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Abnormal uterine bleeding and Management


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Abnormal uterine bleeding and Management

  1. 2. Disorders of the Menstrual Cycle <ul><li>Amenorrhea </li></ul><ul><li>Dysmenorrhea </li></ul><ul><li>Premenstrual Syndrome </li></ul><ul><li>Abnormal Uterine Bleeding </li></ul>
  2. 3. Abnormal Uterine Bleeding: Definitions <ul><li>Menorrhagia : Heavy or prolonged uterine bleeding that occurs at regular intervals. Some sources define further as the loss of ≥ 80 mL blood per cycle or bleeding > 7 days. </li></ul><ul><li>Hypomenorrhea: Periods with unusually light flow, often associated with hypogonadotropic hypogonadism (athletes, anorexia). Also may be associated with Asherman’s syndrome </li></ul><ul><li>Metrorrhagia: Irregular menstrual bleeding or bleeding between periods </li></ul><ul><li>Menometrorrhagia: Metrorrhagia associated with > 80 mL </li></ul><ul><li>Polymenorrhea: Frequent menstrual bleeding. Strictly, menses occur q 21 d or less </li></ul><ul><li>Oligomenorrhea: Menses are > 35 d apart. Most commonly caused by PCOS, pregnancy, and anovulation </li></ul>
  3. 4. Abnormal Uterine Bleeding: Differential Diagnosis <ul><li>Structural </li></ul><ul><ul><li>Cervical or vaginal laceration </li></ul></ul><ul><ul><li>Uterine or cervical polyp </li></ul></ul><ul><ul><li>Uterine leiomyoma </li></ul></ul><ul><ul><li>Adenomyosis </li></ul></ul><ul><ul><li>Cervical stenosis/Asherman’s (hypomenorrhea) </li></ul></ul><ul><li>Hormonal </li></ul><ul><ul><li>Anovulatory bleeding </li></ul></ul><ul><ul><li>Hypogonadotropic hypogonadism </li></ul></ul><ul><ul><li>Pregnancy </li></ul></ul><ul><ul><li>Hormonal Contraception (i.e. OCPs, Depo-Provera) </li></ul></ul><ul><ul><li>Thyroid disorders </li></ul></ul><ul><ul><li>Hyperprolactinemia </li></ul></ul><ul><li>Malignancy </li></ul><ul><ul><li>Uterine or Cervical cancer </li></ul></ul><ul><ul><li>Endometrial hyperplasia (potentially pre-malignant) </li></ul></ul><ul><li>Bleeding disorders </li></ul><ul><ul><li>von Willebrand’s Disease, Hemophilia/Factor deficiencies, platelet disorders </li></ul></ul>
  4. 5. Abnormal Uterine Bleeding: Workup <ul><li>History </li></ul><ul><ul><li>Timing of bleeding, quantity of bleeding, menstrual hx including menarche and recent periods, associated sxs, family hx of bleeding disorders </li></ul></ul><ul><li>Physical </li></ul><ul><ul><li>R/o vaginal or cervical source of bleeding. Bimanual may reveal bulky uterus/discrete fibroids </li></ul></ul><ul><ul><li>Assess for obesity, hirsutism, stigmata of thyroid disease, signs of hyperprolactinemia (visual field testing, galactorrhea) </li></ul></ul><ul><ul><li>Pap smear </li></ul></ul><ul><ul><li>Endometrial biopsy, if appropriate </li></ul></ul><ul><li>Pregnancy Test </li></ul><ul><li>Imaging </li></ul><ul><ul><li>Pelvic ultrasound </li></ul></ul><ul><ul><li>Sonohystogram or hysterosalpingogram </li></ul></ul><ul><li>Surgical </li></ul><ul><ul><li>Hysteroscopy </li></ul></ul><ul><ul><li>D & C </li></ul></ul>
  5. 6. Normal Menstrual Cycle
  6. 7. Normal Ovulatory Cycle <ul><li>Follicular development  ovulation (d14)  corpus luteal function  luteolysis </li></ul><ul><li>Endometrium is exposed to: </li></ul><ul><ul><li>Ovarian production of estrogen  </li></ul></ul><ul><ul><li>(proliferation) </li></ul></ul><ul><ul><li>Combination of estrogen and progesterone  </li></ul></ul><ul><ul><li>(secretory phase) </li></ul></ul><ul><ul><li>Estrogen and progesterone withdrawal </li></ul></ul><ul><ul><ul><li>(desquamation and repair) </li></ul></ul></ul>
