-line test
B.Women aged > 35 years as first-line test
C.Women aged < 45 years with risk factors for endometrial
cancer
D.Women aged < 35 years with risk factors for endometrial
cancer
E.Women with persistent bleeding refractory to medication,
regardless of age
Who should be offered EMB?
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◦ women aged > 45 years as first-line test
◦ women with persistent bleeding refractory to medication,
regardless of age
◦ women aged < 45 years with risk factors for endometrial
cancer, such as
◦ obesity (body mass index > 30 kg/m2)
◦ nulliparity
◦ hypertension
◦ irregular menstruation
◦ polycystic ovary syndrome
◦ diabetes
◦ hereditary nonpolyposis colorectal cancer
◦ family history of endometrial cancer
Practice bulletin no. 128: diagnosis of abnormal uterine bleeding in reproductive-aged women. Obstet Gynecol. 2012 Jul;120(1):197-206. doi:
10.1097/AOG.0b013e318262e320.
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Endometrial
biopsy
EMB Considerations
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A. Consent
1. Cramping is common
2. vaginal bleeding for several days
3. vasovagal
4. pelvic infection
5. uterine perforation (1 to 2 per 1000 procedures - vs 3 to 26 per 1000 D&C)
B. Contraindications
1. Active vaginal/pelvic infection
2. bleeding diathesis
3. pregnancy
C. Preprocedure prep
1. Anesthesia not required, consider NSAID 30-60 min prior
2. Difficult passage - consider 200 to 400 µg misoprostol night before (PV>PO)
3. Don’t need prophylactic abx
Comparison of endometrial aspiration biopsy techniques: specimen adequacy.
Sierecki AR, Gudipudi DK, Montemarano N, Del Priore G Reprod Med. 2008;53(10):760.
EMB procedure
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A. Bimanual
Am Fam Physician. 2001 Mar 15;63(6):1131-5, 1137-41.
Endometrial biopsy. Zuber TJ
B. Speculum then clean cervix
C. +/- tenaculum (if not axial)
D. Insert pipelle - stop @ resistance (avg 6-8cm)
E. Pincer grasp, Pull out piston for suction
F. Corkscrew combined w/ cephalic-caudal motion to sample entire
endometrial surface
G. Don’t remove until sampling completed
H. Expel the specimen into a formalin container (replace piston)
I. Consider second pass if insufficient tissue
◦ If the biopsy material looks like a dark red earthworm and does
not disintegrate in the formalin, it is likely that appropriate biopsy
material has been obtained.
How reliable is the EMB result?
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For diagnosis of endometrial cancer, outpatient endometrial
biopsy had
◦ likelihood ratio 66.48 (95% CI 30.04-147.13) for a positive
test result
◦ likelihood ratio 0.14 (95% CI, 0.08-0.27) for a negative test
result
BJOG 2002 Mar;109(3):313
In cases of abnormal uterine bleeding in which symptoms persist
despite a negative biopsy, further evaluation and input from
individual patients is recommended.
only 34% of patients had an adequate sample
Saso S, et al. Endometrial cancer. BMJ.2011;343:d3954.
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MRI
U/S
Sonohysterogram
Hysteroscopy
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Management
Management
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A.Medical management should be initial treatment for
most patients
B.Need for surgery is based on various factors
(stability of patient, severity of bleed,
contraindications to med management, underlying
cause)
◦ Type of surgery dependent on above + desire
for future fertility
C.Long term maintenance therapy after acute bleed is
controlled
Treatment - Acute
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A. Unstable?
1. High dose hormones vs D&C
◦ IV estrogen – 25 mg IV q 4-6 hours x 24 hrs
2. Endometrial balloon tamponade
B. Stable
1. Oral meds
◦ Monophasic OCPs – One TID for seven days, then daily for
at least one cycle
◦ Medroxyprogesterone (Provera) – 20 mg TID for seven
days, then daily for at least three weeks
◦ Tranexamic acid (Lysteda) – 1.3 mg TID on days 1-5 of
cycle
Chronic Treatment Considerations
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A. Etiology and severity of bleeding (eg, anemia, interference with
daily activities)
B. Associated symptoms (eg, pelvic pain, infertility)
C. Contraceptive needs or plans for future pregnancy
D. Contraindications to hormonal or other medications
E. Medical comorbidities
F. Patient preferences regarding medical versus surgical and
short-term versus long-term therapy
Non-surgical treatment Options
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A. Expectant management
B. NSAIDs
C. Antifibrinolytic agents - Tranexemic acid (Lysteda)
D. Hormonal methods
1. Combination methods
2. Levonorgestrel IUD
3. Cyclic progestin
4. GnRH agonists (leuprolide)
E. Metformin and other insulin-sensitizing drugs for irregular
bleeding in women with polycystic ovary syndrome
Surgical Management Options
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A. D&C
B. Endometrial Ablation
C. Uterine Artery Embolization
D. Hysterectomy
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Ready to test your
knowledge?!
Case 1
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A 35 year old female is evaluated for a 5 month history of heavy
menstrual bleeding. She has been menstruating for the last 8 days and is
still going through 10 maxi pads or more daily with frequent clots. She
has fatigue but no dizziness. She and her husband would like to conceive
a 2nd child next year. She does not smoke.
PMHx: DM2
Vitals: Afebrile, BP 138/71, HR 80. Neg orthostasis. BMI 40.2
Pelvic exam: moderate amount of blood in vaginal vault.
What do you want to do next?
Case 1(continued)
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urine hcg is negative. Hct 30
EMB is negative.
Pelvic u/s shows a large submucosal fibroid. You consult ob/gyn for a
myomectomy, scheduled in 2 weeks.
Which of the following is the most appropriate next step in
management?
