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Abnormal Uterine Bleeding

Randy A. Fink, MD, FACOGObstetrics & Gynecology

A simplified approach for primary care

Disclosures

I have no relevant disclosures pertaining to this program.

Learning Objectives

• Demystify and understand a simple, straightforward template to evaluate premenopausal abnormal uterine bleeding in the primary care setting.

• Review up to date treatment options for heavy menstrual bleeding.

Appreciate the evaluation and management of postmenopausal bleeding.

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What’s In a Name?

• AUB• DUB (Dysfunctional Uterine Bleeding)• Irregular Menstruation• Metrorrhagia• Menorrhagia• Menometrorrhagia• “Hemorrhaging”• “It’s like a murder scene.”

What’s In a Code?

International Classification of Diseases, Tenth Revision (ICD-10): http://www.cdc.gov/nchs/icd/icd10.htm

Oh yeah, it’s a problem…

• One-third of visits to GYN practice1

• 11-13% of reproductive age women at any given time2

• Increasing prevalence with age to 24% by 36-40 years old.

1Kjerulff KH, Erickson BA, Langenberg PW. Am J Public Health. 1996 Feb;86(2):195-9.2Liu Z, Doan QV, Blumenthal P, et al. Value Health. 2007 May-Jun;10(3):183-94.

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Risk Factors for Endometrial Cancer

• Increasing Age (50-70yo)• Early menarche

• Late menopause (after 55yo)

• Chronic anovulation

• Diabetes• Obesity

• tamoxifen• Unopposed estrogen

• Nulliparity• Lynch Syndrome• Estrogen secreting

neoplasm

Smith RA, von Eschenbach AC, Wender R, et al. American Cancer Society guidelines for theearly detection of cancer: Update of early detection guidelines for prostate, colorectal, and endometrial cancers. CA Cancer J Clin 2001; 51:38.

PRE-MENOPAUSAL POST-MENOPAUSAL

PERI-MENOPAUSAL

PRE-MENOPAUSAL WHAT’S NORMAL??

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NORMAL MENSES

• Frequency of menses within a 24 to 38 day window• Regularity (cycle-to-cycle variation) within ± 2 to 20

days• Duration of flow from 4 to 8 days• Volume of blood loss from 5 to 80 ml

Fritz MA, Speroff L. Clinical gynecologic endocrinology and infertility. 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2011.

!!!!!!!!!!!

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SURGICAL ANATOMY OF UTERUS

PRE-MENOPAUSAL WHAT’S NORMAL??

Pregnancy Test (“Do a Beta”)

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Beta-HCG

• Urine Pregnancy Test - within 2 weeks of conception– (20-50 mIU/mL)

• Serum Pregnancy Test (QUANTITATIVE ) – by 1 week after conception– (1-2 mIU/mL)

• False positive (rare)• False negative (more common)

Norman RJ, Menabawey M, Lowings C, Buck RH, Chard T. Obstet Gynecol. 1987 Apr;69(4):590-3.

PRE-MENOPAUSAL WHAT’S NORMAL??

Pregnancy Test (“Do a Beta”) POS �

REFER

Early Pregnancy Bleeding

• RULE-OUT ECTOPIC (2% of all pregnancies)– “Discriminatory Zone”: If Beta-HCG ≥ 2000, Intrauterine

Pregnancy is generally seen by transvaginal ultrasound1

– Normal: Beta-HCG rises by 35% in 48 hours OR doubles in 72 hours during 1st 40 days of pregnancy2

• MISCARRIAGE (15-20% of all pregnancies)– If Fetal Heart Rate is observed, 90-96% of these pregnancies

continue3

1Connolly A, Ryan DH, Stuebe AM, Wolfe HM. Obstet Gynecol. 2013;121(1):65.2Morse CB, et al. Fertil Steril. 2012 Jan;97(1):101-6.e2.3Tannirandorn Y, et al. Int J Gynaecol Obstet. 2003;81(3):263.

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PRE-MENOPAUSAL WHAT’S NORMAL??

Pregnancy Test (“Do a Beta”) POS �

REFERNeg

HORMONAL STRUCTURAL

OVULATIONAN

ANOVULATORY PATTERN

• Polycystic Ovarian Syndrome (PCOS)– Chronic Oligo or Anovulation– Clinical or Biochemical Signs of Hyperandrogenism– Polycystic Morphology by Ultrasound

Rotterdam ESHRE/ASRM-Sponsored PCOS consensus workshop group. Revised 2003 consensus on diagnostic criteria and long-term health risks related topolycystic ovary syndrome (PCOS). Hum Reprod 2004; 19:41.

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Signs of Hyperandrogenism

• Biochemical– Elevated Testosterone (<150

ng/mL)

– Elevated DHEA-S– 8am 17-OHP

– TSH, FSH, Prolactin

Signs of Hyperandrogenism

• Hirsutism– Hair growth in androgen

dependent areas:• Upper lip, chin• Midsternum• Upper and lower abdomen• Upper and lower back• Buttocks

• Differs from – “Unwanted Hair”– Hypertrichosis Madnani N et al. Indian J Dermatol Venereol Leprol 2013;79:310-21

Ferriman-Gallway Hirsutism Scoring

• Score 1-7: Focal (common normal variant)

• Score ≥8: Generalized

• Norms lower in Asians, higher in Mediterraneans

Hatch R, Rosenfield RS, Kim MH, Tredway D. Hirsutism: implications, etiology,and management. Am J Obstet Gynecol 1981; 140:815.

