Abnormal Uterine Bleeding: Not just OCPs or hysterectomy anymore
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Abnormal Uterine Bleeding:Not just OCPs or hysterectomy
anymore
Tony Ogburn MDProfessor, Dept. of Ob/GynUniversity of New Mexico
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Objectives
• Discuss the classification of abnormal uterine bleeding
• Understand the evaluation of abnormal uterine bleeding in reproductive aged women
• List the non surgical treatment options of abnormal uterine bleeding
• Discuss the indications for surgical management for abnormal uterine bleeding
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Disclosures
• Nexplanon trainer – no disclosure
• IUD devotee…
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A lot of confusing terms!Dysfunctional uterine bleeding
Epimenorrhagia
Epimenorrhea
Functional uterine bleeding
Hypermenorrhea
Hypomenorrhea
Menometrorrhagia
Menorrhagia (all usages: essential menorrhagia, idiopathic menorrhagia, primary menorrhagia, functional menorrhagia, ovulatory menorrhagia, anovulatory menorrhagia)
Metrorrhagia
Metropathica hemorrhagica
Oligomenorrhea
Polymenorrhagia
Polymenorrhea
Uterine hemorrhage
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Common TerminologyDescriptive Term Bleeding patternMenorrhagia Regular cycles,
prolonged duration, excessive flow
Metrorrhagia Irregular cyclesMenometorrhagia Irregular, prolonged,
excessiveHypermenorrhea Regular, normal
duration, excessive flowPolymenorrhea Frequent cyclesOligomenorrhea Infrequent cyclesAmenorrhea No cycles
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A new classification systemPALM - COEIN
• Initial conference – 2005– Wide participation of stakeholders
• FIGO, ACOG, FDA, Researchers, Journals• Focused on terminology, defining needs and resources
• Follow-up conference – 2009• Nomenclature and classification systems– Approved by FIGO - 2011
• Useful for clincians, researchers, and educators• Provides a tool for structured history, evaluation
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Nomenclature
• 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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Suggested “norms”Clinical dimensions of menstruation and menstrual cycle
Descriptive term Normal limits (5th-95th percentiles)
Frequency of menses, d
Frequent <24
Normal 24-38
Infrequent >38
Regularity of menses: cycle-to-cycle variation over 12 months, d
Absent No bleeding
Regular Variation ± 2-20
Irregular Variation >20
Duration of flow, d
Prolonged >8.0
Normal 4.5-8.0
Shortened <4.5
Volume of monthly blood loss, mL
Heavy >80
Normal 5-80
Light <5
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PALM-COEIN• 4 categories that are defined by visually objective structural criteria
(PALM) – Polyp– Adenomyosis– Leiomyoma– Malignancy and hyperplasia
• 4 criteria that are unrelated to structural anomalies (COEI)– Coagulopathy– Ovulatory dysfunction– Endometrial– Iatrogenic
• 1 criterion that is reserved for entities that are not yet classified (N).
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Causes of AUBStructural abnormalities (PALM)
• Polyps – AUB-P– endocervical or
endometrial• Detected by ultrasound
or sonohysterography• Often irregular, light
bleeding
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Structural abnormalities (PALM)
• Adenomyosis –AUB-A• Controversial as a cause
of bleeding• Diagnosed with
ultrasound, MRI, pathology
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Structural abnormalities (PALM)
• Leiomyoma – AUB-L– Submucous– Intramural– Subserosal
• Diagnosed with exam, ultrasound, MRI, CT
• Heavy, regular bleeding
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Structural abnormalities (PALM)
• Malignancy and hyperplasia – AUB-M
• Diagnosed by biopsy• Irregular bleeding
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Non Structural Causes - COEI
• Coagulopathy• Usually suspected
based on history• Von Willebrands most
common• Heavy, regular bleeding
• Ovulation disorders• Suspected on history– Variable cycle length
• Can be confirmed with laboratory testing
• Wide range of bleeding patterns – usually irregular
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Causes of AUB
• Anovulatory– Most common cause of
AUB– Many reasons for
anovulation• Unknown• PCOS• Stress, weight change,
exercise• Endocrine
– Thyroid, PRL– Secreting tumors
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Non Structural Causes - COEI
• Endometrial• A diagnosis of exclusion– A wastebasket…
• Iatrogenic– Hormone Use– IUD, implant
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Not Yet Classified - N
• “Other entities that may or may not contribute to or cause AUB but have not been identified or have been poorly defined, inadequately examined, and/or are extremely rare”
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Evaluation• History
– Acute• Stable?
