Abnormal Uterine Bleeding

Transcription

1 Abnormal Uterine Bleeding Dr. Brett Vair, MD FRCSC, Obstetrics & Gynecology 90 th Annual Dalhousie Refresher Course December 2, 2016

2 Disclosure In the past, I have been a presenter with Bayer Mitigating potential bias: The content of this presentation is based on best practice and evidence based medicine

3 Outline New terminology and classification Clinical evaluation Laboratory investigations Imaging studies When should endometrial biopsy be considered? Overview of medical treatment Nonhormonal vs. hormonal options When is referral to Gynecology indicated?

4 A common problem Menstrual disorders are a common indication for medical visits Heavy menstrual bleeding affects up to 30% of women in their reproductive lifetime Significant impact on: Quality of life Time off work Health care system

5 Definitions AUB = Any variation from the normal menstrual cycle Includes changes in: Regularity and frequency of menses Duration of flow Amount of blood loss

6 Definitions Heavy menstrual bleeding The most common complaint of AUB Excessive menstrual blood loss which interferes with the woman s physical, social, and emotional, and/or material quality of life

7 Terminology Menorrhagia Metrorrhagia Dysfunctional uterine bleeding (DUB)

8 Classification System PALM-COEIN (FIGO, 2011)

9 ACOG Practice Bulletin No. 128: Diagnosis of Abnormal Uterine Bleeding in Reproductive- Aged Women. July, 2012

10 Evaluation of AUB Laboratory Investigations Recommended investigations: CBC (II-2A) Urine or serum βhcg ((III-C) Cervical cancer screening Testing for Chlamydia trachomatis in patients at high risk TSH *Only if there are symptoms or findings suggestive of thyroid disease (II-2D) Testing for coagulation disorders in women with risk factors (II-2B)

11 Of all women presenting with heavy menstrual bleeding, which percentage will ultimately be found to have an underlying bleeding disorder? A. 1% B. 3-5% C % D. 30%

12 When should testing for bleeding disorders be ordered? History of heavy, regular, cyclic periods since menarche Up to 50% of adolescents presenting with heavy bleeding at menarche will have a coagulopathy Personal or family history of abnormal bleeding Recommended testing: INR, PTT Special testing for Von Willebrand s disease (factor VIII level, vwf antigen, and vwf functional assay)

13 Evaluation of AUB Laboratory Investigations There is no evidence for routine measurement of: Ferritin TSH if there is no reason to suspect thyroid disease FSH, LH Estradiol Progesterone

14 Evaluation of AUB Imaging Studies Imaging studies may be indicated when: History or physical exam suggests structural causes There is a risk of malignancy Conservative management has failed

15 Evaluation of AUB Imaging Studies Transvaginal ultrasound should be the first line imaging modality for investigation of AUB (I-A) Assists with diagnosis of: Endometrial polyps Leiomyomas Adenomyosis Uterine anomalies Endometrial thickening associated with hyperplasia and malignancy

16 A quick word about uterine fibroids Found in 70% of women by age 50 30% of women experience AUB The majority are asymptomatic and do not require intervention Submucous fibroids that protrude into the uterine cavity are most frequently related to AUB Women with intramural fibroids may also experience AUB

17 And a quick word about endometrial polyps Localized hyperplastic overgrowths of endometrial tissue that form a projection from the surface of the endometrium Majority are benign (95%) May be asymptomatic Intermenstrual bleeding is the most frequent symptom

18 A 42 year-old premenopausal woman has a transvaginal ultrasound reporting a thick endometrium measuring 15 mm. Should this finding alone prompt concern about endometrial hyperplasia or malignancy? A. Yes B. No

19 Ultrasound endometrial assessment The normal endometrium in a premenopausal woman varies in thickness according to the menstrual cycle 4 mm in the follicular phase Up to 16 mm in the luteal phase There is no standard threshold for abnormal endometrial thickness in premenopausal women Further evaluation should be based on the specific clinical situation

20 When should endometrial biopsy be considered? Age >40 Risk factors for endometrial cancer Failure of medical treatment Significant intermenstrual bleeding Anovulatory menstrual cycles (Level of evidence: II-2A)

21 Endometrial cancer risk factors Age Average age 61 years 5%-30% of cases occur in premenopausal women Obesity (BMI >30 kg/m 2 ) Nulliparity PCOS Diabetes HNPCC Lifetime risk for endometrial cancer 40-60%

