Case scenario. Abnormal Bleeding. Managing Abnormal Bleeding and Uterine Fibroids in a Primary Care Setting

Transcription

1 Managing Abnormal Bleeding and Uterine Fibroids in a Primary Care Setting Buvana Reddy MD HealthPartners OB/GYN Department Case scenario 45yo female s/p tubal ligation who presents with a history of heavy menses, now worse. Her menses are every 28 days, lasting 7 days. She changes a pad an hour on the first two days. She feels tired. Abnormal Bleeding What is normal bleeding? In general cycle length d, lasting 4 6 days with average volume of 30cc. When is abnormal bleeding normal? Menarche Immature hypothalamic pituitary gonadal axis Cycle lengths (from period to period) usually long and gradually decrease in length Perimenopause More anovulatory cycles Increased variability in cycle length and mean cycle length longer than 35 days 1

2 So what is abnormal or dysfunctional? No menses (amenorrhea) Cycle lengths longer than 35 days (oligomenorrhea) or shorter than 21 days (polymenorrhea) Irregular bleeding or bleeding in between the menses (metrorrhagia) Heavy bleeding (menorrhagia) Postmenopausal bleeding Reasons for dysfunctional bleeding Pregnancy Obtain a urine pregnancy test Thyroid disorders Menstrual irregularities are seen in about 20% of hyperthyroidism or hypothyroidism. Obtain a TSH PCOS Generally causes anovulation, so the endometrium thickens, becomes fragile, and bleeds erratically. Consider this in women with hirsutism, obesity, acne, etc. Can obtain an ultrasound to look for polycystic ovaries and to assess the endometrium. Reasons for dysfunctional bleeding Fibroids and polyps Obtain an ultrasound with hydrosonography for evaluation Disorders of coagulation Von Willebrand s disease is the most common. Generally have history of heavy bleeding beginning at menarche, postpartum hemorrhage, ecchymoses, etc. Endometrial cancer Risk increases with increasing age, prolonged anovulation, and obesity. Hyperprolactinemia Causes amenorrhea Often see galactorrhea 2

3 Evaluation of dysfunctional bleeding When to evaluate? When there is a pattern of abnormal bleeding. When bleeding is interfering with patient s daily activities or creating patient anxiety. How to evaluate: UPT TSH, prolactin Hemoglobin and ferritin Ultrasound For dysfunctional bleeding, postmenopausal bleeding, new onset intermenstrual bleeding. Testing for coagulation disorders if needed. Endometrial biopsy if indicated. How to treat if workup is normal Medical management Good for anovulation and for menorrhagia. May use combination OCPs if no contraindications. May also use progesterone only options such as progesterone only pills, Depo Provera, Mirena IUD. Nexplanon may have irregular bleeding so is not recommended for menstrual management. How to slow a heavy bleed: Use monophasic pill Use a taper usually 3 pills daily for 3 days, 2 pills daily for 3 days, then one pill daily. Skip placebo pills and proceed straight to second pack. Expect heavy, painful period within 2 4 days after stopping regimen Can use progesterone Provera 10mg daily for 10 days Does not always work for the bleeding. Other treatment options Endometrial ablation Destroying the endometrium using various methods. Has a high satisfaction rate (people say they still have menses but it is much lighter) but a lower amenorrhea rate. It is temporary (lasts for about 5 years) Patient has to be done with childbearing. Risks include hematometra (blood collecting in the uterus), post ablation syndrome, cervical stenosis. 3

4 When to refer to OB/GYN Postmenopausal bleeding Anovulatory bleeding (high risk of endometrial cancer and needs endometrial biopsy) Dysfunctional bleeding requiring endometrial biopsy Bleeding unresponsive to medical management. Structural problems (fibroids, polyps, etc) Any concerns Overview of abnormal bleeding Standard workup of abnormal bleeding: Hemoglobin and ferritin (if heavy bleeding) TSH (prolactin if amenorrhea) UPT if indicated Ultrasound Workup for postmenopausal bleeding Ultrasound Treatment for abnormal bleeding Medical management is first line True or False Q: Evaluate a patient if they have a pattern of abnormal bleeding or it is affecting them. A: True Q: Ultrasounds are not useful in evaluation of abnormal bleeding. A: False Q: For anovulation and menorrhagia, surgical management is preferred. A: False Q: Endometrial ablation has a high satisfaction rate but lower amenorrhea rate A: True Q: All patients with postmenopausal bleeding need workup. A: True. 4

5 Back to our patient For workup, this patient with the heavy menses had the following: TSH normal Hemoglobin 9.0, ferritin 6 UPT negative Ultrasound shows a 3cm subserosal leiomyoma and a 2.5 cm submucosal leiomyoma Endometrial biopsy is benign. Uterine Fibroids What are they? Otherwise known as leiomyomas. Benign tumors that arise from the smooth muscle cells of the myometrium. Most common pelvic tumor in women. Some studies state myomas are present in 70% of white women and >80% of black women by age 50. Arise in reproductive aged women. Growth is variable in this population Some grow rapidly and some remain stable. Most but not all shrink during menopause. Cancer and fibroids Cancer is exceedingly rare from fibroids. Risk of sarcoma is 3 7 per 100,000, with median age of 60. Risk of carcinosarcoma is 1 4 per 100,000 with median age of 62 67yo 5

