Perimenopausal DUB. Mary Anne Jamieson, MD Associate Professor, OB/GYN Queen s University Kingston, Ontario

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Elfrieda Jefferson
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1 Perimenopausal DUB Mary Anne Jamieson, MD Associate Professor, OB/GYN Queen s University Kingston, Ontario

2 Objectives Clinicians will: Make a confident diagnosis for Perimenopausal DUB (know how/when to exclude other etiologies in that age group) Choose first-line treatment options that are most likely to be satisfactory and effective. Know when reassurance is all that is necessary Confidently decide when to refer to gynecology

3 No conflict to disclose

4 Abnormal Vaginal Bleeding Differential Diagnosis HPOO Axis & Miscellaneous Hypothalamic / Central Pituitary Ovarian/Gonadal (Adrenal) Outflow (Uterus, Cervix, Vagina, Vulva) Miscellaneous

5 AVB Differential Diagnosis HPOO Axis Hypothalamic / Central Extremes of Diet/Stress/Exercise Chronic Illness CNS lesion

6 AVB Differential Diagnosis HPOO Axis Pituitary Lesion: Prolactinoma, neoplasm Thyroid endocrinopathy

7 AVB Differential Diagnosis HPOO Axis Ovarian/gonadal (Adrenal) Perimenarchal / Perimenopausal PCOS (*obesity*) Neoplasm (ovary or adrenal) Menopause / POF (POI) CAH/addisons/cushings Meds (dopamine)

8 AVB Differential Diagnosis Outflow tract Uterus: HPOO Axis Fibroids, polyps, adenomyosis, (*endometriosis*), endometritis, hyperplasia/cancer Cervix Polyps, cervicitis, ectropion, dysplasia / cancer Vagina/Vulva Infection, neoplasm, dermopathy

9 AVB Differential Diagnosis Miscellaneous Pregnancy Medications: Psychotropic & anticonvulsants Stomach motility agents Anticoagulants Coagulopathy

10 Abnormal Vaginal Bleeding: HX & PE HPOO AXIS History: What exactly is the menstrual history Is she consistently and regularly ovulatory? Stigmata: ex Extremes diet, Thyroid symptoms, galactorrhea, acne/hirsutism, hot flashes, psychotropic meds Physical Exam: Ht, Wt, BMI Stigmata: ex Disordered eating, periph vision, hyperandrogenism, AN, abdominal mass, V/V/Cx & Bimanual: ex, enlarged uterus, cervix polyp

11 YOU CONCLUDE: Most Likely Perimenopausal Menometrorragia

12 Perimenopausal Menometrorrhagia Labs (just to quantify & be confident): CBC, TSH, *?prolactin*,?fsh, Cx swabs, (pap) Consider Endometrial biopsy Endometritis Hyperplasia or cancer Fragment of polyp Pelvic Ultrasound +/- saline-enhancement

13 When to Biopsy Endometrium IN CONTEXT OF PERIMENOPAUSAL DUB, ALMOST ALWAYS Risk Factors for Endometrial Hyperplasia / Cancer Age >45 Obesity Family History of Endometrial Cancer Family History of Colon Cancer Chronic Anovulation Infertility & Nulliparity

14 YOU CONCLUDE: Most Likely Perimenopausal Menometrorragia If they are coping you don t HAVE TO Treat

15 Perimenopausal Menometro: Treatment Options NSAIDS (* only really if predictable &/or painful) Tranexamic Acid: mg Q8h Combined contraceptives (+/- extended cycle) Long-acting progestins (Depo, LIUS) Danazol: start at 200mg po daily GnRH analogue (temporize or preop) Ablation (childbearing complete-not adeno or # fibroids) Embolization (fibroids, childbearing complete) Hysterectomy D&C is NOT Effective as Treatment Myomectomy would very rarely be appropriate in perimenopause unless Hysteroscopic

16 Treatment Options How do you decide? Is she in need of Contraception? Is there both PAIN & FLOW complaints? Did you find coexisting Intramural fibroids? Is she otherwise symptomatic from perimenopause? (ex hot flushes) Does she have any contraindications to particular modalities? (ex smoker >35 yo) Does she have Health Benefits? Short term disability, Coverage for Meds Is she willing to take a daily pill? How long do you think this problem will last? Is she already skipping periods and convincingly symptomatic

17 Perimenopausal Menometro: Treatment Options NSAIDS (* only really if predictable &/or painful) Tranexamic Acid: mg Q8h Combined contraceptives (+/- extended cycle) Long-acting progestins (Depo, LIUS) Danazol: start at 200mg po daily GnRH analogue (temporize or preop) Ablation (childbearing complete- not adeno or # fibroids) Embolization (fibroids, childbearing complete) Hysterectomy

18 A few key reviews Guidelines for the Mgmt of Abnormal Uterine Bleeding. SOGC CPG 106, Aug/01 Gyne & OBs Mgmt of Women with Inherited Bleeding Disorders. SOGC CPG 163, July/05 How Best to Manage DUB. Maness DL, Journal of Family Practice 59(8) Aug Mgmt of DUB. Casablanca Y, ObGyn Clinics of NA # Diagnosis if Abnormal Bleeding. Mohan S. Best Practice & Res Clin OB/GYN 21(6) 2007 SOGC.org has CPGs on Embolization, Mgmt of Fibroids

19 A few other refs Fraser IS. The promise and reality of the intrauterine route for hormone delivery for prevention & therapy of gynecological disease. Contraception Jun 2007 #75 Buttini MJ. The effect of the levonorgl releasing intrauterine system on endometrial hyperplasia. Aust NZJ of OB/GYN June 2009 #49(3) Mansour D. Modern mgmt of abn uterine bleeding: the LIUS. Best Pract Res Clin OB/GYN Dec 2007 #21(6) Sitruk-Ware R. The LIUS for use in peri- and postmenopausal women. Contraception June 2007 #75. Kaunitz A. Levo Releasing Intrauterine System and Endometrial Ablation in Heavy Menstrual Bleeding. A systematic review and meta-analysis. Obstet Gyne May 2009 #13(5)

Abnormal Uterine Bleeding: Evaluation of Premenopausal Women. Vanessa Jacoby, MD, MAS Assistant Professor Ob, Gyn, & Reproductive Sciences UCSF

Abnormal Uterine Bleeding: Evaluation of Premenopausal Women Vanessa Jacoby, MD, MAS Assistant Professor Ob, Gyn, & Reproductive Sciences UCSF Objectives Define normal and abnormal uterine bleeding Review