Update on Abnormal Uterine Bleeding. Susan M. Sheridan, M.D., F.A.C.O.G Casper Obstetrical and Gynecological Associates Casper, WY
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1 Update on Abnormal Uterine Bleeding Susan M. Sheridan, M.D., F.A.C.O.G Casper Obstetrical and Gynecological Associates Casper, WY
2 Defining Abnormal Uterine Bleeding (AUB) Normal menstrual cycle Frequency days (1 st day to 1 st day) Fairly regular intervals Blood loss <80 ml (???) Soaks pad or tampon in less than 2 hours AND/OR amount interferes with daily activities (work, stains clothing or bedding, leaving the house) Duration of 5 days
3 Taking a Gynecologic History Menstrual history: 1 st and last day over several cycles, number of days of heavy/light menses, intermenstrual or postcoital bleeding, number of episode of bleeding over the past 12 months Sexual history: Cervicitis or endometritis/pid Contraceptive history: Iatrogenic bleeding (Paraguard-heavy, Mirena/Nexplanonirregular or absent, OCPs-BTB) Family history: Bleeding disorders, colon/gyn malignancy (Lynch/Cowden)
4 DEFINING AND CODING THE PROBLEM ICD-10 AUB paired with descriptor DENOTES PATTERN Heavy menstrual bleeding (HMB) Intermenstrual bleeding (IMB) (replaces menorrhagia and metromenorrhagia) AUB with letter qualifier DENOTES CAUSE (AUB-P): Polyps (AUB-A): Adenomyosis (AUB-L): Leiomyoma SM or O (AUB-M): Malignancy
5 Terminology (and DD) Defines Pattern & Etiology PALM COEIN Polyps Adenomyosis Leiomyomas Malignancy Coagulopathy Ovulatory dysfxn Endometrial Iatrogenic Not yet classified
6 DD by History Fibroids: heavy, prolonged bleeding Polyps: irregular/intermenstrual bleeding, Tamoxifen use, Lynch/Cowden, endometrial cells on Pap smear, obesity Adenomyosis: heavy, painful bleeding, dysparunia, uterine tenderness, on exam globular, soft uterus enlarged to less than 12 weeks size Malignancy: irregular, prolonged, sometimes heavy, does not respond to initial treatments, risk factors such as obesity, unopposed estrogen
7 DD by Hx/Cause Coagulopathy: family history, present since menarche, bleeding with procedures, not responsive to treatments (20% risk!) Ovulatory dysfunction: prolonged intervals of no bleeding, cycles length varies by more than 10 days, lack of molima, elevated androgens, hirsuitism Multifactorial: endometritis related to IUD, fibroids present with anovulatory cycles or malignancy
8 EVALUATION Labs: Hgb/Hct, -HCG, Pap, GC/Chlam, TSH, androgens, E/P Ultrasound: Abnormal exam, suspect pathology such as polyps/adenomyosis Endometrial stripe only in PMB Endometrial biopsy: Age greater than 45 Inadequate treatment response Risk factors for malignancy or hyperplasia
9 Additional Tests Saline Infusion Sonohysterography (SIS) Preferrably between end of menses and day 8 Hysteroscopy
10 Treatment Polyps: hysteroscopic resection Adenomyosis: hysterectomy, UAE Hormones may improve in some women with COC continuous use Leiomyomas: hysteroscopic resection (requires additional imaging), GnRH agonist, UAE, hysterectomy Malignancy: surgical for cancer, medical high dose progestins for hyperplasia 20% risk of cancer with atypia surgical recommended
11 Treatment Coagulopathy: treat underlying defect Ovulatory dysfunction: stop acute bleeding (estrogen) and prevent recurrence: Hormonal: Mirena/Skyla, Depo Provera, COCs, Nexplanon metformin in PCOS-not recommended as sole treatment
12 Treatment Endometrial: Medical: NSAIDs Decrease in COX/endoperoxides vasoconstriction of spiral arterioles and contraction of myometrial smooth muscle tranexamic acid (Lysteda) 1300 mg TID for up to 5 days during menses Anti-fibrinolytic: stabilizes fibrin plug by preventing plasmin from binding, lowers tpa level Mirena Pseudodecidualization, glandular atrophy, leukocytic infiltration, decrease glandlar to stromal mitosis Surgical: Endometrial ablation: Novasure, Thermachoice
13 Endometrium and the Brick Wall Analogy Normal endometrium Simple hyperplasia Complex hyperplasia without atypia Complex hyperplasia with atypia
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