22 Differentiating ovulatory from anovulatory menstrual cycles Anovulatory bleeding is more likely to be associated with endometrial hyperplasia and malignancy Ovulatory bleeding Regular menstrual cycles Associated with premenstrual symptoms and dysmenorrhea Anovulatory bleeding Irregular Heavy Prolonged Common near menarche and the perimenopause

23 Medical Treatment The first line therapeutic option Should be initiated once malignancy and significant pelvic pathology have been ruled out Women found to be anemic from AUB should be started on iron supplementation immediately

24 Medical Treatment Effective medical treatment options for abnormal uterine bleeding Non-hormonal options Hormonal options Non-steroidal anti-inflammatory drugs (I-A) Antifibrinolytics (I-A) Combined hormonal contraceptives (I-A) LNG-IUS (I-A) Oral progestins Depot-medroxyprogesterone acetate (I-A) Danazol (I-C) GnRH agonists (I-C)

25 Medical Treatment: Non-hormonal options NSAIDs Cochrane Review 2007: Reduction of menstrual blood loss by 33%-55% vs. placebo No significant difference in adverse effects Improvement in dysmenorrhea in up to 70% of patients Therapy ideally begins the day before menses and continues for 3-5 days or until bleeding ceases Clinical trials comparing NSAIDs to other medical agents have found them to be less effective in reducing menstrual blood loss

26 Medical Treatment: Non-hormonal options Antifibrinolytics (tranexamic acid) Placebo-controlled trials: reduction in menstrual blood loss 40%-59% from baseline Most commonly studied regimen: 1 g po q6h during menstruation Single daily dose of 4 g also found to be effective Does not treat dysmenorrhea Controversy regarding possible elevated risk of venous thromboembolism

27 Medical Treatment: Hormonal options Combined hormonal contraceptives Advantages: Cycle control Reduction of menstrual losses 40%-50% Improvement of dysmenorrhea Contraception Continuous use may offer superior effect

28 Medical Treatment: Hormonal options The levonorgestrel-releasing intrauterine system (LNG-IUS) Approved by Health Canada for treatment of heavy menstrual bleeding 70%-97% reduction in blood loss Amenorrhea in up to 80% at one year Other advantages: Contraception Treatment of dysmenorrhea, pelvic pain due to endometriosis Cochrane Review 2006: LNG-IUS provides equivalent improvement in quality of life vs. surgical treatment options

29 A 14 year-old female presents to your office with heavy, irregular menstrual periods. She has never been sexually active. Is the levonorgestrel-releasing intrauterine system a treatment option that may be discussed with her? A. Yes B. No

30 Medical Treatment: Hormonal options Oral progestins A recognized treatment for anovulatory bleeding Cyclic progestins taken for days each month 50% of women with irregular cycles will achieve menstrual regularity Offer endometrial protection from effects of unopposed estrogen Not an effective treatment for regular heavy menstrual bleeding (I-E)

31 When is referral to Gynecology indicated? Acute presentation of AUB Severe iron-deficiency anemia Failure of conservative treatment Concern about possible malignancy Focal endometrial lesion Structural uterine abnormalities Endometrial biopsy indicated Desire for surgical treatment

32 Summary AUB is a common condition which has a significant impact both at the individual level, and at the level of the health care system Recommended investigations: CBC, BhCG, cervical screening, cervical swabs TSH and coagulopathy screening if clinically indicated TVUS is the first-line imaging modality for AUB

33 Summary Endometrial biopsy should be considered in women >40 years or in those with bleeding not responsive to medical therapy Also in younger women with risk factors for endometrial cancer Medical treatment is the first-line therapeutic option Both non-hormonal and hormonal options may be considered

34 Resources ACOG Practice Bulletin No. 128: Diagnosis of Abnormal Uterine Bleeding in Reproductive-Aged Women. Obstetrics & Gynecology, July 2012; 120 (1). ACOG Practice Bulletin No. 136: Management of Abnormal Uterine Bleeding Associated with Ovulatory Dysfunction. Obstetrics & Gynecology, July 2013; 122 (1). SOGC Clincial Practive Guideline No. 292: Abnormal Uterine Bleeding in Pre-Menopausal Women. J Obstet Gynaecol Can, May 2013; 35: S1-S28.

35 Questions?