A. Levonorgestrel IUD (Mirena)
B. IV estrogen
C. Estrogen-progesterin oral contraceptive
D. Re-evaluate in 2 weeks
Case 1: Correct Answer = C
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Estrogen-progestin OCP and IUD are effective
treatments for heavy menstrual bleeding.
Estrogen/progestin OCP is the better choice as pt is
planning to conceive in the near future. Pt also does not
have any contraindications to estrogen.
IV Estrogen (B) would be appropriate if pt was
orthostatic or dizzy from blood loss. PE and DVT are
complications of IV estrogen.
Monitoring (D) is not appropriate given her significant,
ongoing blood loss.
Case 2
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49 year old women presents to your primary care clinic with a 3 day history of heavy
menstrual bleeding. She denies dysmenorrhea but reports that her menstruation cycle
have been increasingly irregular over the past couple years, including bleeding between
periods. She is not sexually active and had a bilateral tubal ligation 10 years ago.
Her physical exam demonstrated normal vital signs, no signs of hypovolemia, no bruises.
Pelvic exam was unremarkable for tenderness, nodularities, or abnormal size uterus.
Cervix was normal with blood in the os.
What do you want to do next?
Case 2 (continued)
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Pregnancy test is negative and pap smear was performed and
was wnl.
Which of the following is the most appropriate next step in
management of this patient?
A. Endometrial biopsy
B. Measure serum LH and FSH
C. Pelvic U/S
D. Oral contraceptives
Case 2: Correct Answer = A
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A. Endometrial biopsy—Need to rule out
endometrial cancer in patients older than 45 with
AUB
B. Measuring LH and FSH can confirm menopause, but
does not rule out endometrial cancer.
C. Pelvic ultrasound– good with uncertain findings on
pelvic exams
D. Oral contraceptives are appropriate for patients
with anovulatory bleedings. But endometrial
carcinoma needs to be ruled out first
Case 3
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26 year old female presents with 4 days of history of light vaginal bleeding after
intercourse. Prior to this incident, she reports regular menstruation cycle and no vaginal
discharge. She is in a monogamous relationship with her husband.
Her physical exam was unremarkable. Her pelvic exam was unremarkable except small
amount of blood in the cervical os.
What is the next best step in management?
A. Perform endometrial biopsy
B. Start oral contraceptive
C. Perform pelvic ultrasound
D. Urine HCG
Case 3: Correct Answer = D
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A. Endometrial biopsy is important to rule of endometrial cancer. In this
younger patient, need to rule out more common causes initially
B. Oral contraceptives are appropriate in anovulatory women.
However, need to rule out endocrine and pregnancy first
C. Pelvic ultrasound important for the identification of anatomical
abnormalities or staging of pregnancy. However, pelvic exam was
unremarkable and screening of pregnancy with serum markers has
not been performed yet
D. Urine HCG– Pregnancy is a common cause of abnormal uterine
bleeding and needs to be ruled out in all women who have not
gone through menopause
Case 4
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A 46 year old woman presents to your office with a complaint of intermenstrual bleeding. Her last
menstrual period ended 10 days ago, however for the past 3 days she noticed bleeding requiring 3-4
pads/daily. She reports that prior to this her periods were regular, lasting 5 days with occasional light
intermenstrual bleeding over the last 6 months. She is sexually active only with her husband and uses
barrier contraception.
On physical exam she was afebrile, BP 134/86, HR 74, negative orthostasis. Pelvic exam demonstrated
slightly enlarged, globular uterus, with blood noted in cervical os. Pregnancy test is negative.
Which of the following is the most appropriate next step in the evaluation of this patient?
A. Magnetic resonance imaging
B. Transvaginal ultrasound
C. Hysteroscopy
D. Reassurance and monitoring
Case 4: Correct Answer = B
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A. MRI is not the primary imaging modality to
evaluate AUB, however may be used as a followup test after ultrasonography
B. Transvaginal ultrasound is important in this patient
with AUB and exam findings suggestive of structural
abnormality. Would consider EMB as >45 yo.
C. Hysteroscopy/SIS should be done in patients with
concerning uterine cavity findings on TVUS
D. Monitoring would not be appropriate in the setting
of abnormal bleeding and concerning physical
exam findings
Case 5
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A 29 year old woman presents to your office with a complaint of heavy menstrual
bleeding. She has been menstruating for the last week with persistent heavy bleeding
and passage of clots. She denies being sexually active. She is a current smoker (1-2
pack/day) and her only medications are metformin and lisinopril.
On physical exam she was afebrile, BP 154/102, HR 62, negative orthostasis. BMI 31.
Pelvic exam demonstrated moderate amount of blood in vault.
What do you want to do?
Case 5 (continued)
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Pregnancy test negative. Endometrial biopsy was performed and results are negative
for malignant or hyperplastic disease.
Which of the following is the most appropriate next step in the management of this
patient?
A. Estrogen-progestin oral contraceptive
B. Endometrial ablation
C. Levonorgestrel (Mirena) IUD
D. Hysterectomy
Case 5: Correct Answer = C
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A. Estrogen-progestin OCPs are effective in the treatment of
heavy menstrual bleeding, however this patient has several
risk factors for thrombosis
B. Endometrial ablation is a minimally invasive option in patients
in which medical therapy has failed. Medical therapy should
be initiated, also it is unknown whether the patient wants to
maintain fertility
C. Levonorgestrel IUDs are effective in the treatment of heavy
menstrual bleeding and would be an appropriate choice in
this patient with contraindications to estrogen use
D. Hysterectomy is curative in the treatment of uterine bleeding,
however medical therapy and less invasive treatments are
preferred initially
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Thank you!
Now let’s go play with Pipelles!