  7. 8. Anovulatory Bleeding <ul><li>Corpus luteum is not produced </li></ul><ul><ul><li>Ovary fails to secrete progesterone, although estrogen production continues </li></ul></ul><ul><ul><li>Result is continuous, unopposed E stimulation of endometrium: </li></ul></ul><ul><ul><ul><li>Endometrial proliferation without P-induced differentiation / stabilization </li></ul></ul></ul><ul><ul><li>Endometrium becomes excessively vascular without stromal support  fragility and irregular endometrial bleeding </li></ul></ul>
  8. 9. Anovulatory Bleeding: Etiologies <ul><li>Hyperandrogenic anovulation (PCOS, CAH, androgen-producing tumors) </li></ul><ul><li>Hypothalamic dysfunction (stress, anorexia, exercise) </li></ul><ul><li>Hyperprolactinemia </li></ul><ul><li>Hypothyroidism </li></ul><ul><li>Primary pituitary disease </li></ul><ul><li>Premature ovarian failure </li></ul><ul><li>Iatrogenic (secondary to radiation or chemo) </li></ul>
  9. 10. Anovulatory Bleeding: Adolescents (13-18 years) <ul><li>Anovulatory bleeding may be normal physiologic process, with ovulatory cycles not established until 1-2 yrs after menarche (immature HPG axis) </li></ul><ul><li>Screen for coagulation disorders (PT/PTT, plts) </li></ul><ul><li>May be caused by leukemia, ITP, hypersplenism </li></ul><ul><li>Consider endometrial bx in adolescents with 2-3 year history of untreated anovulatory bleeding, especially if obese </li></ul>
  10. 11. Anovulatory Bleeding: Management in Adolescents <ul><li>High dose estrogen therapy for acute bleeding episodes (promotes rapid endometrial growth to cover denuded endometrial surfaces): conjugated equine estrogens PO up to 10 mg/d in 4 divided doses or IV 25 mg q 4 hrs for 24 hrs </li></ul><ul><li>Treat pts with blood dyscrasias for their specific diseases, r/o leukemia </li></ul><ul><li>Prevent recurrent anovulatory bleeding with: </li></ul><ul><ul><ul><li>cyclic progestin (i.e. Provera) </li></ul></ul></ul><ul><ul><ul><li> or </li></ul></ul></ul><ul><ul><ul><li>low dose (≤ 35 μg ethinyl estradiol) oral contraceptive </li></ul></ul></ul><ul><ul><ul><ul><li>suppresses ovarian and adrenal androgen production and increases SHBG  decreasing bioavailable androgens </li></ul></ul></ul></ul>
  11. 12. Anovulatory Bleeding: Reproductive Age (19-39 years) <ul><li>Anovulatory bleeding not considered physiologic, evaluation required </li></ul><ul><li>6-10% of women have hyperandrogenic chronic anovulation (i.e. PCOS), characterized by noncyclic bleeding, hirsutism, obesity (BMI ≥ 25) </li></ul><ul><ul><li>Underlying biochemical abnormalities: noncyclic estrogen production, elevated serum testosterone, hypersecretion of LH, hyperinsulinemia. </li></ul></ul><ul><ul><li>h/o rapidly progressing hirsutism with virilization  suggests tumor </li></ul></ul><ul><li>Lab testing: HCG, TSH, fasting serum prolactin </li></ul><ul><ul><li>If androgen-producing tumor is suspected, serum DHEAS and testosterone levels </li></ul></ul><ul><ul><li>If POF suspected, serum FSH </li></ul></ul><ul><li>Chronic anovulation resulting from hypothalamic dysfunction (dx’d by low FSH level) may be due to excessive psychologic stress, exercise, or weight loss </li></ul>
