ABNORMAL UTERINE BLEEDING ovulatory vs anovulatory

1. ABNORMAL UTERINE BLEEDING ovulatory vs anovulatory Mary E. Arens, MS, PA-C Henry Ford Macomb Hospital Clinton Township, MI

2. Introduction • Menstrual / Ovarian cycle • Hypothalamic Pituitary-ovarian axis • Release of gonadotrophins (FSH/LH) • Causes of Abnormal and Dysfunctional uterine bleeding • Bleeding patterns and intervals • Evaluation and management

3. MENSTRUAL CYCLE • Definition: Periodic vaginal bleeding that occurs with the shedding of the uterine mucosa. • Length ranges from 21-35 days (avg. 28 days) lasting 4-6 days. (30 mL normal volume) • The effect of progesterone and estrogen, that is released form the ovary, on the endometrium. • Ovarian cycle is controlled by the hypothalamic-pituitary-ovarian axis.

4. Ovarian cycle: phase one • Two phases: • Follicular (proliferative) phase begins with the onset of menses & ends with LH surge. (duration varies) • FSH is released in response to a decline in estrogen and progesterone (negative feedback). • FSH matures a dominate follicle which releases estrogen. (influences growth of endometrial cells)

5. Ovarian cycle: Phase two • Luteal (secretory) phase begins with the LH-surge & ends with first day of next menses (duration fairly constant 14 days) • LH surge is a result of an increase in estrogen production just prior to ovulation (positive feedback). • Ovum released 34-36 hours after LH surge.

7. Corpus luteum • Present during the luteal phase. • The result of the ruptured dominate follicle (after ovum is released). • Lifespan 14 days (if no pregnancy occurs) • Progesterone has thermogenic effect-increase body temperature. (BBT) • Source of progesterone to sustain pregnancy (lifespan up to 10 weeks). • Regresses if pregnancy does not occur. Causes a decline in progesterone and endometrial lining is shed.

9. Basal body temp chart

10. Abnormal uterine bleeding (AUB) ovulatory • Uterine bleeding that is excessive or outside of normal cyclic menstruation. • Usually secondary to pathologic entities such as fibroids, endometrial polyps, cancer, coagulopathies and bleeding during pregnancy

11. Causes of AUB (ovulatory) uterus • Fibroid *most common (Submucosal, Intramural and subserosal) • When adjacent to the endometrium • Adenomyosis • Glandular tissue inside endometrium • Endometrial hyperplasia or polyps. • IUD • PID/ Endometritis • Endometriosis • Miscarriage • Gestational trophoblastic disease • Endometrial cancer

13. AUB (ovulatory) non- uterus • Ovarian cyst or estrogen producing tumors (granulosa cell tumors) • Ectopic pregnancy • Cervicitis (Gonorrhea and Chlamydia) • Cervical eversion / polyps • Vulvovaginitis-yeast or trichomonas infection • Atrophic vaginitis • Coagulation disorders (von Willebrand’s disease- Factor VIII deficiency) • Common in younger adolescants • Cancer

15. AUB (anovulatory) • “anovulatory uterine bleeding” relating to a disruption in normal ovarian function. • Uterine bleeding that is unrelated to an anatomic lesion, (no pathology) • A diagnosis of exclusion • Most commonly occurs at extreme of reproductive ages (20% adolescence and 40% over 40)

16. Anatomy & Physiology • Without ovulation the corpus luteum is not formed and no progesterone production. • Continual unopposed-estrogen secretion from ovaries result in endometrial proliferation. • Results in bleeding that is non-cyclic, unpredictable and inconsistent in volume

17. Physiologic causes AUB (anovulatory) • Adolescence- • immaturity of the hypothalamic-pituitary-ovarian axis. Lack of regular ovulation. • Peri-menopause- decline in ovarian function. • Lactation- elevated prolactin prevents ovulation. • Pregnancy • Hormone therapy (birth control) • Obesity- • Adipose tissue produces extra androgens which are converted to estrogen in the ovaries which suppress FSH LH release.

