Abnormal Uterine Bleeding

Transcription

1 Abnormal Uterine Bleeding Randy A. Fink, MD, FACOG Obstetrics & Gynecology A simplified approach for primary care Disclosures I have no relevant disclosures pertaining to this program. Learning Objectives Demystify and understand a simple, straightforward template to evaluate premenopausal abnormal uterine bleeding in the primary care setting. Review up to date treatment options for heavy menstrual bleeding. Appreciate the evaluation and management of postmenopausal bleeding. 1

2 What s In a Name? AUB DUB (Dysfunctional Uterine Bleeding) Irregular Menstruation Metrorrhagia Menorrhagia Menometrorrhagia Hemorrhaging It s like a murder scene. What s In a Code? International Classification of Diseases, Tenth Revision (ICD-10): Oh yeah, it s a problem One-third of visits to GYN practice % of reproductive age women at any given time 2 Increasing prevalence with age to 24% by years old. 1 Kjerulff KH, Erickson BA, Langenberg PW. Am J Public Health Feb;86(2): Liu Z, Doan QV, Blumenthal P, et al. Value Health May-Jun;10(3):

3 Risk Factors for Endometrial Cancer Increasing Age (50-70yo) Early menarche Late menopause (after 55yo) Chronic anovulation Diabetes Obesity tamoxifen Unopposed estrogen Nulliparity Lynch Syndrome Estrogen secreting neoplasm Smith RA, von Eschenbach AC, Wender R, et al. American Cancer Society guidelines for the early detection of cancer: Update of early detection guidelines for prostate, colorectal, and endometrial cancers. CA Cancer J Clin 2001; 51:38. PRE-MENOPAUSAL POST-MENOPAUSAL PERI-MENOPAUSAL PRE-MENOPAUSAL WHAT S NORMAL?? 3

4 NORMAL MENSES Frequency of menses within a 24 to 38 day window Regularity (cycle-to-cycle variation) within ± 2 to 20 days Duration of flow from 4 to 8 days Volume of blood loss from 5 to 80 ml Fritz MA, Speroff L. Clinical gynecologic endocrinology and infertility. 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2011.!!!!!!!!!!! 4

5 SURGICAL ANATOMY OF UTERUS PRE-MENOPAUSAL WHAT S NORMAL?? Pregnancy Test ( Do a Beta ) 5

6 Beta-HCG Urine Pregnancy Test - within 2 weeks of conception (20-50 miu/ml) Serum Pregnancy Test (QUANTITATIVE) by 1 week after conception (1-2 miu/ml) False positive (rare) False negative (more common) Norman RJ, Menabawey M, Lowings C, Buck RH, Chard T. Obstet Gynecol Apr;69(4): PRE-MENOPAUSAL WHAT S NORMAL?? Pregnancy Test ( Do a Beta ) POS REFER Early Pregnancy Bleeding RULE-OUT ECTOPIC (2% of all pregnancies) Discriminatory Zone : If Beta-HCG 2000, Intrauterine Pregnancy is generally seen by transvaginal ultrasound 1 Normal: Beta-HCG rises by 35% in 48 hours OR doubles in 72 hours during 1 st 40 days of pregnancy 2 MISCARRIAGE (15-20% of all pregnancies) If Fetal Heart Rate is observed, 90-96% of these pregnancies continue 3 1 Connolly A, Ryan DH, Stuebe AM, Wolfe HM. Obstet Gynecol. 2013;121(1):65. 2 Morse CB, et al. Fertil Steril Jan;97(1):101-6.e2. 3 Tannirandorn Y, et al. Int J Gynaecol Obstet. 2003;81(3):263. 6

7 PRE-MENOPAUSAL WHAT S NORMAL?? Pregnancy Test ( Do a Beta ) POS REFER Neg HORMONAL STRUCTURAL ANOVULATION ANOVULATORY PATTERN Polycystic Ovarian Syndrome (PCOS) Chronic Oligo or Anovulation Clinical or Biochemical Signs of Hyperandrogenism Polycystic Morphology by Ultrasound Rotterdam ESHRE/ASRM-Sponsored PCOS consensus workshop group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Hum Reprod 2004; 19:41. 7

8 Signs of Hyperandrogenism Biochemical Elevated Testosterone (<150 ng/ml) Elevated DHEA-S 8am 17-OHP TSH, FSH, Prolactin Signs of Hyperandrogenism Hirsutism Hair growth in androgen dependent areas: Upper lip, chin Midsternum Upper and lower abdomen Upper and lower back Buttocks Differs from Unwanted Hair Hypertrichosis Madnani N et al. Indian J Dermatol Venereol Leprol 2013;79: Ferriman-Gallway Hirsutism Scoring Score 1-7: Focal (common normal variant) Score 8: Generalized Norms lower in Asians, higher in Mediterraneans Hatch R, Rosenfield RS, Kim MH, Tredway D. Hirsutism: implications, etiology, and management. Am J Obstet Gynecol 1981; 140:815. 8

