Dr. Nancy Van Eyk Associate Professor, Dalhousie University Chief of Gynaecology, IWK Health Centre
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1 Dr. Nancy Van Eyk Associate Professor, Dalhousie University Chief of Gynaecology, IWK Health Centre
2 AUB Outline Terminology Classification/Etiology Assessment Treatment Referral to Gynaecology
3 U c pt 4 HMB?
4
5
6 FIGO: AUB Classification
7 FIGO: AUB etiology Recognize that any patient could have several entities that could cause/contribute to AUB Adenomyosis, leiomyomas, endometrial/endocervical polyps may frequently be asymptomatic and therefore not contribute to the presenting symptoms
8 FIGO Structural: Polyp, Adenomyosis, Leiomyoma Exam: Cervical polyp Adenomyosis enlarged, uniform uterus Fibroids enlarged, asymmetrical uterus Imaging: Transvaginal Ultrasound
9 FIGO: Leiomyoma
10 FIGO: Malignancy/Hyperplasia Sub classified using appropriate WHO or FIGO system
11 FIGO: Coagulopathy
12 FIGO: Ovulatory Dysfunction Unpredictable timing & amount of flow Endocrinopathies PCOS (Hypothyroid) Hyperprolactinemia Stress : psychological, physical - anorexia/weight loss, extreme exercise, obesity Adolescence (young) immature HPO axis Menopausal transition (old) decreased ovarian reserve
13 FIGO: Endometrial Predictable, cyclic bleeding, no other definable causes identified = primary disorder of endometrium HMB, IMB: 2 o?primary disorder of mechanisms regulating local endometrial hemostasis Prolonged bleeding: 2 o?deficiency in molecular mechanisms of endometrial repair
14 FIGO: Iatrogenic IUD Medical Rx: affect Endometrium (Blood coagulation) Ovulation BTB (breakthrough bleeding): unscheduled endometrial bleeding with gonadal steroid therapy
15 FIGO: Not Yet Classified Chronic endometritis Arterio-venous malformations Myometrial hypertrophy Future entities
16 R/O: -Pregnancy -Cervical (PAP) Assessment of AUB
17 Assessment of AUB
18 Endometrial Biopsy
19 Endometrial Biopsy Age: >40yo (*35yo) Obesity BMI >30 Anovulatory (PCOS, infertility) Diabetes Family History endometrial / colon cancer Failure medical treatment (? x2) Significant intermenstrual bleeding (Nulliparity)
20 Medical Treatment AUB Tranexamic acid (Cyklokapron) Combined hormonal contraceptives (CHC) Progesterone only pill (Micronor) Depo-medroxyprogesterone (Depo-Provera) Levonorgestrel intrauterine system (Mirena) Surgical Directive: polypectomy, submucosal myomectomy Endometrial ablation Hysterectomy
21 Tranexamic Acid (Cyklokapron) Antifibrinolytic Can decrease flow up to 50% 2-3 (500mg) bid-qid Contraindications: thromboembolic disease Pharmacy flags if CHC combo S/E: GI Sx (dose dependent), visual disturbance (rare) Only option if actively planning pregnancy
22 Combined Hormonal Contraceptives Extended use: ANY monophasic CHC: pill, patch, ring Seasonale: ug ethinyl estradiol ug levonorgestrel x 84 days Placebo x 7 days Seasonique: ug ethinyl estradiol ug levonorgestrel x 84 days 10 ug EE x 7 days
23 Micronor Very safe Lighter, shorter cycles Not great to regulate cycles Cannot suppress menses Break-through-bleeding Time sensitive (21 hour half-life, 3 hour window)
24 Depo-Provera Inform patients about effects on BMD Counsel them on bone health : Ca, Vit D, stop smoking, weight-bearing exercise, alcohol and caffeine No restriction on use/duration in women 18-45yo who are otherwise eligible (WHO) Risks/benefits discussed at regular intervals No evidence for routine BMD testing SOGC May 2006
25 LN-IUS: Bleeding 1 yr Defn: Bleeding/90 days *Jaydess (3 yrs) (13.5 mg) Mirena (5 yrs) (52 mg) Amenorrhea None 6% 16-20% Infrequent 1-2 d 20% 57% 75% Frequent > 5 d 8% Irregular 3-5 bleeding episodes & <3 bleeding-free episodes of > 14d 23% 19% Prolonged Episodes > 14 days 9% 3% Mean Days/month 5.6d 3.8d *Product monograph: WHO 90-day reference period method Kyleena info pending
26 Global Endometrial Ablation Predictors of poor results/failure (hyst) <45 yo (ahr 2.6) Parity > 5 (ahr 6.0), Uterus > 9mm (OR 1.8) Prior tubal ligation (ahr 2.2) Dysmenorrhea (ahr 3.7) Endometrium > 4mm (OR 2.7) Thermal balloon vs. *radiofrequency (OR 2.8) *Re-ablation ~not feasible with radiofrequency (Novasure)
27 Treatment Failure
28 Minimally Invasive Vaginal Hysterectomy Lowest risks, fast recovery Limitations: parity, uterine size (eg: fibroids), removal/pathology of ovaries, pelvic pathology (previous surgery, c-section, endometriosis) Laparoscopic Limitations: uterine size, pelvic pathology
29 AUB referral if: Needs endometrial biopsy (see list) and provider does not perform Complex medical comorbidities (eg: bleeding disorder), contraindications Fails 2 or more medical treatments* Desires IUS and provider does not insert Needs directed surgery: endometrial polyp, submucosal fibroid Desires endometrial ablation or hysterectomy
30 AUB referral includes: Nature of AUB: HMB, BTB, PCB, IMB List prior treatments (eg: names OCPs) PAP smear result (within 3 yrs) Transvaginal ultrasound report (adult patients) or state ordered; if prior, repeat if > 3 yrs* Relevant lab results (eg: CBC, ferritin)
31 Questions??
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