Abnormal Uterine Bleeding

Benjie B. Mills, MD

Division Director, Pediatric & Adolescent Gynecology Medical Director of Gynecology, GHS OB/GYN Center

Associate Professor of Clinical Obstetrics & Gynecology

University of South Carolina School of Medicine Greenville

Disclosures

• I have nothing to disclose • This presentation will discuss off-label use of

medications

Objectives

• Describe etiologies, work up, and clinical course of abnormal uterine bleeding

• Formulate a patient-centered and evidence-based treatment plan

• Focus on issues of particular importance to the PCP such as prevention, therapeutic lifestyle changes, health maintenance, and when to refer to a specialist

Etiologies

Abnormal Uterine Bleeding Heavy Menstrual Bleeding (AUB-HMB)

Intermenstrual Menstrual Bleeding (AUB-IMB)

PALM: Structural Polyp (AUB-P)

Adenomyosis (AUB-A) Leiomyoma (AUB-L)

Malignancy & Hyperplasia (AUB-M)

COEIN: Non-Structural Coagulopathy (AUB-C)

Ovulatory Dysfunction (AUB-O) Endometrial (AUB-E)

Iatrogenic (AUB-I) Not Yet Classified (AUB-N)

Structural

• Polyps

Structural

• Adenomyosis

Structural

• Leiomyomata

Structural

• Malignancy and Hyperplasia

Coagulopathy

• Inherited and acquired • Occurs in up to 20% of patients with HMB • Indications for evaluation

– Heavy menstrual bleeding since menarche, or – Postpartum hemorrhage, excessive surgical bleeding

or bleeding with dental work, or – Any two of the following

• Bruising 1-2 times per month • Epistaxis 1-2 times per month • Frequent gum bleeding • Family history of bleeding symptoms

Ovulatory Dysfunction

• Encompasses amenorrhea to frequent irregular menses and in between – Hypothalamic hypogonadotropic hypogonadism – Thyroid dysfunction – Hyperprolactinemia – Hyperandrogenemia/PCOS – Premature ovarian insufficiency – Idiopathic anovulation – Chronic illness

Endometrial Abnormalities

• Abnormal endometrial angiogenesis • Prostaglandin production • Vasoconstriction • Increased fibrinolysis

Iatrogenic

• Contraceptives – OCPs, contraceptive patch or ring – DepoProvera (DMPA) – Contraceptive implant (Nexplanon) – Intrauterine device

• Hormonal (levonorgestrel IUD, Mirena, Skyla) • Non-hormonal (Paragard, copper T)

• Other medications – Antipsychotics – Anticoagulants – Other

Evaluation

Evaluation: History

• Age of menarche • Menstrual bleeding pattern • Severity of bleeding (clots or flooding) • Pain • Medical history • Surgical history • Family history of bleeding disorders, PCOS,

diabetes …

Medications

• Anticoagulants • Hormonal medications • NSAIDs • Antipsychotics • Ginkgo • Ginseng • Motherwort

Physical Exam

• Abnormalities of weight • Skin

– Acanthosis nigricans – Hirsutism – Pallor – Petechiae or ecchymoses

• Thyroid • Abdomen • Pelvic

Laboratory Testing

• Pregnancy test • STD testing if indicated • CBC with diff • TSH

Laboratory Testing

• Bleeding disorder – PT/PTT/INR – Platelet function screen – Fibrinogen

• Hyperandrogenism/PCOS – Testosterone, free and total – DHEAS – 17 hydroxyprogesterone – HgbA1C, lipids, CMP

Laboratory Testing

• Amenorrhea/Oligomenorrhea – Prolactin – FSH/LH – Estradiol

• Ultrasound – Transvaginal – Transabdominal

• MRI – Müllerian

anomalies – Fibroid mapping – Adenomyosis

• Saline infusion sonogram – Cavity assessment – Endometrial biopsy

• Hysteroscopy • Endometrial biopsy

Imaging and Tissue Sampling

Differential Diagnosis by Age Category

Ages 13-18 Years

• Pregnancy – UCG – TV Ultrasound for positive UCG and bleeding

and/or pain • Pelvic infection

– GC and chlamydia NAATs – Trichomonas or cervicitis – PID

Ages 13-18 Years

• Anovulation – immaturity or dysregulation of the hypothalamic-pituitary-ovarian axis – Irregular cycle length – Within 3 years of menarche (80% in a regular pattern) – Plan:

