Dr. Nancy Van Eyk Associate Professor, Dalhousie University Chief of Gynaecology, IWK Health Centre

Dr. Nancy Van Eyk Associate Professor, Dalhousie University Chief of Gynaecology, IWK Health Centre

AUB Outline Terminology Classification/Etiology Assessment Treatment Referral to Gynaecology

U c pt 4 HMB?

FIGO: AUB Classification

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

FIGO Structural: Polyp, Adenomyosis, Leiomyoma Exam: Cervical polyp Adenomyosis enlarged, uniform uterus Fibroids enlarged, asymmetrical uterus Imaging: Transvaginal Ultrasound

FIGO: Leiomyoma

FIGO: Malignancy/Hyperplasia Sub classified using appropriate WHO or FIGO system

FIGO: Coagulopathy

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

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

FIGO: Iatrogenic IUD Medical Rx: affect Endometrium (Blood coagulation) Ovulation BTB (breakthrough bleeding): unscheduled endometrial bleeding with gonadal steroid therapy

FIGO: Not Yet Classified Chronic endometritis Arterio-venous malformations Myometrial hypertrophy Future entities

R/O: -Pregnancy -Cervical (PAP) Assessment of AUB

Assessment of AUB

Endometrial Biopsy

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)

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

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

Combined Hormonal Contraceptives Extended use: ANY monophasic CHC: pill, patch, ring Seasonale: 2008 30 ug ethinyl estradiol + 150 ug levonorgestrel x 84 days Placebo x 7 days Seasonique: 2011 30 ug ethinyl estradiol + 150 ug levonorgestrel x 84 days 10 ug EE x 7 days

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)

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

LN-IUS: Bleeding 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

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)

Treatment Failure

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

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

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)

Questions??