Conflicts 10/5/2016. Abnormal Uterine Bleeding. Objectives Review diagnosis and updated nomenclature. Management options for acute and chronic AUB.

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1 Abnormal Uterine Bleeding Barbara L. Keller, MD JD Naval Hospital Oak Harbor OB/GYN Physician Conflicts I have no conflicts or financial interests to disclose. Objectives Review diagnosis and updated nomenclature. Management options for acute and chronic AUB. 1

2 Case Presentation 38 yo G4P3013 with 8 months of heavy and irregular menses What additional questions do you have? What is AUB? NORMAL menstrual cycle: 5 day menses every days Commonly-used OLD descriptive terms: Menorrhagia Metrorrhagia Hypermenorrhea Postcoital Polymenorrhea Oligomenorrhea New Nomenclature: PALM- COEIN System Abnormal Uterine Bleeding Heavy menstrual bleeding Intermenstrual bleeding PALM: Structural Causes Polyp (AUB-P) Adenomyosis (AUB-A) Leiomyoma (AUB-L) Malignancy & hyperplasia (AUB-M) COIEN: Nonstructural Causes Coagulopathy (AUB-C) Ovulatory dysfunction (AUB-O) Endometrial (AUB-E) Iatrogenic (AUB-I) Not yet classified (AUB-N) 2

3 Structural Causes of AUB Causes of AUB-O Normal endometrial cycle depends on follicular development, ovulation, corpus luteum development, and luteolysis. At end of the cycle, estrogen and progesterone withdrawal occurs to trigger menses. Overview of menstrual cycle 3

4 AUB-O Cont d Absence of ovulation: no progesterone surge resulting in endometrial proliferation that is fragile, vascular, and lacking sufficient stromal support. Causes of anovulation: Physiologic: adolescence, perimenopause, lactation, pregnancy. Pathologic: hyperandrogenic, hypothalamic, thyroid, prolactin, pituitary, premature ovarian failure, iatrogenic, medications Diagnosis HPI: Description of the bleeding, pain, mass PMH, PSH, OB/GYN, Family When to consider disorder of hemostasis Medications Birth control ROS: identify ovulatory dysfunction (sx of thyroid disease, PCOS) Diagnosis - Exam Weight Signs of PCOS, thyroid disease, insulin resistance, anemia, bruising/petechiae Pelvic exam (speculum and bimanual) 4

5 10/5/2016 Exam Cervical Polyp Diagnosis - Labs Pregnancy test, CBC, TSH, GC/CT Willebrands disease: CBC, PT, PTT, other specific tests per hematology Possible additional AUB-O labs: FSH/LH, DHEA-S, testosterone, prolactin, fasting insulin and/or HbA1c Endometrial sampling (ALL postmenopausal bleeding) Von When Is Endometrial Sampling Indicated? AUB AUB in patients older than 45 yrs in patients < 45 yrs with: Hx unopposed estrogen exposure (PCOS or obesity) Failed medical mgmt Persistent AUB 5

6 How is Endometrial Sampling Best Performed? First-line method = office endometrial biopsy High accuracy in diagnosing cancer when adequate specimen and global process Persistent bleeding with previously benign pathology needs to be further evaluated Dilation and curettage Hysteroscopy and guided biopsies or D&C Imaging Transvaginal ultrasound Saline sonohysterography MRI Hysteroscopy Ultrasonography/SIS 6

7 SIS Hysteroscopy Hysteroscopy - Polyps 7

8 Hysteroscopy - Fibroids When Is Imaging Indicated? Abnormal physical exam Normal exam but symptoms persist despite treatment Clinical suspicion for polyps or fibroids Endometrial thickness in premenopausal women is NOT helpful in the evaluation. Diagnosing Adenomyosis TVUS: Heterogeneous myometrium Myometrial cysts Asymmetric myometrial thickening Subendometrial echogenic linear striations MRI with T2 weighted images Used when diagnosis inconclusive, when further delineation would affect mgmt, and when coexisting myomas suspected 8

