Abnormal Uterine Bleeding: Not just OCPs and hysterectomies

Report
Abnormal Uterine Bleeding:
Not just OCPs or hysterectomy
anymore
Tony Ogburn MD
Professor, Dept. of Ob/Gyn
University of New Mexico
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
Disclosures
• Nexplanon trainer –
no disclosure
• IUD devotee…
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
Common Terminology
Descriptive Term
Menorrhagia
Metrorrhagia
Menometorrhagia
Hypermenorrhea
Polymenorrhea
Oligomenorrhea
Amenorrhea
Bleeding pattern
Regular cycles,
prolonged duration,
excessive flow
Irregular cycles
Irregular, prolonged,
excessive
Regular, normal
duration, excessive flow
Frequent cycles
Infrequent cycles
No cycles
A new classification system
PALM - 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
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.”
Suggested “norms”
Clinical dimensions of
menstruation and
menstrual cycle
Frequency of menses, d
Descriptive term
Normal limits (5th-95th
percentiles)
Frequent
<24
Normal
24-38
Infrequent
Regularity of menses: cycleto-cycle variation over 12
months, d
Duration of flow, d
Volume of monthly blood
loss, mL
>38
Absent
No bleeding
Regular
Variation ± 2-20
Irregular
Variation >20
Prolonged
>8.0
Normal
4.5-8.0
Shortened
<4.5
Heavy
>80
Normal
5-80
Light
<5
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).
Causes of AUB
Structural abnormalities (PALM)
• Polyps – AUB-P
– endocervical or
endometrial
• Detected by ultrasound
or sonohysterography
• Often irregular, light
bleeding
Structural abnormalities (PALM)
• Adenomyosis –AUB-A
• Controversial as a cause
of bleeding
• Diagnosed with
ultrasound, MRI,
pathology
Structural abnormalities (PALM)
• Leiomyoma – AUB-L
– Submucous
– Intramural
– Subserosal
• Diagnosed with exam,
ultrasound, MRI, CT
• Heavy, regular bleeding
Structural abnormalities (PALM)
• Malignancy and
hyperplasia – AUB-M
• Diagnosed by biopsy
• Irregular bleeding
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
Causes of AUB
• Anovulatory
– Most common cause of
AUB
– Many reasons for
anovulation
• Unknown
• PCOS
• Stress, weight change,
exercise
• Endocrine
– Thyroid, PRL
– Secreting tumors
Non Structural Causes - COEI
• Endometrial
• A diagnosis of exclusion
– A wastebasket…
• Iatrogenic
– Hormone Use
– IUD, implant
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”
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
Evaluation
• Other diagnostic procedures
– EMB
• Consider in all patients over 45 or refractory bleeding
• Pipelle vs. D&C
– Ultrasound
– Sonohysterogram
– Hysteroscopy
Endometrial biopsy
Ultrasound
- Abdominal or transvaginal
- Inexpensive and readily
available in most of the world
Sonohysterogram
– Inject small amount
of fluid in uterine
cavity
– Transvaginal
ultrasound
– Endometrial
thickness and
evaluation of
intrauterine
structures
Hysteroscopy
Expensive
Can be used for treatment
MRI
• Very expensive
• Not readily available
• Rarely needed!
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?
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
Treatment - Chronic
Considerations
• 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
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
Levonorgestrel IUD
• FDA approved for
treatment of abnormal
bleeding
– More effective than OCPs,
oral progestins, DepoProvera, NSAIDs
• Cost effective
• Few side effects
• Reduces blood loss by up
to 97%
• Takes 3-6 months for
optimal effect
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
Other?
• Depo Provera
• Implant
Surgical Treatment
• Two main approaches
– Global endometrial ablation
– Hysterectomy
• Future pregnancy contraindicated/impossible
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
Thermachoice
• Eight minute cycle
• Lots of cramping during
procedure
HTA
- 10 minute cycle
- Vaginal burns an early issue
Her Option
- Takes a long time…
Novasure
-
1-2 minutes
Have to dilate cervix more
We have it at CRH!!!
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
Questions
?
Maria
• 32 yo G2P2 with post – coital spotting for
several months
• History completely unremarkable
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.
Erica
• 62 yo postmenopausal for 11 years with
spotting for several months
Stephanie
• 24 yo G0 with very heavy menses and
cramping increasing over one year
Jane
• 42 yo G3P3 presents with heavy, regular
bleeding for 9-12 months.
• Bleeds 2-3 weeks each month with large clots
and cramps.
Sara
• 46 yo G2P2 with heavy, irregular menses for
two years. Now increasing in frequency and
flow
• Previous C/S X 2

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