6 Fibroid Locations are important Intramural Within the uterine wall Can cause abnormal bleeding, bulk symptoms Submucosal Often protrude into the endometrial cavity Can cause abnormal bleeding Subserosal Can be pedunculated or broad based Can cause pain or bulk symptoms Cervical At the cervix rather than the uterine body Symptoms of fibroids No symptoms Many women are asymptomatic and fibroids are noted incidentally. Abnormal uterine bleeding Most common Generally heavy or prolonged bleeding The location rather than size plays a large role. NOTE: Intermenstrual bleeding or postmenopausal bleeding are NOT typical of fibroids Symptoms cont. Pelvic pressure and pain, i.e. bulk symptoms Urinary frequency Difficulty emptying the bladder Urinary retention Hydronephrosis Constipation Dysmenorrhea Pain from torsion of the myoma Reproductive effects Infertility Increased risk of miscarriage with submucous fibroids 6

7 Diagnosis Physical examination Enlarged uterus with irregular contour Imaging First line: Ultrasound Saline infusion sonography helps with defining submucous myomas. Second line: MRI generally used for surgical planning or uterine artery embolization Treatment depends on symptoms Postmenopausal women Refer if the myoma is new or enlarging No symptoms Expectant management. Annual pelvic exam and/or ultrasound after diagnosis. If myomas are increasing or symptoms present, consider other options. Abnormal bleeding Can try medical management if no other contraindications. Hormonal management Estrogen and progesterone therapy Combination OCPs First line for abnormal bleeding or dysmenorrhea with fibroids (as long as no contraindications) May not cause further fibroid growth. Progesterone only therapy Depo Provera or progesterone only pills Mixed results with management of abnormal bleeding. Some studies show a decrease in fibroid growth, and others show an increase in fibroid growth Levonorgestrel IUD (Mirena) Can treat menorrhagia in women with fibroids Higher rate of expulsion 7

8 Other medical options GnRH Agonist (Leuprolide, Lupron) Cause 35 65% reduction in leiomyoma volume with 3 months of treatment. Best for large fibroids and for preop treatment in women with anemia. Effects are temporary (fibroids grow back after cessation of treatment) Do no use more than 6 months due to risk of bone loss Options rarely used Aromatase inhibitors (not FDA approved) Antiprogestins (mifepristone) Not FDA approved for treatment of fibroids. Antifibrinolytic (Tranexamic acid) FDA approved for heavy menstrual bleeding Not well studied with fibroid related menorrhagia. Surgical options If childbearing is desired: Myomectomy Surgical removal of the fibroids alone Main option for women who desire childbearing Can be done with laparotomy or laparoscopy. Can be done hysteroscopically for submucous or intracavitary myomas Risk that new fibroids can develop in the future or symptoms recur. Surgical options If childbearing is NOT desired: Endometrial ablation Destruction of the endometrial lining and small submucous fibroids <3cm For women who have completed childbearing recommend permanent sterilization Used only for bleeding abnormalities. High satisfaction rate but lower amenorrhea rate Risk that new fibroids can develop in the future or symptoms recur. Hysterectomy Removal of the uterus and/or cervix with attached fibroids Definitive therapy. For women who have completed childbearing. Generally try minimally invasive options first. 8

9 Surgical options cont Uterine Fibroid Embolization Interventional radiologist injects PVC particles into the fibroid via a femoral approach. Shrinks myomas by 30 46% Works for the RIGHT patient Ptatient has to be done with childbearing Small risk of ovarian dysfunction Risk of pain, fever, infection, need for hysterectomy MRI Guided Focused Ultrasound Surgery (experimental) Uses high density ultrasound waves directed at the myoma. Need longer term studes Review of management of fibroids Asymptomatic women Expectant management Annual pelvic exams and/or ultrasound. Postmenopausal bleeding Refer if new or enlarging mass Most fibroids decrease in size after menopause. Abnormal bleeding Medical management is first line. Refer if not improving or patient desires surgical management. Overview of fibroids Myomas are generally benign. Symptoms can be grouped into abnormal bleeding, pelvic pain and pressure, or reproductive issues. Intermenstrual bleeding and postmenopausal bleeding are NOT typical of myomas. Diagnosis is by pelvic exam and ultrasound. Myomas have variable growth in the premenopausal period and generally decrease in size in the postmenopausal period. New masses or enlarging masses in a postmenopausal woman warrants further evaluation. There are many treatment options that do not involve hysterectomy. 9

10 True or False Q: Fibroids are generally benign A: True Q: If the patient has no symptoms, you should still recommend treatment. A: False Q: If a patient desires children, you should recommend endometrial ablation A: False Q: A new or enlarging mass in a postmenopausal woman is concerning. A: True References ACOG Practice Bulletin No. 96, August UpToDate Overview of treatment of uterine leiomyomas. UpToDate Epidemiology, clinical manifestations, and natural history of uterine leiomyomas (fibroids) 10