Abnormal Uterine Bleeding

Anne Whitworth, M.D.

Learning ObjectivesLearning Objectives

– Identify the causes of abnormal uterine bleeding

– Demonstrate a knowledge of the evaluation of abnormal uterine bleeding

– Describe the treatments for the different causes of abnormal uterine bleeding

– Identify the causes of abnormal uterine bleeding

– Demonstrate a knowledge of the evaluation of abnormal uterine bleeding

– Describe the treatments for the different causes of abnormal uterine bleeding

Abnormal Uterine Bleeding

Definition:

Bleeding outside of normal physiologic menstruation

Includes both dysfunctional uterine bleeding & structural bleeding

Normal Menstrual Cycle

Proliferative Phase/Follicular (8-14 d) Predominance of estrogen over

progesterone and a build up of endometrium

Secretory Phase/Luteal(14 d) Begins after ovulation triggers

progesterone production Marked by a reaction to the combination

of estrogen and progesterone and stabilization in the thickness of the endometrium

Normal Menstrual Cycle

Pituitary gonadotropin secretion is stimulated by the GnRH

Estradiol results in increased secretion of LH and decreased secretion of FSH

Leading to release of the egg

Corpus luteum has negative feedback on LH and FSH

Normal Menstrual Cycle

Normal Menstrual Cycle

Interval 28 days +/- 7 days

Duration 4-6 days (3-5 pads/tampons per day)

Blood loss 25-69 ml (average 35 to 40 ml) no clots, no mid cycle bleeding

Normal Menstrual Cycle

The average female will have around 400 menstrual cycles in her life

Up to 20% of women will present to the office with the complaint of excessive blood loss

Definitions of Abnormal Uterine Bleeding Menorrhagia

Prolonged or excessive uterine bleeding at regular intervals

Metrorrhagia Uterine bleeding at irregular but frequent

intervals, amount is variable Menometrorrhagia

Prolonged uterine bleeding at irregular intervals

Definitions of Abnormal Uterine Bleeding

Intermenstrual bleeding Bleeding of variable amounts between

regular menstrual periods Polymenorrhea

Uterine bleeding at regular intervals of less than 21d

Oligomenorrhea Uterine bleeding in which the interval

between bleeding episodes may vary from 35 days to 6 months

Amenorrhea No uterine bleeding for at least 6 months

Causes of Abnormal Uterine Bleeding

Disruption of regularity, frequency, volume and duration of menstrual flow

The cause can be physiologic, pathologic or pharmocologic

Causes of Abnormal Uterine BleedingDifferential

Complications of Pregnancy

Pelvic Pathology

Systemic Ovulatory vs. anovulatory

Iatrogenic (pharmacologic)

Causes of Abnormal Uterine BleedingDifferential

1. Complications of Pregnancy

Ectopic pregnacy Miscarriage Placenta previa Gestational trophoblastic disease

Causes of Abnormal Uterine BleedingDifferential

2. Pelvic Pathology

Benign Pregnancy, myoma, adenomyosis,

endometriosis,endometrial/cervical polyp, PID, infection,trauma, vascular abnormality, foreign body

Malignant Carcinoma of the reproductive tract Endometrial hyperplasia (pre- malignant

changes)

Uterine Fibroids

Causes of Abnormal Uterine BleedingDifferential

3. Systemic Ovulatory

Coagulation disorder Thrombocytopathy, von Willibrand’s disease,

Leukemia Systemic Lupus erythematosus Cirrhosis

Anovulatory Hypothyroid, hyperprolactenemia, PCOD,

hypothalamic dysfunction

Causes of Abnormal Uterine Bleeding

4. Iatrogenic

Hormone therapy Contraceptive devices and injections Medications

Antidepressants, anticoagulants, steroids

Causes of Abnormal Uterine Bleeding

If no etiology in above categories then by exclusion the diagnosis is dysfunctional uterine bleeding--it applies not only to menorrhagia but also menometrorrhagia

