Abnormal Uterine Bleeding

1. Abnormal Uterine Bleeding Melissa Mirosh MD FRCSC Assistant Professor Department of Obstetrics, Gynecology, and Reproductive Sciences College of Medicine, University of Saskatchewan Family Medicine Review September 20, 2013

2. Objectives • Review the new SOGC guidelines for AUB • Discuss the new terminology regarding AUB • Outline an approach to evaluation and management of AUB

3. SOGC Guideline on AUB May 2013 • New terminology introduced regarding AUB • No longer using menorrhagia, menometrorragia, etc • Aiming for more descriptive terms that are easier to understand and communicate to others

4. Terminology • Volume: heavy, normal, light • Regularity: irregular, regular, absent • Frequency: frequent, normal, infrequent • Duration: prolonged, normal, shortened • Other: intermenstrual, premenstrual, breakthrough

5. Heavy menstrual bleeding Excessive menstrual blood loss which interferes with the woman’s physical, emotional, social, and material quality of life, and which can occur alone or in combination with other symptoms. Note: no description of volume, pads, etc!

6. Regularity & Frequency • Based on 90 day intervals • Normal frequency 24-38 days • Normal duration 3-8 days • Chronic AUB present longer than 6 mos • Acute AUB often requires immediate intervention

7. Evaluation • History • Physical • Investigations

8. History • Determine ovulatory vs. anovulatory bleeding • Sx of anemia (severity of blood loss) • Sexual and reproductive hx • Impact on social and sexual fxn • Sx of systemic causes (thyroid, PRL, coag disorder, PCOS, hypothalamic) • Personal or family hx of cancer (HPNCC) • Meds

9. Physical Exam • Vitals, weight, BMI • Thyroid exam • Skin (pallor, bruising, striae, hirsuitism) • Abdominal exam • Gyne exam: • Inspection • Bimanual exam • Rectal if indicated • Pap and cultures if appropriate

10. Investigations • CBC (ferritin of no help if CBC is normal) • Pregnancy test (urine or serum) • Coagulation testing if hx of heavy bleeding from menarche or personal/famhx • Thyroid FXN if sx or clinical findings present

11. Imaging • Imaging is helpful if: • Exam suggests a structural cause • Conservative management has failed • Risk of malignancy

12. Imaging • Transvaginal ultrasound • Helpful for assessment of endometrial thickness (ET) and other structural abnormalities

13. Imaging • Saline Infusion Sonohysterography (SIS) • sonoHSG • Excellent for evaluation of the endometrial cavity • Polyp, septum, submucosal fibroids

14. Hysteroscopy • Allows direct visualization of the cavity • Allows surgical correction of many abnormalities • Septum, polyp, resection of fibroid, directed biopsy

15. Endometrial Assessment & Biopsy • Average age of endometrial CA is 61, but may present in 30s or 40s if unopposed or excessive estrogen exposure • Risks include: • Age Obesity (BMI >30) • NulliparityPCOS • Diabetes HNPCC

16. Endometrial Biopsy • Recommended in women: • over age 40 • Risk factors for endo CA • Failure of medical tx • Significant intermenstrual bleeding • History of anovulation

17. Endometrial biopsy is the initial evaluation of choice • Picks up 90% of lesions • D&C is NOT recommended as it is no better than endobx and carries more risk

18. Medical Therapy • Non-hormonal • High dose NSAIDS • Tranexamic Acid • Hormonal • CHCs • Progestin tx (levonorgestrel IUS, DMPA, long cycle oral progestin) • Danazol • GnRH agonists

19. Non-Hormonal • NSAID and Tranexamic Acid • 30-50% decrease in flow • NSAIDS may cause GI disturbance but usually limited as it is only taken during menses • Tranexamic acid effective but expensive

20. Hormonal • Mainstay items are CHC’s and Levonorgestrel IUS • Decrease of 50-98% of menstrual flow • IUS shows some improvement with fibroid volume as well • May be ineffective when structural pathology is present (fibroid, polyp)

21. Hormonal • Cyclic progestin is ineffective for women with regular cycles and heavy flow • More helpful for irregular/anovulatory cycles • DMPA carries more breakthrough bleeding than the IUS – higher rates of discontinuation

22. Hormonal • Danazol and GnRH agonists are less common • GnRH agonist requires add back therapy to prevent bone loss if used greater than 6 months • GnRH agonist often used as a temporizing measure prior to definitive surgery (chemical menopause)

23. Surgical Therapy • Remember that the main treatment goal is improvement in quality of life, not amenorrhea! • Majority of these techniques will render a patient infertile • D&C is a diagnostic tool, not a method of therapy

24. Endometrial Ablation • Traditionally done by a hysteroscopic resection or rollerball ablation • “cook” the lining of the uterus • Many non-hysteroscopic methods available • Heated balloon • Radiofrequency bipolar technology • Microwave

25. Endometrial Ablation • Benefits of the non-hysteroscopic methods include shorter duration, shorter and less anaesthetic and lower risk • Drawbacks include inability to treat pathology like fibroids or polyps, limits with large or small uterine cavities

26. Patient Satisfaction • Same for endometrial ablation and levonorgestrel IUS • Up to 30% will go on to hysterectomy • Hysterectomy is definitive therapy but carries the highest risk and longest recovery

27. Fibroids • May be managed: • Medically: hormonal suppression • New ulipristal acetate – pre-op only for now • Uterine artery embolization • Surgical resection (hysteroscopy or laparoscopy) • Hysterectomy

28. Acute Bleeding • ABC’s and pt stabilization • Typically high dose estrogen (IV or PO) • Can also use tranexamic acid (IV or PO) • Further evaluation done once stabilized • Occasionally will perform surgical tx in the acute setting but less desirable due to anemia, poor healing, and infection

29. Special Cases • Bleeding Disorders • Adolescents

30. Bleeding Disorders • Think of this with a long personal and family hx of heavy or prolonged bleeds • 50% of teens with a menarchal flow heavy enough to present for medical care will have a bleeding disorder • Tranexamic acid and OCP/IUS mainstay of tx • NSAIDS contraindicated due to interference with platelet function • May use desmopressin in responsive pts

31. Adolescents • Many cycles in first 2 years are anovulatory • Due to immature HPO axis, NOT PCOS! • May consider non-hormonal or hormonal methods – CHC’s safe anytime after menarche • Surgical management is very uncommon • Consider bleeding disorder if very heavy flow and anemia from menarche • Also think of contraceptive needs and pregnancy