Abnormal Uterine Bleeding

Transcription

1 Abnormal Uterine Bleeding Rochelle Lindenbaum, M.D. Assistant Professor Department of Obstetrics and Gynecology Hospital of the University of Pennsylvania

2 The Normal Cycle: Results from a complex feedback system involving the hypothalamus, pituitary, ovary, and uterus. The endometrium proliferates from estrogen stimulation, then undergoes secretory changes when exposed to progesterone, and ultimately desquamates upon withdrawal of ovarian steroid support.

3 The Normal Cycle Cessation of bleeding depends on clot formation and uterine factors, such as vasoconstriction and uterine contraction, which is regulated by local prostaglandins.

4 What is normal uterine bleeding? Age of patient Frequency Duration Flow

5 What is normal uterine bleeding? Frequency of menses 21 days (0.5%) to 35 days (0.9%) Age 25, 40% are between 25 and 28 days Age 25-35, 60% are between 25 and 28 days Teens and women over 40 s cycles may be longer apart Munster K et al, Br J Obstet Gynaecology

6 What is normal uterine bleeding? Duration of menses 2 days to 8 days Usually 4-6 days Hallberg L et al, Acta Obstet Gynecology Scandinavica

7 What is normal uterine bleeding? Flow/amount of menses Normal volume of menstrual blood loss is 30 cc Hallberg L et al, Acta Obstet Gynecology Scandinavica

8 Traditional terminologies Menorrhagia Regular intervals, excessive menstrual blood loss amount >80mL Metrorrhagia Irregular intervals, excessive flow and duration Oligomenorrhea Interval longer than 35 days Polymenorrhea Interval less than 21 days Cohen BJB et al, Obstetrical and Gynecologic Survey

9 Etiology Organic vs Dysfunctional Organic: reproductive and systemic Dysfunctional: usually anovulatory

10 Pregnancy Anatomic Malignancy Infectious Trauma Drugs Reproductive:

11 Differential diagnosis Pregnancy related complications Ectopic Abortion: threatened, inevitable, complete/incomplete GTD

12 Differential diagnosis Disease of the cervix Polyp, ectropian, dysplasia, invasive cancer

13 Differential diagnosis Disease of the uterus Infection: endometritis Endometrial polyp, adenomyosis, hyperplasia, adenocarcinoma Fibroids One third of patients with symptoms Correlation between the severity of the bleeding and the area of endometrial surface» Sehgal N, et al American Journal of Surgery Histologic abnormalities of the endometrium, ranging from atrophy to hyperplasia» Deligdish, et al Journal of Clinical Pathology Endometrial venule ectasia» Faulkner RL American J of Obstetrics and Gynecology; Farrer-Brown G, et al Journal of Obstetrics and Gynaecology Br Common W

14 Differential diagnosis Disease of the ovary Germ cell tumors Choriocarcinomas Embryonal carcinoma Sex cord-stromal tumors Granulosa cell tumors(1-2% of all ovarian tumors) Peak incidence between 50 and 55 years of age

15 Differential diagnosis Thyroid disease Prolactinomas Coagulation defects Renal, liver failure

16 Differential diagnosis Trauma Foreign bodies

17 Differential diagnosis Medications Hormonal contraceptives Hormone replacement therapy Phytoestrogens, ginseng SSRIs Anti-psychotic drugs

18 DUB Defined Excessive noncyclic endometrial bleeding unrelated to anatomical lesions of the uterus or to systemic disease It is a diagnosis of exclusion. It is anovulatory bleeding that may be related to a systemic medical disease or factors which affect the hypothalamic pituitary axis.

19 Differential diagnosis Dysfunctional uterine bleeding Anovulatory cycles Loss of normal regulatory mechanism Immaturity Dysfunction» Psychiatric medications, stress, anxiety, exercise, rapid weight loss, anorexia nervosa Ovarian failure Obesity PCOS

20 Evaluation History and physical Labs Pregnancy test CBC TSH Prolactin (Liver function tests) (Coagulation panels) (Androgen profile) Testosterone, DHEAS, Hydroxyprogesterone

21 Evaluation (cont) Cytopathology Pap Endometrial biopsy Imaging studies Surgical D&C hysteroscopy

22 Treatments Medical therapy Hormonal Progestin, estrogen (IV), combination OCPs GnRH agonist Surgical therapy D&C Endometrial ablation Myomectomy/hysterectomy Radiologic therapy Uterine artery embolization (UAE)