18. Pathologic causes AUB (anovulatory) • Hyper-androgenic disorders • PCOS, congenital adrenal hyperplasia • Hypothalamic dysfunction • excessive wt loss (anorexia nervosa), psychological stress &/or exercise). Suppression and dysfunction of GnRH pulse generator. • Hyperprolactinemia –(pituitary microadenoma) • Hypothyroidism • Primary pituitary disease • Premature ovarian failure (<40 years) • estrogen producing tumors (granulosa cell tumors) • Iatrogenic- chemo or XRT

19. Pattern of AUB • Metrorrhagia (inter-menstrual bleeding). Bleeding at anytime between menses. • Hormones (OCP, HRT) most common • Ovulatory bleeding • Endometrial polyps or cancer

20. Menorrhagia- Excessive and/or prolonged menses at normal intervals (>80mL and >7days) • Hypermenorrhea / Menometrorrhagia- excessive and/or prolonged menses at irregular intervals. • Polymenorrhea- Frequent menses at intervals <21 days. • Oligomenorrhea, cycles >35 days apart. • Amenorrhea- no bleeding for 6 months or 3 cycles. • Post-menopausal bleeding- bleeding occurring more than 1 year of reaching menopause.

21. Postcoital bleeding (contact bleeding) with intercourse • Cervical cancer must be ruled out by colposcopy. • Cervical polyp / eversion (most common) • Cervicitis (GC/C) • Vaginal infection (Trichomoniasis) • Vaginal atrophy (post-menopausal)

22. Evaluation of AUB • History- document menstrual cycle, interval, length and flow. LMP (menstrual diary) • Medication and/or (IUD?) • h/o excessive wt loss, exercise or stress. • Provoking factors, i.e. after sex. • Fatigue, hair loss, wt gain (Thyroid) • BBT (if infertility is a concern)

23. Physical exam- • Uterus: Enlarged, bulky irregular (fibroid) or symmetrical enlarged (adenomyosis) • Ovaries: adnexal pain (ovarian cyst) • Cervicitis or polyps (infection?) • Obesity and hirsutisim (PCOS) • Galactorrhea (hyperprlactinemia

24. Labs • B-HCG- pregnancy must always be ruled out (reproductive age). Serial for poss ectopic • FSH/LH >30 menopausal LH 2-3 x’s higher possible PCOS • TSH- elevated in hypothyroidism • DHEA-S and Free testosterone (PCOS) • Fasting insulin (PCOS) • Prolactin (Hyperprolactin Tumor amen) • CBC- anemia (if bleeding is heavy) • PT, PTT and Platelets (adolescence) von Willebrands • Cultures –GC&C, Trich • Pap smear if sexually active

25. Evaluation continue • Ultrasound • Fibroids • Ovarian cysts or tumors • Endometrial thickness • Pre-menopausal <10mm (normal) (May depend on what day of cycle) • Post-menopausal <5mm (normal) • Sono-hysterogram- saline-infusion in the uterine cavity. To evaluate abnormal liining of uterus

26. Endometrial sampling • Done in women >35 years to exclude endometrial cancer/hyperplasia. • Especially in postmenopausal bleeding. • Risk factors for endometrial hyperplasia • Heavy bleeding >35 • Obesity • Anovulation >6 months • Unapposed estrogen • Endometrial biopsy • D&C (with Hysteroscopy)

27. Medical Management • Treat underlying medical cause (thyroid, correct anemia) • Contraceptives (pills, injection or ring) • Estrogen containing OC are not for women >35 who smoke. (DVT’s) • Be cautious in women with HTN or elevated Triglycerides or gallbladder dz. • Progesterone therapy (14-26 of cycle) or Depo Provera injection • Post tubal ligation, if don’t want birth control • Implanon (progesterone implant on skin • IUD with progestin (Mirena) • Marina has progesterone on IUD • Clomid for infertility

28. Surgical Management • When medical therapy fails • If childbearing is still a consideration • D & C Hysteroscopy • Myomectomy • If childbearing is complete • Endometrial ablation (Novasure) • Burn uterine lining • Hysterectomy (with possible bilateral salpingo-ophorrectomy) • Uterine artery embolizaion- acute bleeding for patients may not tolerate surgery and want to preserve the uterus