9 Case Presentation Bleeding x 8 months, saturating 10 large pads/day for 8 days of the month. She occasionally has bleeding between menses and after intercourse. No significant past or family history. She is taking Ortho Novum for birth control. Exam is normal. Labs are all normal, and endometrial biopsy shows proliferative endometrium. Case Presentation TVUS: thickened endometrial stripe with focal echogenicity at the fundus. SIS: 1 x 1.5 cm suspected polyp noted at the anterior uterine fundus. Is endometrial sampling adequate? What next? Management of AUB Tailored to: Goals of therapy (stop acute bleeding, prevent future heavy or irreg bleeding, prevent complications, quality of life) The etiology (ex AUB-O is an endocrinologic abnormality and should be treated medically) Age Contraceptive and future fertility desires Contraindications 9

10 Management of Acute AUB Assess hemodynamic stability IV access Identify cause if possible Consider admission for IV therapy Blood transfusion and/or clotting products IV or oral iron therapy Management of Acute AUB High-dose estrogen: OCP taper Oral estrogen only IV estrogen Oral progestins Tranexamic Acid Desmopressin (if known von Willebrands) Mechanical tamponade (30 ml foley) Management of Acute AUB Surgical mgmt: if unstable, failing medical therapy, or not suitable for medical mgmt Dilation and curettage Endometrial ablation Uterine artery embolization Hysterectomy 10

11 Hormonal Therapy Combination contraceptives (pills, patches, ring) Cyclic or continuous Can increase Factor VIII and von Willebrand factor Can reduce bioavailable androgens, improving hirsutism and acne with PCOS Cyclic progestin (ie last days of cycle) Hormonal Therapy Cont d Progestin-only therapy Depo Provera Daily progestin Progestin IUD (Mirena or Skyla) Cyclic hormonal therapy (HRT) Progestin IUDs Can be considered in ALL age groups Studies show effects are superior to usual treatments in all domains, including continuation of treatment May prevent hysterectomy in approx 50% and reduce overall costs by 30% 11

12 Non-Hormonal Therapy Weight loss NSAIDs Mefenamic acid Naproxen Tranexamic acid (TXA) 1.3 mg PO TID x up to 5 days per cycle RCT demonstrated 40.4% reduction in mean menstrual blood loss compared to placebo 8.2% Systematic Review of Mgmt Options Review of 26 RCT s of nonsurgical treatments for AUB presumed secondary to ovulatory or endometrial dysfunction Results with percent reduction in bleeding: Progestin IUD: 71-95% Combined OCPs: 35-69% Extended cycle oral progestins: 87% TXA: 26-54% NSAIDS: 10-52% Luteal-phase progestins least effective Surgical Therapy Hysteroscopy D&C Polypectomy Myomectomy Mgmt of fibroids: UAE, myomectomy Endometrial ablation Hysterectomy 12

13 Endometrial Ablation Techniques Circulating hot water (Hydrothermablator) Bipolar radiofrequency (Novasure) Hot liquid-filled balloon (ThermaChoice) Microwave Cryotherapy (Her Option) Resectoscope Case Presentation What treatment option(s) may be good for our 38 yo with a suspected endometrial polyp? Questions? 13

14 References ACOG Practice Bulletin #128 (Jul 2012): Diagnosis of Abnormal Uterine Bleeding in Reproductive-Aged Women. ACOG Practice Bulletin #136 (Jul 2013): Management of Abnormal Uterine Bleeding Associated With Ovulatory Dysfunction. ACOG Committee Opinion #557 (Apr 2013): Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive- Aged Women. Gupta et al. NEJM 2013: Levonorgestrel intrauterine system versus medical therapy for menorrhagia. Heliovaara-Peippo et al. Am J Obstet Gynecol 2013: Quality of Life and Costs of Levonorgestrel Releasing Intrauterine System or Hysterectomy in the Treatment of Menorrhagia: A 10-Year Randomized Controlled Trial. Lukes et al. Obstet & Gynecol 2010: Tranexamic Acid Treatment for Heavy Menstrual Bleeding. Matteson et al. Obstet & Gynecol 2013: Nonsurgical Management of Heavy Menstrual Bleeding: A Systematic Review. 14

5/5/2010 FINANCIAL DISCLOSURE. Abnormal Uterine Bleeding. Is This A Problem? About me % of visits to gynecologist

5/5/2010 FINANCIAL DISCLOSURE. Abnormal Uterine Bleeding. Is This A Problem? About me % of visits to gynecologist 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 May 5, 2010 About