1 Management of Abnormal Uterine BleedingSonnie Kim-Ashchi, MD. FACOG

2 Patient No 1 Emily is 14 years old, started her first menses last year, irregular at the beginning , now regular monthly. But she reports heavy bleeding that soaks through her uniform. And very “ inconvenient” to have heavy bleeding during her soccer/ lacrosse/crew practices.

4 Patient No. 3 Mrs. Robinson is 50 years old. Her last period was 6 months ago. Now bleeding heavily for 10 days passing clots.

5 Patient No. 4 Mrs. Hopkins is 70 years old. She has been postmenopausal since her early 50’s. She noticed pink spotting about three months ago. At that time, she was too embarrassed to her PCP during her routine checkup. But now, spotting changed to heavy bright red bleeding.

6 Abnormal Uterine Bleeding Associated with Ovulatory Dysfunction ( AUB-O)The most common cause for gyn visits and referrals. Ovulatory dysfunction presents with heavy irregular uterine bleeding due to the effects of chronic unopposed estrogen on the endometrium. Acute AUB Chronic AUB- topic today Acute AUB is a critical emergency. We need to stabilize the pt from hypovolemic shock. Possibly IV estrogen or even emergency hysterectomy.

7 Causes of Anovulation Physiologic Pathologic Adolescence PregnancyLactation Perimenopause Hypothalamic dysfunction (secondary to anorexia nervosa) Hyperprolactinemia Primary pituitary disease Premature ovarian failure Thyroid disease Hyper androgenic anovulation(PCOS, CAH, or Androgen-producing tumor) Iatrogenic(secondary to radiation or chemotherapy) Medication This is kind ofanovulation busy slides to tell you about the causes of

8 Causes of AUB by FIGO and ACOGPALM-Structural Causes COEIN-Nonstructural causes Polyp and Pregnancy Adenomyosis Leiomyoma Malignancy and hyperplasia Coagulopathy Ovulatory dysfunction Endometrial Iatrogenic Not yet classified With this system, the etiologies of chronic AUB are classified as “ related to uterine structural abnormalities and “ unrelated to structual abnormalities” and categorized following the acronym PALM-COEIN . You have to determine the most likely etiology of AUB to come up with the most effective and appropriate mgt for your pts. This is done by history, physical exam, lab and imaging tests. -----UP to 13% of women with heavy menses have some variant of vW disease and up to 12% of women may have an underlying coagulation disorders. Von willebrand-ristocetin cofactor activity, vW factor antigen, factor Viii8 International Federation of Gynecology and Obstetrics ( FIGO) American College of Ob/Gyn ( ACOG)

9 Age-Based Consideration in Differential Diagnosis 13-18 YearsDifferential diagnosis is similar to other age groups except endometrial hyperplasia and malignancy. 1. Anovulation; Hypothalamic immaturity ( 90%) 2.Stree-exercise-induced 3. Obesity 4. Coagulation disorder like Von Willebrand disease 5. Pregnancy, sexual trauma, STD regardless of her “reported “ sexual history 6. Look for PCOS such as acne, hirsutism,

10 Age-Based Consideration in Differential Diagnosis; 19-39 YearsPCOS is one of the most common causes in this group. Anovulation Obesity is comorbid condition. Endocrine disorder eg. hypothyroidism Pregnancy Polyp, fibroids, adenomyosis Medication related esp. OCP Infection Premalignant or malignant endometrial pathology must be considered for high risk patients especially medical management is not successful.

11 Age-Based Considerations in differential diagnosis ;40 Years to MenopauseMost likely normal perimenopausal changes with irregular sometimes heavy menses Anovulation-unppopsed estrogen and hyperplasia Mean age of menopause is 52 years. The average duration of the menopausal transition is 4 years. Polyp, fibroid, adenomyosis Hyperplasia or cancer Pregnancy must be excluded. Definition of Menopause-cessation of menses for 12 consecutive months, NOT blood hormone tests

12 Age-Based Considerations in differential diagnosis; Menopause and on1.Vaginal atrophy 2.Cancer/polyp 3. Estrogen therapy

