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Abnormal Uterine Bleeding

Abnormal Uterine Bleeding. Douglas Brown M.D. GYNOSPEAK. Dysfunctional Uterine Bleeding – non-menstrual bleeding due to failure of ovulation May be frequent e.g. every 2 weeks May be infrequent e.g. every 6 months Generally heavier than menses. More Gynospeak.

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Abnormal Uterine Bleeding

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  1. Abnormal Uterine Bleeding Douglas Brown M.D.

  2. GYNOSPEAK • Dysfunctional Uterine Bleeding – non-menstrual bleeding due to failure of ovulation • May be frequent e.g. every 2 weeks • May be infrequent e.g. every 6 months • Generally heavier than menses

  3. More Gynospeak • Menorrhagia – heavy menstrual bleeding • Menometrorrhagia – heavy irregular bleeding – may be DUB or organic • Midcycle bleeding – periovulatory bleeding, usually light, lasting 1-5 days • Premenstrual bleeding – spotting or light bleeding 2-7 days prior to menses, leading into menses

  4. Even More Gynospeak • Breakthrough bleeding (BTB) – irregular bleeding associated with exogenous hormone use such as OCPs ot HRT • Oligomenorrhea – infrequent menses, generally less often than every 6 weeks • Postmenopausal bleeding – occurs afer 1 year following cessation of menses

  5. Adolescent • Expect DUB with the first several “periods” as the hypothalamus matures • Regular menses may take a year to develop • DUB more likely to be chronic in obese teens (?genetic?) Watch for PCO • Watch for amenorrhea in athletic teens • Consider OCPs, calcium supplement

  6. Adolescent Menorrhagia • Distinguish menorrhagia from DUB • 15-20% of teens requiring transfusion will have a coagulation disorder • Von Willebrand’s is most common • If VW test other women in family

  7. Isolated Early or Late Menses • Most common etiology is stress • Change in environment • Short term corticosteroid use • Exclude pregnancy with home test or serum HCG • The Holiday Rule

  8. Meds and Medical conditions • Hyper and hypo thyroidism • Chronic renal or endocrine disease • Endometriosis • Hyperprolactinemia due to CNS or pituitary disease • Phenothiazenes • Metoclopromide • Tricyclics

  9. Postcoital Bleeding • Cervical lesion – polyp, cancer, ectropion • Vaginal atrophy • Endometritis • Unstable or atrophic endometrium due to OCs, HRT or Depoprovera • Endometrial polyp or myoma • Have a low threshold for endometrial biopsy

  10. Bleeding with Contraception • BTB with OCs – change pills – increase estrogen, change progestin • Depoprovera or minipill – add estrogen until bleeding stops • Paraguard copper IUD –irregular bleeding, menorrhagia – may be endometritis • Mirena levonorgestrel IUD – may cause 2-4 months irregular bleeding, then hypomenorrhea or amenorrhea

  11. DUB • Due to anovulation • Distinguish from oligomenorrhea • Risk is endometrial hyperplasia or Ca • Consider endometrial biopsy (later) • If chronic evaluate for PCO • Draw fasting glucose and insulin

  12. DUB Acute therapy • IV premarin 25mg q 4-6 hrs – vasospasm • Monophasic OCs “OCP Taper” – qid for 4 days, tid for 3 days, bid for 2 days, daily for remainder of two packs • MPA (provera,cycrin) – 10 mg 2-3x/day for 2 weeks

  13. DUB long term therapy • OCPs • Withdrawal with progestin for 10-14 days every 6-8 weeks • Use provera 10 mg, prometrium 100 mg, aygestin 2.5 – 5 mg

  14. Menorrhagia • Myoma • Polyp • Coagulation Disorder • “Humoral” • Idiopathic

  15. Uterine Myoma • Menorrhagia is most common symptom • Look for intramural or submucous myomas • Interruption of contractile hemostasis • Dx with ultrasound • Smell any fish?

  16. Therapy for Myomas • Continuous OCPs • GnRH agonists e.g Lupron • Myomectomy/Hysterectomy • Operative hysteroscopy • Uterine artery embolization • Post-DUBYA – Mifepristone 50 mg/day

  17. Humoral Menorrhagia • Diagnosis of exclusion • Consider coagulopathy workup – 10% • Diff Dx: VWDz, thrombocytopenia,TTP, ITP,vasculitis, liver disease • Desmopressin nasal spray for VW Dz

  18. Medical Therapy • NSAIDs – Ibuprofen, Naproxen, Mefenamic acid (meclomen, ponstel) • OCPs – consider continuous regimen • Depoprovera • Iron replacement • Endometrial ablation – Rollerball, Novasure (mesh), Thermachoice (balloon), MEA (microwave)

  19. Perimenopause • Oligomenorrhea if you’re lucky • Anovulatory biweekly “menorrhagia” if you’re not • Therapy – low dose OCPs or higher dose HRT such as Activella or FemHRT • Don’t forget space-occupying disease

  20. Postmenopause • All postmenopausal bleeding is cancer until proven otherwise • 90% of BTB due to atrophy • Prove it with endometrial Bx or TV U/S • On U/S endometrial “stripe” should be less than 5 mm • BTB common in new start HRT • Obese patients may require withdrawal

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