ABNORMAL UTERINE BLEEDING

1. ABNORMAL UTERINE BLEEDING Fawaz Edris MD, RDMS, FRCSC, FACOG, AAACS

2. INTRODUCTION • 1/3 of outpatient visits • Most after menarche or perimenopausal • Multiple causes, but mostly: • Pregnancy related (always R/O) • Structural uterine pathology (fibroids, polyps, adenomyosis) • Anovulation • Disorder of hemostasis • Neoplasia • Trauma • Infection • More than 1 !! (myoma + cancer) • Non gynecological source (urethra, rectum)

3. MENSTRUAL CYCLE • Mechanism: Estrogen  Ovulation  Preogesteron  withdrawal  menstruation • 24 - 35 days, lasting 2 to 7 days, flowing <80 mL/cycle • Predictable cyclic menses reflect regular ovulation • DUB vs. AUB • DUB: anovulation – no anatomical or systemic disease – by exclusion

4. PATTERNS OF AUB • Menorrhagia: excessive (>80 mL/cycle) or prolonged menstrual bleeding (>7 days) • Amenorrhea: absence of bleeding ≥ 3 usual cycles • Oligomenorrhea: bleeding with interval > 35 days • Polymenorrhea: bleeding with interval < 24 days • Metrorrhagia: light bleeding at irregular intervals • Menometrorrhagia: heavy bleeding at irregular intervals • Intermenstrual bleeding: bleeding between menses • Premenstrual spotting: light bleeding preceding menses • Post coital spotting: vaginal bleeding within 24h of intercourse

5. HISTORY  • What is the nature of the bleeding (frequency, duration, volume, relationship to activities such as coitus) • Quantity – number of pads, soakness • Intermenstrual bleeding - structural lesion (endometrial polyp, fibroid, cervical neoplasia) • Menometrorrhagia - anovulatory bleeding • Regular cyclic periods – ovulatory • Menorrhagea - bleeding diathesis, fibroid, adenomyosis.

6. HISTORY • Are there symptoms of ovulation? (molimina) • When did the bleeding start? • Menorrhagia since menarche - Bleeding diathesis • Perimenarcheal and perimenopausal - Anovulation • Perimenopausal - polyps, adenomyosis, and fibroids • Were there precipitating factors, such as trauma?

7. HISTORY • Any associated symptoms? • Lower abdominal pain, fever, vaginal discharge - infection (endometritis, vaginitis) • Changes in bladder or bowel function - mass effect from a local neoplasm or nonuterine bleeding • Headaches, breast discharge, visual disturbances - prolactinoma or other cranial tumor • Hirsutism or hair loss, acne – PCOS • Cold or Hot intolerence, Constipation or diarrhea - thyroid disease

8. HISTORY • Is there a personal or family history of a bleeding disorder? • bleeding associated with surgery, dental extraction, childbirth, or bruising (>5 cm)/epistaxis/bleeding gums once or twice a month • Does she have a systemic disorder? • chronic liver or renal disease, thrombocytopenia - menorrhagia • Any medications? • Anticoagulants – menorrhagia • IUCD or OCP - intermenstrual bleeding

9. HISTORY • Is she having coital relations? • Pregnancy related • Always do pregnancy test • Change in weight, eating disorder, excessive exercise, illness, or stress? • Anovulatory bleeding

10. PHYSICAL EXAMINATION  • Speculum and pelvic examinations • Bleeding site: vulva, vagina, cervix, urethra, or anus • Any suspicious findings (mass, laceration, ulceration, vaginal discharge, foreign body) • Assess the size, contour, and tenderness of the uterus • fibroids, adenomyosis, pregnancy, or infection • Examine the adnexa for an ovarian tumor • Evaluate for pain - infection

11. PHYSICAL EXAMINATION  • General examination • Signs of systemic illness, such as fever • Ecchymoses • Enlarged thyroid gland • Hyperandrogenism (hirsutism, acne, clitoromegaly, or male pattern balding) • Acanthosis nigricans - insulin resistance and anovulation. • Galactorrhea - hyperprolactinemia.

12. LABORATORY EVALUATION • Pregnancy test in all reproductive age women • Intrauterine pregnancy • Ectopic • Gestational trophoblastic disease • Cervical cytology  • Any visible cervical lesion should be biopsied

13. LABORATORY EVALUATION • Endometrial biopsy - endometrial cancer hyperplasia •  All women > 35 years • 18 and 35 years if with risk factors for endometrial cancer (family or personal history of ovarian, breast, colon, or endometrial cancer; tamoxifen use; chronic anovulation; obesity; estrogen therapy; prior endometrial hyperplasia; diabetes) • Always r/o pregnancy then do in second half of cycle • Secretory endometrium - ovulation • Proliferative endometrium – anovulation • Inflammation of the endometrium - endometritis

14. ADDITIONAL LAB. EVALUATION   • Hemoglobin/hematocrit  • TSH • Coagulation tests  • Platelet count – thrombocytopenia • Coagulation testing - PTT, PT, factor VIII, and von Willebrand factor antigen and activity • STD: Gonorrhea, Chlamydia, trichomonads • Prolactin level  • Androgen levels: Testosterone, DHEAS

15. ADDITIONAL LAB. EVALUATION   • Ultrasound • Fibroids, adenomyosis, endometrial lining, ovaries • Saline infusion sonography (sonohysterography) • Fibroids, polyps • Hysteroscopy 

16. MANAGEMENT  • Is bleeding ovulatory or anovulatory?  • Ovulatory  treat the underlying cause • Anovulatory • Acute management • Estrogen: Oral or IV • D&C (temporary measure – not therapeutic) • Ongoing management • Replace Progesterone • Progesterone: pills (continuous or cyclical), injections • OCP • Other measures • Thin the endometriam: hormonal IUCD • Remove the endometriam: Ablation • Remove the organ: Hysterectomy

17. MANAGEMENT  • If bleeding persists after treatment • Additional etiologies  continue to evaluate

18. Thank you