9 Signs of Hyperandrogenism Hirsutism with Acanthosis Nigricans Insulin resistance Madnani N et al. Indian J Dermatol Venereol Leprol 2013;79: Signs of Hyperandrogenism Acne Vulgaris Minimally responsive to traditional treatment Lower half of face and jawline Back, chest Rapid recurrence on cessation of treatment Persist beyond typical 5-7 days Archer JS, Chang RJ. Hirsutism and acne in polycystic ovary syndrome. Best Pract Res Clin Obstet Gynaecol 2004;18: Signs of Hyperandrogenism Androgenic Alopecia May be difficult to distinguish from other patterns of hair loss in women Olsen EA. Female pattern hair loss. J Am Acad Dermatol 2001;45:

10 6/26/2018 ANOVULATORY PATTERN Common Clinical Presentation 33yo nulligravid, BMI 30, states not sexually active. c/o vaginal bleeding daily for the past 24 days LNMP 3 months prior, no bleeding since until this episode Hormone Dysfunction: Estrogen Dominance Progesterone Challenge Medroxyprogesterone acetate 10mg PO BID x 5 days or 1 PO QD x 10 days Norethindrone acetate 10mg PO QD x 5 days Deeper Issues Prolactinoma Thyroid abnormalities Premature Ovarian Insufficiency Coagulopathy/Bleeding Diathesis TSH, FSH, PROLACTIN 10

11 PRE-MENOPAUSAL WHAT S NORMAL?? Pregnancy Test ( Do a Beta ) Neg REFER HORMONAL STRUCTURAL Cervical Fibroids Polyps Adenomyosis Is it Uterine Bleeding? Remember Cervix! Cervical Dysplasia Is Pap up to date? If not, DO IT! Cervicitis Friable cervix Purulent discharge Pelvic tenderness 11

12 Fibroids Most common pelvic tumor in women 1 Prevalence as high as 77% Clinically significant (4cm, 9 weeks size, Submucosal) by u/s 2 50% of Black Women 35% White Women 1 Baird DD, Dunson DB, Hill MC, Cousins D, Schectman JM. Am J Obstet Gynecol. 2003;188(1): Marshall LM, et al. Obstet Gynecol. 1997;90(6):967. Fibroids Heavy or prolonged menstrual bleeding Bulk-related symptoms, such as pelvic pressure and pain Reproductive dysfunction (i.e., infertility or obstetric complications) 12

13 Endometrial Polyps Common source of perimenopausal and postmenopausal bleeding Receptor issue Saline sonography Can be stimulated by estrogen therapy, tamoxifen, endogenous estrogen 95% are benign Baiocchi G., et al. Am J Obstet Gynecol. 2009;201(5):462.e1. 13

14 6/26/2018 Adenomyosis Adenomyosis Common cause of pelvic pain, dysmenorrhea, abnormal uterine bleeding Globular uterus Asymetric endometrial growth Heterogeneous echotexture Diffuse or confined (Adenomyoma) Templeman C, et al. Fertil Steril. 2008;90(2):415. Epub 2007 Oct

15 Treatment Options - HMB NSAID Hormonal Contraceptives Tranexamic Acid 650mg, 2 tabs PO TID starting at onset of menses, not to exceed 5 days use LNG IUD Endometrial Ablation PRE-MENOPAUSAL POST-MENOPAUSAL Post-Menopausal Bleeding IS IT UTERINE? Cervical Vaginal Atrophy Urethral Rectal IS IT MEDICAL? HRT Anti-coagulants 15

16 TRANS-VAGINAL ULTRASOUND 4 mm 16

17 6/26/2018 4mm Endometrial Stripe Essentially rules out endometrial cancer >4mm suggestive of proliferative process Filling defect (polyp, fibroid) PMP proliferative endometrium Endometrial hyperplasia Endometrial cancer Sladkevicius P, Opolskiene G, Valentin L. Ultrasound Obstet Gynecol. 2017;49(5):649. Epub 2017 Apr 6. 17

18 PRE-MENOPAUSAL POST-MENOPAUSAL ULTRASOUND 4 mm or less >4mm Probably Refer REFER The Take Home: A simplified approach for primary care. Is it NORMAL? PRE-MENOPAUSAL POST-MENOPAUSAL Pregnancy Test ( Do a Beta ) POS REFER HORMONAL Related to Ovulation NEG STRUCTURAL Cervical Fibroids Polyps Adenomyosis ULTRASOUND 4 mm or less >4mm Probably Refer REFER 18

19 Office Contact: Randy A. Fink, MD, FACOG 19