11/5/2009 FINANCIAL DISCLOSURE. Abnormal Uterine Bleeding. Is This A Problem? About me % of visits to gynecologist

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1 Abnormal Uterine FINANCIAL DISCLOSURE I HAVE NO FINANCIAL INTEREST IN ANY OF THE PRODUCTS MENTIONED IN MY PRESENTATION Bryan K. Rone, M.D. University of Kentucky Obstetrics and Gynecology November 5, 2009 About me Born in Bowling Green, KY Undergraduate WKU Medical School and Ob/Gyn Residency at the University of Kentucky General OB/Gyn UK with focus in: Minimally Invasive Gynecologic Surgery Pelvic Support Surgery Director of Ob/Gyn Resident Continuity Clinic at Polk Dalton Clinic UKMD Is This A Problem? 30 40% of visits to gynecologist Affects women s lifestyle.clothing, spontaneity, sex, fatigue, self esteem Anemia Cancer Symptom of other systemic diseases AUB Causes Across the Lifespan Postmenopausal Menopause: 12 months of amenorrhea Mean Age: 52 Always needs evaluation Top Causes: Atrophy (59%) Polyps(11%) Endometrial Cancer (10%) Endometrial Hyperplasia (10%) Hormonal Effect (7%) Others (3%) Karlsson B, Am J Obstet Gynecol 1995 May;172(5):

2 Patient PMB Algorithm 59 year old G2P2 with vaginal bleeding 2 3 times per week over the last month. No abd/pelvic pain. Last nl menses at 51 years old. Exam: Look for extrauterine causes Evaluate uterine size Evaluate adnexa Endometrial Sampling Endometrial Biopsy TVUS Hysteroscopy NO PMB HRT?? YES YES < 6 months >6 months Observe Increase Progesterone Continued PMB?? NO Great! Transvaginal Ultrasound for PMB Endometrial Biopsy Acceptable first line evaluation tool Not if pt is on HRT or Tamoxifen Measurement of endometrial stripe If 4 mm, then suspect atrophic endometrium < 1 % chance of endometrial cancer If > 4 mm, then need endometrial biopsy Can be performed in clinic Detection rate of endometrial cancer with pipelle is 99.6% WARNING: May cause vagal response during or after the procedure Urine Pregnancy Test Motrin prior to procedure Insert speculum Endometrial Bx Procedure Clean cervix with betadine or hibiclens Place single tooth tenaculum on cervix Use os finder to dilate cervix if needed Insert pipelle Pull plunger to create suction Endometrial Bx Procedure Turn pipelle multiple times while moving it in and out of the endometrium Take second pass if limited tissue 2

3 Hysteroscopy with Endometrial Curettage PMB Treatment Definitive technique for endometrial sampling if other methods inconclusive Can be performed in the gynecology office, but most performed as an outpatient surgery Atrophic endometrium: HRT, vaginal estrogen, observation Polyps Hysteroscopic Removal, Hysterectomy Endometrial Hyperplasia Referral to gynecologist, progesterone vs. hysterectomy Endometrial Cancer Referral to gynecologic oncologist for surgical staging and potentially adjuvant radiation/chemotherapy AUB Causes Across the Lifespan Normal Menstrual Cycle day cycle 2 7 days of bleeding <80 ml flow Three Ingredients for Normal Menses Menstrual History is Key Gonadotropins Sex Hormones Believe your patient There is a wide range of normal menstrual patterns, if a patient presents with AUB it represents a change to them and is likely abnormal Describe menstrual bleeding pattern Past 6 12 cycles Length Days of bleeding Amount of bleeding (subjective) Endometrial Tissue 3

4 AUB Terminology Cases Oligomenorrhea: Cycle length > 35 days Polymenorrhea: Cycle length < 24 days Menorrhagia: Flow > 80 ml during normal cyclic bleeding Metrorrhagia : irregular, normal volume bleeding Menometrorrhagia: irregular, heavy volume bleeding 36 year old G3P3 with regular cycles who states her periods have been becoming heavier over the last 6 months. She reports 6 days of bleeding. Menorrhagia 28 year old G0 with normal cycles until 2 years ago. She states that for the past two years she has very irregular cycles and an unpredictable bleeding pattern Metrorrhagia Two Categories of Premenopausal AUB Ovulatory Evaluation Premenopausal AUB Intermenstrual Menorrhagia Mt Metrorrhagia /Spotting Ovulatory Anovulatory Always think Uterine Pathology Evaluate the uterus Pelvic Exam Size Shape Tenderness Transvaginal Ultrasound Endometrial Sampling (Pipelle or Hysteroscopy) > 35 years old < 35 years old with risk factors Obesity, diabetes, family hx of uterine cancer, chronic anovulation Ovulatory Treatment Anovulatory AUB Cause Diagnosis Treatment Fibroids Exam and TVUS OCP s, Progesterone, Mirena IUD, Myomectomy, Hysterectomy, Uterine Artery Embolization, US Ablation Endometrial Polyp History, TVUS, Endometrial Bx, OCP s, Progesterone, Mirena IUD, Endometrial Curettage, Hysterectomy, Hysteroscopy Global Endometrial Ablation Neoplasm Endometrial Bx, Hysteroscopy Referral to gynecologic oncologist for surgery and adjuvant treatment Disorders Adenomyosis History, Labs History, TVUS,???MRI OCP s, Antifibrinolytics, Progesterone, Mirena IUD, Global Endometrial Ablation OCP s, Progesterone, Mirena IUD, Global Endometrial Ablation, Hysterectomy Caused by imbalance of estrogen/progesterone effect on the endometrial layer of the uterus Most always due to higher ratio of estrogen Endometrial tissue grows in response to excess estrogen and sporadically bleeds because of localized necrosis and shedding 4

5 Anovulatory Causes Anovulatory Evaluation PCOS Most likely cause Physiologic Adolescents and perimenopausal ages Thyroid Disease Prolactinoma Weight BMI > 35 and BMI < 19 Stress History HA/Visual changes, Heat/Cold tolerance, Wt changes, abnl hair growth, voice changes, external genitalia changes Exam: Weight, Thyroid, Skin (look for hair or evidence of hair removal), acanthosis nigricans, Pelvic exam Labs Urine pregnancy test TSH/Prolactin PCOS labs if suspected Anovulatory Evaluation Anovulatory Treatment Uterine Evaluation Transvaginal ultrasound if abnormal pelvic exam or other pelvic sx per history Endometrial Evaluation > 35 years old < 35 years old with risk factors Obesity, diabetes, family hx of uterine cancer, chronic anovulation Cause Diagnosis Treatment PCOS NIH Criteria Cycle control and endometrial protection with OCP s or progesterone or Mirena IUD, wt loss, metformin Thyroid Disease TSH Correct thyroid function Prolactinoma Prolactin and MRI Cabergoline/Bromocriptine, Cycle control and endometrial protection with OCP s or progesterone or Mirena IUD, Surgery Weight BMI < 19 or > 35 Wt changes Stress Exclusion Stress reduction?? Questions?? Waimea Canyon Kauaʹi, Hawaii 5