13 Basic information about your patients via,,,,History Physical Exam Pertinent medical and surgical history-- Surgery-related bleeding? Bleeding after dental work? Bruising easily? Frequent nose bleeding or gum bleeding? Family history of bleeding? Medication– anticoagulant? Chemo agents? Detailed gyn history-menarche? Current bleeding frequency, interval, duration, related symptoms such as vaginal discharge, pain, LMP General—signs of systemic illness, ecchymosis, thyromegaly, signs of hyperandrogenism such as hirsutism, acne, male pattern balding. Acanthosis nigricans Pelvic exam including speculum exam and bimanual exam to look for genital trauma, cervical tumor, uterine enlargement. Now keeping in the acronym PALM-COEIN, lets take Hand P UP to 13% of women with heavy menses have some variant of vW disease and up to 12% of women may have an underlying coagulation disorders. Von willebrand-ristocetin cofactor activity, vW factor antigen, factor Viii8

15 Treatment approach to guide therapy for AUB-OThe choice of treatment is according to the goals of therapy √ Age group, 13 ? 25? 50? 75? √ To stop acute bleeding? √ To avoid future irregular heavy bleeding? √ Need for contraception? √ Need for comorbidity such as anemia √ Need for surgical treatment? Only when medical therapy fails, is contraindicated, is not tolerated by the patient, or the patient has intracavitary lesions.

16 FIGO and ACOG recommendsAbnormal Uterine Bleeding, NOT Dysfunctional Uterine bleeding, DUB which was used in the past for the bleeding with no systemic or structural cause. DUB

19 Surgical Management of AUB-O, ONLY IF medical managements failHysteroscopy Dilatation and Curettage Endometrial ablation Hysterectomy

20 Lab tests- urine hCG, CBC, TSH, vWd factor Patient No 1 Lab tests- urine hCG, CBC, TSH, vWd factor Treatment – Iron supplements and/or Low dose OCP or Progesterone IUD ( Skyla) Consider CONTINOUS combined hormonal contraceptives e.g., Seasonale, Seasonique. 4 periods a year Emily is 14 years old, started her first menses last year, irregular at the beginning , now regular monthly. But she reports heavy bleeding that soaks through her uniform. And very “ inconvenient” to have heavy bleeding during her soccer/ lacrosse/swimming practices.

22 Need to rule out endometrial hyperplasia and cancer with EMB!Patient No. 3 Mrs. Robinson is 50 years old, last period was 6 months ago. Now bleeding heavily for 10 days passing clots. Very frustrated. Need to rule out endometrial hyperplasia and cancer with EMB! Labs- B HCG, CBC, TSH, Prolactin Pelvic ultrasound Treatment- low dose OCP, cyclic progestin therapy, Mirena IUD or endometrial ablation. Remember perimenopausal women can get pregnant!!

23 Patient No. 4 Mrs. Hopkins is 70 years old. She has been postmenopausal since her early 50’s. She noticed pink spotting about three months ago. At that time, she was embarrassed to see her gynecologist. But now spotting changed to heavy bright red bleeding. EMDOMETRIAL BIOPSY!! Transvaginal ultrasound especially endometrial stripe

24 When is EMB indicated? § Purpose of EMB is to rule out hyperplasia and cancer. § Incidences of endometrial cancer in different age groups Younger than 20; 0.2 in 100, 000 Age 20-34; 1.6% Age 35-44; 6.2%, the incidence increases with aging, Age 70-74; 88 cases per 100,ooo § EMB is indicated for patients older than 45 years with AUB-O § Also indicated younger than 45, 1.if medical management failed and systemic diseases such as leukemia or liver disease were ruled out in young patients. 2.patients with h/o unopposed estrogen exposure such as obesity (BMI greater than 30) and PCOS, chronic anovulation, h/o breast cancer, Tamoxifen use, family h/o endometrial cancer.

25 Surgical management for AUB-O ONLY IF medical managements failSaline infused sonohysterogram Hysteroscopy Dilation and Curettage Endometrial ablation Hysterectomy

27 Surgical management for AUB Endometrial ablation“ Hysterectomy Alternative” Can be done in the office,= Just copay for the office visit Resectoscopic endometrial ablation since 1937 Global nonresectoscopic ablation Freeze-Cryotherapy Radiofrequency electricity-Novasure Heated fluid- Thermachoice, HydroThermAblator Microwave-Microsulis Treatment Goal is to “ normalize “ menses ( 70 to 90 % patient satisfaction rate) , NOT amenorrhea. Prerequisites -uterus less than 10 cm, no cavitary lesion, adequate contraception after the procedure Patient must be counseled about the risks of masking endometrial cancer in the future. Post ablation Asherman syndrome, synechiae, endometrial distortion/stricture

31 Last Note,,Health apps for PatientsObjective data collection instead of “ I bleed a lot”

32 Thank you Questions about Abnormal Uterine Bleeding?