• R/O pregnancy • Cyclic medroxyprogesterone acetate 10 mg x 10 days per

month or OCPs if desires treatment • TSH in patients with other symptoms of thyroid dysfunction • Coagulopathy workup if heavy since menarche • Assess for anemia if heavy or prolonged bleeding

Ages 13-18 Years

• Coagulopathies – Prolonged, heavy menses – May be irregular due to immature HPO axis – Plan:

• TSH • Bleeding disorder labs • Treat underlying condition • Treatment choices

– OCPs (increases factor secretion) – Anti-fibrinolytics – Menstrual suppression

Ages 13-18 Years

• Hormonal contraceptive use – OCPs

Cycle 1 Cycle 4

Extended Cycle OCP

> 7 days 65% 42% > 20 days 35% 15%

Cycles 1-4 Cycles 10-13

28d Cyclic OCP

> 7 days 38% 39% > 20 days 6% 4%

Ages 13-18 Years

• Hormonal contraceptive use – Etonogestrel implant

Bleeding Patterns Definitions %*

Infrequent Less than three bleeding and/or spotting episodes in 90 days (excluding amenorrhea)

33.6

Amenorrhea No bleeding and/or spotting in 90 days 22.2

Prolonged Any bleeding and/or spotting episode lasting more than 14 days in 90 days

17.7

Frequent More than 5 bleeding and/or spotting episodes in 90 days 6.7

Ages 13-18 Years

• Hormonal contraceptive use – Depo Medroxyprogesterone Acetate (DMPA)

• 54% with AUB at 1 year • 46% with amenorrhea • 25% discontinue because of AUB

Ages 19-39 Years

• Pregnancy • Infection • Hormonal contraception • Structural abnormalities

– Fibroids – Polyps – Adenomyosis

Ages 19-39 Years

• Anovulation – Polycystic ovarian syndrome is the most common

cause – Chronic disease – Idiopathic – Premature ovarian insufficiency

• Endometrial hyperplasia and malignancy (rare) – Endometrial sampling in high risk patients

Ages 40 to Menopause

• Pregnancy • Anovulation

– Physiologic when approaching menopause – PCOS

• Structural abnormalities • Endometrial hyperplasia and malignancy

Imaging & Tissue Sampling

Who gets imaging?

• Abnormal pelvic examination • Unresponsive to initial treatment in a patient

with a normal pelvic exam • Suspicion for structural abnormality

Which imaging is best?

• Transvaginal ultrasound (2D and 3D) – Screening test – Intracavitary pathology

• Sensitivity 56% • Specificity 73%

– Endometrial thickness is not helpful • Saline infusion sonography

– Superior at determining intracavitary pathology – Global changes vs. specific lesions

• MRI is not recommended for evaluation of AUB

Who needs endometrial sampling? • Women > age 45 with AUB • Women < age 45 with AUB and chronic

anovulation (unopposed estrogen) – Obesity – PCOS – Endometrial cancers and hyperplasias can be

diagnosed in young patients at very high risk

Evidence-Based Evaluation and Treatment Plans

Adolescent with AUB (IMB or HMB)

History & Physical Exam

Peripubertal Anovulatory

Bleeding Bleeding Disorder

Labs Refer to Peds Gyn

Expectant Management

Treat with Cyclic MPA or

OCPs

Reproductive Age with HMB

History, Physical Exam & Labs

Abnormal Pelvic Exam Normal Pelvic Exam

Treat: OCPs

LngIUD DMPA

Tranexamic acid

Ultrasound Treat Abnormality

Treatment Success No further workup

Treatment Failure Ultrasound

Refer to OB/Gyn

Reproductive Age with IMB History, Physical Exam, Normal

Pelvic Exam & Labs

Long-standing IMB

Expectant Management or

Treat: OCPs

Cyclic MPA

Treatment Success No further workup

Treatment Failure Needs Cavity Eval Refer to OB/Gyn

Short-term IMB

EMB and Cavity Evaluation

Refer to OB/Gyn

Prevention

Prevention

• Maintain healthy weight • Evaluate for PCOS if patient is 3 years post-

menarche and having IMB – Prevent hirsutism – Prevent long-term morbidity of PCOS via education

and health maintenance – Prevent psychologic sequelae

• Avoid use of DMPA for AUB • Recognize patients at high-risk for hyperplasia or

malignancy