Abnormal Uterine Bleeding. Howard Herrell, MD FACOG

Transcription

1 Abnormal Uterine Bleeding Howard Herrell, MD FACOG

2 Disclosures I, Howard Herrell, DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation. DO NOT anticipate discussing the unapproved/investigative use of a commercial product/device during this activity or presentation.

3 Normal Menses Lasts 2-7 days (average of 5) day cycle (mode of 28) Less than 80 ml volume

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5 Abnormal Menses Menorrhagia: More than 80mL or subjectively heavy Metrorrhagia: Bleeding between periods Menometrorrhagia: combo of both Polymenorrhea: Bleeding more frequent than every 21 days Oligomenorrhea: Bleeding less frequent than every 35 days

6 New FIGO System Proposed in 2011 to simplify classification and further reseach Adopted by ACOG in 2012 Classifies by bleeding pattern and etiology

7 PALM-COEIN Gets rid of term Dysfunctional Uterine Bleeding Makes irrelevant the terms menorrhagia and metrorrhagia (replaced with Heavy Menstrual Bleeding and Intermenstrual Bleeding)

8 Classification

9 Classification AUB-P (Polyps) AUB-A (Adenomyosis) AUB-L (Leiomyoma-Submucosal or other) AUB-M (malignancy and hyperplasia)

10 Classification

11 Classification AUB-C (inherited and acquired coagulopathies, e.g. vwb) AUB-O (ovulatory, with problems ranging from amenorrhea to irregular heavy periods; e.g. PCOS, unopposed E2) AUB-E (endometrial) AUB-I (iatrogenic, ERT, etc.) AUB-N (not yet classified)

12 Screening for Dyscrasia

13 Work-up

14 13-18yo AUB usually due to anovulation Also BC use, pregnancy, infection, coagulopathies, tumors All need to be screened for coagulation disorders

15 19-39yo Most common causes include pregnancy, structural lesions, anovulatory cycles, BC and endometrial hyperplasia.

16 40yo-Menopause Most common causes are anovulatory bleeding related to decline ovarian function. Also hyperplasia and carcinoma, atrophy, and fibroids.

17 Menopause Most common causes include atrophy, ERT. Hyperplasia and cancer must be excluded.

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19 Treatment

20 Medical Options Iron therapy Antifibrinolytics Cyclo-oxygenase inhibitors Progestins Continuous/cyclic Local progestins Implantable progestins Estrogens plus progestins Androgens GNRH agonists and antagonists

21 Antifibrinolytics Tranexamic acid 1g QID first 4 days cycle for ovulatory AUB Most cases bleeding reduces 40-60% No evidence of increased risk thromboembolic disease even if high risk Commonly used world-wide but usually non-formulary in the US

22 COX inhibitors (NSAIDS) Unclear exactly how work but likely generally reduce PGs locally, therefore vasoconstrict 5/7 trials Cochrane showed mean menstrual blood loss decreased c/w placebo, 2/7 no change. Trials usually used mefanamic acid (Ponstan) mg 2-4x daily, also naproxen and ibuprofen Randomized trials comparing danazol & tranexamic acid to NSAIDS show both superior

23 Progestins: cyclic 10/7 Most commonly used is Norethindrone Most with anovulatory AUB will regulate with cyclic norethindrone, 10 days per month (luteal phase prog) Women who ovulate are unlikely to benefit, and may get worse Cochrane says less effective than tranexamic acid, danazol, Mirena in ovulatory DUB if used 10/7

24 Progestins: long cycle/ continuous Norethindrone 5mg daily days 5-26 reduced menstrual volume by 87% Only 22% were willing to continue therapy beyond 3/12, preferred IUD No large studies with continuous progestin but appear to work well

25 Local Progestins: IUD Mirena, 20mcg levonorgestrel daily 5 ys Greatest impact on bleeding volume of any med treatment if ovulatory (94% decr blood vol at 3/12, 76% of women wanted to continue post 3/12). Less data if anovulatory. IUD c/w hysteroscopic endometrial ablation by experts showed 79% decr Vs 89% at 12/12, equivalent patient satisfaction Scandinavian open trial with ovulatory AUB scheduled for hysterectomy, 64.3% elected to cancel surgery

26 Progestins: Implantable Nexplanon (etonogestrel) 3 ys Less bleeding, variable pattern 30-40% cycles amenorrhoeic (c/w 51% Depo) 30% infrequent bleeding (c/w 16% Depo) 10-20% frequent or prolonged bleeding (c/w 35%) Usually know within 3/12 what pattern will be but stabilizes at 12/12

27 OCPs Generally considered effective in both ovulatory and anovulatory Few available data to support 1 RCT demonstrated 50% reduced flow 1 RCT compared triphasic OPC & placebo in anovulatory AUB: 50% much improved vs 20%, with better life table scores Nuvaring can be used in a continuous manner

28 Surgery Hysteroscopic/Global Endometrial Ablation Embolic treatment of fibroids Hysterectomy

29 Questions?