Vaginal Bleeding in the Perimenopause (Age 35-50)

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1 Vaginal Bleeding in the Perimenopause (Age 35-50) Ralph Anderson, M.D., F.A.C.O.G., F.R.C.S. (C) Chairman and Professor Department of Obstetrics and Gynecology University of North Texas Health Sciences Center Fort Worth, Texas 1

2 Classification of Abnormal Uterine Bleeding Menorrhagia: heavy bleeding; loss of more than 80 ml of blood and/or increased duration of flow (> 7 days) at regular intervals. Menometrorrhagia: increased loss or duration of bleeding occurring at irregular intervals. 2

3 A 40-year-old female presents with irregular bleeding over the past year. Menstrual history 1 st period age 15 Bleeding q x 3-5 days until 1 year ago Now bleeding is heavy and very irregular (menometorrhagia) Gen Px normal Pelvic no abnormalities Hb 9.5 Hct 28 What is the first step in the management? Pregnancy test Pregnancy Related Complications Threatened abortion Incomplete abortion Complete abortion Missed abortion Trophoblastic disease 3

4 A 40-year-old female presents with irregular bleeding over the past year. Menstrual history 1 st period age 15 Bleeding q x 3-5 days until 1 year ago Now bleeding is heavy and very irregular (menometorrhagia) Gen Px normal Pelvic no abnormalities Hb 9.5 Hct 28 What is the first step in the management? Pregnancy test negative What is the next step in the management? Endometrial biopsy Proliferative endometrium Ultrasound Normal uterus, tubes and ovaries What is the likely diagnosis? Anovulatory cycles 4

5 Menometorrhagia (Heavy bleeding at Irregular Intervals) Excessive estrogen production and domination Anovulatory cycles Polycystic ovaries Obesity Hypothalamic Dysfunction Anorexia Exercise 5

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7 Management of Perimenopausal Patient with Menometorragia Due to Anovulatory Cycles 1. Observation 2. Oral contraceptives 3. Oral progesterone Provera 5mg daily Provera 5mg for 14 days of each month 4. Depoprovera 5. Progesterone IUD 6. D&C 7 7. Hysterectomy

8 Management of Perimenopausal Patient with Menometorragia Due to Anovulatory Cycles 1. Observation 2. Oral contraceptives 3. Oral progesterone Provera 5mg daily Provera 5mg for 14 days of each month 4. Depoprovera 5. Progesterone IUD 6. D&C 8 7. Hysterectomy

9 A 43-year-old g3p3 female presents with a history of having had heavy normal periods her entire life until 1 year ago when they began to be heavier and have progressively become heavier until now she bleeds heavily for 9-10 days and uses approximately 8 pad 1 day. General Physical Examination normal Pelvic examination Uterus enlarged to 8 week size Hb 9.2 Hct 26 Pregnancy test negative Endometrial biopsy shows secretory endometrium with the evidence of hyperplasia or malignancy. What is the next step in the management? Transvaginal ultrasound Saline Infusion Transvaginal ultrasound 9

10 Heavy Bleeding with Regular Menstrual Cycles (Menorrhagia) Benign gynecologic disease Endometrial polyp Fibroids Adenomyosis Neoplasm of uterus Hyperplasia Cancer 10

11 Benign Conditions of the Uterus 11

12 A 43-year-old g3p3 female presents with a history of having had heavy normal periods her entire life until 1 year ago when they began to be heavier and have progressively become heavier until now she bleeds heavily for 9-10 days and uses approximately 8 pad 1 day. General Physical Examination normal Pelvic examination Uterus enlarged to 8 week size Hb 9.2 Hct 26 Pregnancy test negative Endometrial biopsy shows adenomatous hyperplasia with atypia. What is the management A. D&C B. Progesterone IUD C. Provera or Megace D. Hysterectomy 12

13 Hyperplasia of Endometrium Oral progesterone Progesterone IUD (Mirena) D&C Hysterectomy and Bilateral salpingo oophorectomy 1% risk of cancer 1-3% risk of cancer % risk of cancer

14 Cancer of the Endometrium 14

15 A 43-year-old g3p3 female presents with a history of having had heavy normal periods her entire life until 1 year ago when they began to be heavier and have progressively become heavier until now she bleeds heavily for 9-10 days and uses approximately 8 pad 1 day. General Physical Examination normal Pelvic reveals a normal size uterus and no pelvic pathology. Hb 9.2 Hct 26 Pregnancy test negative Endometrial biopsy reveals secretory endometrium Transvaginal ultrasound reveals normal uterus and ovaries. What are your thoughts? 15

16 In a reproductive age woman with menorrhagia or menometorrhagia not related to Pregnancy Benign uterine pathology Hyperplasia or cancer Think of Systemic Disorders Endocrine Hyperthyroidism Liver Disease Renal Disease Obesity Hypothalamic Disorders Anorexia Exercise 16

17 Abnormal Uterine Bleeding Medications Associated with Menorrhagia Antidepressants Antipsychotics Interferes with stimulatory and inhibitory nervous impulses that control hypothalamic function resulting in anovulation and abnormal uterine bleeding Anabolic steroids Amenorrhea or irregular vaginal bleeding due to the androgenic effects of the steroids. Aspirin and other prostaglandin synthase inhibitors inhibit platelet function Heparin and warfarin interferes with clotting mechanisms. Digoxin Propranolol Corticosteroids 17

18 Iatrogenic Causes of Menorrhagia and Menometorrhagia in the Perimenopausal Female Oral contraceptives Depot medroxyprogesterone acetate Post menopausal therapy Anticoagulants Herbal supplements 18

19 Vaginal Bleeding in the Perimenopause (35-50) Pregnancy Related Problems Heavy bleeding at Irregular Intervals Anovulatory cycles Heavy bleeding with Regular Menstrual Cycles Benign gynecologic disease Polyp Fibroids Adenomyosis Neoplasm of the uterus Hyperplasia Cancer Metabolic Disorders Hypothyroidism Renal Cirrhosis Obesity Medications associated with Menorrhagia Antidepressants Antipsychotics Aspirin 19

20 Vaginal Bleeding in the Perimenopause (35-50) Pregnancy Related Problems Heavy bleeding at Irregular Intervals Anovulatory cycles Heavy bleeding with Regular Menstrual Cycles Benign gynecologic disease Polyp Fibroids Adenomyosis Neoplasm of the uterus Hyperplasia Cancer Metabolic Disorders Hypothyroidism Renal Cirrhosis Obesity Medications associated with Menorrhagia Antidepressants Antipsychotics Aspirin 20