  12. 13. Anovulatory Bleeding: Reproductive Age (19-39 yrs) <ul><li>When is endometrial evaluation indicated? </li></ul><ul><li>Sharp increase in incidence of endometrial CA from 2.3/100,000 ages 30-34 yrs  6.1/100,000 ages 35-39 yrs </li></ul><ul><li>Therefore, endometrial bx to exclude CA is indicated in any woman > 35 yrs old with suspected anovulatory bleeding </li></ul><ul><li>Pts 19-35 who don’t respond to medical therapy or have prolonged periods of unopposed estrogen 2/2 anovulation merit endometrial bx </li></ul>
  13. 14. Anovulatory Bleeding: Reproductive Age (19-39 yrs) <ul><li> Medical therapies </li></ul><ul><li>Can be treated safely with either cyclic progestin or OCPs, similar to adolescents. </li></ul><ul><li>Estrogen-containing OCPs </li></ul><ul><ul><li>relatively contraindicated in women with HTN or DM </li></ul></ul><ul><ul><li>contraindicated for women > 35 who smoke or have h/o thromboembolic dz </li></ul></ul><ul><li>If pregnancy is desired, ovulation induction with clomid is initial tx of choice </li></ul><ul><ul><li>Can induce withdrawal bleed with progestin (i.e. provera), followed by initiation of therapy with Clomid, 50 mg/d for 5 days, starting b/t days 3 and 5 of menstrual cycle </li></ul></ul>
  14. 15. Anovulatory Bleeding: Later Reproductive Age (40-Menopause) <ul><li>Incidence of anovulatory bleeding increases toward end of reproductive years </li></ul><ul><li>In perimenopausal women, onset of anovulatory cycles is due to declining ovarian function. </li></ul><ul><li>Can initiate hormone therapy for cycle control </li></ul><ul><li>When is endometrial evaluation indicated? </li></ul><ul><li>Incidence of endometrial CA in women 40-49 years: 36.2/100,000 </li></ul><ul><li>All women > 40 yrs who present with suspected anovulatory bleeding merit endometrial bx after excluding pregnancy </li></ul>
  15. 16. Anovulatory Bleeding: Later Reproductive Age (40-Menopause) <ul><li> Medical therapy </li></ul><ul><li>Cyclic progestin, low-dose OCPs, or cyclic HRT are all options </li></ul><ul><li>Women with hot flashes secondary to decreased estrogen production can have symptomatic relief with ERT in combination with continuous or cyclic progestin </li></ul>
  16. 17. Anovulatory Bleeding: Later Reproductive Age (40-Menopause) <ul><li>Surgical therapy </li></ul><ul><li>Surgical options include: hysterectomy and endometrial ablation </li></ul><ul><li>Surgical tx only indicated when medical mgmt has failed and childbearing complete </li></ul><ul><li>Some studies suggest hysterectomy may have higher long-term satisfaction than ablation </li></ul><ul><li>Endometrial ablation: NovaSure, thermal balloon </li></ul><ul><ul><li>YAG laser and rollerball less widely-used currently </li></ul></ul><ul><ul><li>45% of women achieve amenorrhea after YAG laser or resectoscope. 12 month post-op satisfaction is 90%. Only 15% of women achieve amenorrhea after thermal balloon ablation, and 1 yr satisfaction rate still 90% </li></ul></ul><ul><ul><li>Long-term satisfaction with ablation may be lower: </li></ul></ul><ul><ul><ul><li>in 3-year f/u study, 8.5% of women who had undergone ablation were re-ablated, an additional 8.5% had hyst </li></ul></ul></ul><ul><ul><ul><li>In a 5-year follow up study, 34% of women who underwent ablation later had a hyst. </li></ul></ul></ul>
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