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Signs of Hyperandrogenism

• Hirsutism with Acanthosis Nigricans– Insulin resistance

Madnani N et al. Indian J Dermatol Venereol Leprol 2013;79:310-21

Signs of Hyperandrogenism

• Acne Vulgaris– Minimally responsive to

traditional treatment

– Lower half of face and jawline

– Back, chest– Rapid recurrence on cessation

of treatment

– Persist beyond typical 5-7 days

Archer JS, Chang RJ. Hirsutism and acne in polycystic ovary syndrome. Best Pract Res Clin Obstet Gynaecol 2004;18:737-54.

Signs of Hyperandrogenism

• Androgenic Alopecia– May be difficult to distinguish

from other patterns of hair loss in women

Olsen EA. Female pattern hair loss. J Am Acad Dermatol 2001;45:70-80.

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ANOVULATORY PATTERN

• Common Clinical Presentation– 33yo nulligravid, BMI 30, states not sexually active.

• c/o vaginal bleeding daily for the past 24 days• LNMP 3 months prior, no bleeding since until this episode

• Hormone Dysfunction: Estrogen Dominance– Progesterone Challenge

• Medroxyprogesterone acetate 10mg PO BID x 5 days or 1 PO QD x 10 days

• Norethindrone acetate 10mg PO QD x 5 days

Deeper Issues

• Prolactinoma• Thyroid abnormalities• Premature Ovarian Insufficiency• Coagulopathy/Bleeding Diathesis

TSH, FSH, PROLACTIN

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PRE-MENOPAUSAL WHAT’S NORMAL??

Pregnancy Test (“Do a Beta”) ➕ � REFER

Neg

HORMONAL STRUCTURAL• Cervical• Fibroids• Polyps• Adenomyosis

Is it Uterine Bleeding? Remember Cervix!

• Cervical Dysplasia– Is Pap up to date? If not, DO IT!

• Cervicitis– Friable cervix– Purulent discharge

– Pelvic tenderness

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Fibroids

• Most common pelvic tumor in women1

• Prevalence as high as 77%

• Clinically significant (4cm, 9 weeks size, Submucosal) by u/s2

– 50% of Black Women

– 35% White Women1Baird DD, Dunson DB, Hill MC, Cousins D, Schectman JM. Am J Obstet Gynecol. 2003;188(1):100.2Marshall LM, et al. Obstet Gynecol. 1997;90(6):967.

Fibroids

• Heavy or prolonged menstrual bleeding• Bulk-related symptoms, such as pelvic pressure and

pain

• Reproductive dysfunction (i.e., infertility or obstetric complications)

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Endometrial Polyps

• Common source of perimenopausal and postmenopausal bleeding

• Receptor issue• Saline sonography• Can be stimulated by estrogen therapy, tamoxifen,

endogenous estrogen• 95% are benign

Baiocchi G., et al. Am J Obstet Gynecol. 2009;201(5):462.e1.

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Adenomyosis

Adenomyosis

• Common cause of pelvic pain, dysmenorrhea, abnormal uterine bleeding

• Globular uterus• Asymetric endometrial growth• Heterogeneous echotexture• Diffuse or confined (Adenomyoma)

Templeman C, et al. Fertil Steril. 2008;90(2):415. Epub 2007 Oct 24.

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Treatment Options - HMB

• NSAID• Hormonal Contraceptives

• Tranexamic Acid 650mg, 2 tabs PO TID starting at onset of menses, not to exceed 5 days use

• LNG IUD

• Endometrial Ablation

PRE-MENOPAUSAL POST-MENOPAUSAL

Post-Menopausal Bleeding

• IS IT UTERINE?– Cervical– Vaginal Atrophy– Urethral– Rectal

• IS IT MEDICAL?– HRT– Anti-coagulants

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TRANS-VAGINAL ULTRASOUND

4 mm

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4mm Endometrial Stripe

• Essentially rules out endometrial cancer• >4mm suggestive of proliferative process

– Filling defect (polyp, fibroid)– PMP proliferative endometrium– Endometrial hyperplasia

– Endometrial cancer

Sladkevicius P, Opolskiene G, Valentin L. Ultrasound Obstet Gynecol. 2017;49(5):649. Epub 2017 Apr 6.

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PRE-MENOPAUSAL POST-MENOPAUSAL

ULTRASOUND

4 mm or less >4mm

REFERProbably Refer

The Take Home:A simplified approach for primary care.

PRE-MENOPAUSAL POST-MENOPAUSAL

ULTRASOUND

4 mm or less >4mm

REFERProbably Refer

Is it NORMAL?

Pregnancy Test (“Do a Beta”) POS � REFER

NEG

HORMONAL STRUCTURAL

• Relatedto Ovulation

• Cervical• Fibroids• Polyps• Adenomyosis

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Randy A. Fink, MD, FACOGOffice Contact: 305-515-5425