– Chronic– Characterize bleeding pattern
• Examination– Is it from the uterus?!
• Laboratory studies– Pregnancy test– Hct/CBC– Other labs only if indicated – e.g.
• TSH/PRL• Iron studies• Labs for disorders of hemostasis
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Evaluation
• Other diagnostic procedures– EMB• Consider in all patients over 45 or refractory bleeding• Pipelle vs. D&C
– Ultrasound– Sonohysterogram– Hysteroscopy
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Endometrial biopsy
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Ultrasound- Abdominal or transvaginal- Inexpensive and readily available in most of the world
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Sonohysterogram– Inject small amount
of fluid in uterine cavity
– Transvaginal ultrasound
– Endometrial thickness and evaluation of intrauterine structures
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HysteroscopyExpensiveCan be used for treatment
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MRI
• Very expensive
• Not readily available
• Rarely needed!
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Treatment
• Acute or chronic?• If you find something in your evaluation– Treat it!– Thyroid disease, cervical polyp, pregnancy, etc.
• Structural – consider referral early on– Surgery, embolization, hormonal Rx
• Often left with no obvious cause– Now what?
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Treatment - Acute
• Unstable?– High dose hormones vs D&C
• IV estrogen – 25 mg IV q 4-6 hours
• Stable– 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 for five days
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Treatment - ChronicConsiderations
• Etiology and severity of bleeding (eg, anemia, interference with daily activities)
• Associated symptoms (eg, pelvic pain, infertility)• Contraceptive needs or plans for future pregnancy• Contraindications to hormonal or other
medications• Medical comorbidities• Patient preferences regarding medical versus
surgical and short-term versus long-term therapy
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Treatment Options
• Non-surgical – usually the first line of treatment– Expectant management– NSAIDs
• Reduce blood loss by ~50% – Antifibrinolytic agents - Tranexemic acid (Lysteda)
• Expensive– Hormonal methods
• Combination methods– Reduce blood loss by ~50%– Regulate cycles in ~85%
• Levonorgestrel IUD – Reduce blood loss by ~85%– Less effective at regulating cycles but usually not an issue
• Cyclic progestin– Most appropriate for anovulatory bleeding if other methods contraindicated
• GnRH agonists (leuprolide) – Expensive for long term use but good for pre-procedure preparation
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Levonorgestrel IUD• FDA approved for treatment
of abnormal bleeding– More effective than OCPs,
oral progestins, Depo-Provera, NSAIDs
• Cost effective • Few side effects• Reduces blood loss by up to
97%• Takes 3-6 months for
optimal effect
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Combination Methods
• OCPs– Use monophasic at least
for first three months– Use 30-35 of estrogen– Continuous vs. cyclic
• Patch/Rings– No good trials about
efficacy for this indication
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Other?
• Depo Provera• Implant
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Surgical Treatment
• Two main approaches– Global endometrial ablation– Hysterectomy
• Future pregnancy contraindicated/impossible
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Global Endometrial Ablation• Outpatient procedure• Excellent safety profile• A variety of methods
– Balloon – Thermachoice– Radiofrequency electricity – Novasure– Freezing – Her Option– Circulating hot water – HTA
• Unclear which, if any, is best!– All have about 80% “success”– Less in younger patients…– Equal to IUD in efficacy
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Thermachoice
• Eight minute cycle• Lots of cramping during
procedure
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HTA- 10 minute cycle- Vaginal burns an early issue
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Her Option
- Takes a long time…
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Novasure- 1-2 minutes- Have to dilate cervix more We have it at CRH!!!
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Hysterectomy
• Random facts…– 100% effective for AUB– A significant minority of women with
“conservative” management end up with a hyst eventually
– Satisfaction rates are very high– Major complications do happen– Expensive
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Questions
?
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Maria
• 32 yo G2P2 with post – coital spotting for several months
• History completely unremarkable
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Cora
• 37 yo with longstanding history of regular, heavy menses now bleeding heavily for 16 days. Passed out at home and brought in by ambulance.
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Erica
• 62 yo postmenopausal for 11 years with spotting for several months
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Stephanie
• 24 yo G0 with very heavy menses and cramping increasing over one year
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Jane
• 42 yo G3P3 presents with heavy, regular bleeding for 9-12 months.
• Bleeds 2-3 weeks each month with large clots and cramps.
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Sara
• 46 yo G2P2 with heavy, irregular menses for two years. Now increasing in frequency and flow
• Previous C/S X 2