Causes of Abnormal Uterine Bleeding

Dysfunctional Uterine Bleeding

Causes 80% of menorrhagia

Bleeding is UTERINE and mechanism is HORMONAL

Causes of DUB

DUB is usually related to one of four hormonal-imbalance conditions

Estrogen breakthrough bleeding

Estrogen withdrawl bleeding

Progesterone breakthrough bleeding

Progesterone withdrawl bleeding

Causes of DUB

Estrogen breakthrough bleeding:

This occurs when excess estrogen stimulates the endometrium to proliferate in an undifferentiated manner--if there is insufficient progesterone to provide structural support the endometrium will slough at irregular intervals

Causes of DUB

Estrogen withdrawl bleeding:

This results from a sudden decrease in estrogen levels, such as occurs after bilateral oophorectomy, cessation of exogenous estrogen therapy or just before ovulation in the normal menstrual cycle

Causes of DUB

Progesterone breakthrough bleeding:

This occurs when the progesterone:estrogen ratio is high. (progesterone only contraception)

The endometrium becomes atrophic and is prone to frequent, irregular bleeding.

Causes of DUB

Progesterone Withdrawl Bleeding:

This occurs only if the endometrium is initially proliferated by exogenous or endogenous estrogen

Evaluation of Abnormal Uterine Bleeding Obtain a History

Menstrual history Recent cycle length and duration, blood flow,

and pattern Color and character of flow (pain, discharge,

odor) Estimate of amount of blood loss Use of contraception

Medical history Thyroid disorder Current medications

Evaluation of Abnormal Uterine Bleeding Physical Exam

Height, weight, vital signs Body fat distribution Tanner staging Pelvic examination

External-bruising, laceration, discharge, cervix

Bimanual exam- uterine size, adnexal mass or pain

Evaluation of Abnormal Uterine Bleeding Laboratory assessment

Rule out pregnancy!

CBC, PAP, cultures

Maybe TSH, Prolactin level

Maybe coagulation studies

Evaluation of Abnormal Uterine Bleeding Further evaluation is based on

menopausal status

Premenopausal--look for cause of anovulatory bleeding

Peri and postmenopausal--need to evaluate for endometrial hyperplasia or cancer

Evaluation of Abnormal Uterine Bleeding Tests to rule out endometrial

hyperplasia or carcinoma

Endometrial Biopsy

Ultrasound

Hysteroscopy

Evaluation- Endometrial Biopsy

Treatment

Goal of treatment is to control bleeding, prevent recurrence, and preserve fertility (if desired)

Treatment

Acute, heavy bleeding

Hemodynamically unstable: High dose IV estrogen, or D& C

Hemodynamically stable: oral estrogen

Treatment

Chronic abnormal bleeding—medical Rx

observation NSAIDS Oral contraceptives Progesterones Hormone replacement Inhibit GnRH stimulation Danazol

Treatment-Medical

Drug/Class

Efficacy Side effects Mechanism/other

NSAIDs 20-30% GI upset Decrease cyclooxygenase and increase thromboxane to prostaglandin

OCPs 50% H/A, nausea, edema, wt gain, mood changes,

50 micrograms ethinyl estradiol

Progestins 15% Same Days 15-26, blood loss reduction 88% with IUD by month 3

Treatment –Merina IUD

Treatment- Medical

Drug/class Efficacy Side effects Mechanism/other

Danazol 60% Androgenic, endometrial atrophy

Alters pulsitile gonadotropin release, higher doses inhibits ovulation

GnRH Agonists

100% Hypoestrogenic/ bone loss deplete further pituitary of bioactive goanadotropins and desensitize it to further GnRh stimulation

Antifibrin-olytic agents

80% H/A, Gi upset, vertigo, possible increased thrombotic activity

Decrease blood loss by 84% by preventing the activation of plasminogen