Normal & Abnormal Uterine Bleeding

1. Normal & Abnormal Uterine Bleeding Suzanne Bush, MD, FACOG Clinical Associate Professor FSU College of Medicine

2. Objectives • Recognize the characteristics of Normal Menstrual Bleeding (The LMP as the fourth vital sign!) • Describe the etiologies of Abnormal Uterine Bleeding (AUB.) • Understand etiologies of AUB with respect to the life stages of women. • Understand the diagnostic tools to identify the etiology of the AUB. • State the medical & surgical options available in primary care and gynecology settings.

3. Case One • 16 year old G0P0 presents because she is concerned about her periods being irregular. She describes her cycles as coming the 18th of one month & the 16th the next month. She never knows when it is coming. • How would you counsel this patient?

4. How would you counsel this patient? • Oral combined contraception pills will regulate her cycles • She needs to do 3 months of a menstrual diary using an App on her smartphone • She probably has a luteal phase defect and needs progesterone days 15-25. • She has normal cycles and needs reassurance.

5. Normal Menstruation • The Menstrual Cycle In the normal menstrual cycle, orderly cyclic hormone production and parallel proliferation of the uterine lining prepare for implantation of the embryo. Berek & Novak’s Gynecology, 2012, p.145

6. Normal Menstruation • “The menstrual cycle starts with the first day of bleeding of one period and ends with the first day of the next. In most women, the cycle lasts about 28 days. Cycles that are shorter or longer by 7 days are normal.” ACOG Website: FAQ095

7. The Normal Menstrual Period • Blood loss < 80 ml (average 30-35 ml) • Duration of flow 2-7 days (average 4 days) • Cycle length 21 - 35 days (average 29 days) {28 days +/- 7 days}

8. Phases of the Menstrual CycleReproductive Cycle • Follicular (variable) • Begins with Menses & ends with luteinizing (LH) hormone surge • Ovulation (30-36 hours) • Begins with LH surge and ends with ovulation • Luteal (14 days) • Begins with the end of the LH surge and ends with onset of menses

9. Phases of the Menstrual CycleEndometrium • Proliferative • Begins with menses and ends at ovulation • Secretory • Begins at ovulation and ends with menses

10. Case Two • A 25 year old G0P0 just moved to the area and desires a pregnancy. She has irregular menses. She was told by her previous doctor that she has polycystic ovarian syndrome (PCOS) and does not ovulate. She has results of a day 21 endometrial biopsy that shows “Secretory Endometrium.” What can you tell this patient?

11. What can you tell this patient? • The biopsy confirms anovulation • The biopsy was done on the wrong day • The biopsy confirms ovulation. • This patient does not have PCOS

12. Compare Phases of the Reproductive Cycle Phases of the Endometrium Proliferative Secretory • Follicular • Ovulatory • Luteal

13. The Normal Menstrual CycleAnother Way of Looking at It M. Manting; DUB LECTURE 2008

14. Regulation:Hypothalamic Pituitary Axis • Hypothalamus is the pulse generator mediated through GnRH • GnRH cannot be directly measured • Negative FeedbackLoop

15. Regulation of The Ovary2 Cell Theory • Theca Cell • Granulosa Cell

16. Abnormal Uterine Bleeding (AUB) • Definition: • Any change in menstrual period • Flow • Duration • Frequency • Bleeding between cycles • Prevalence: • 20 million office visits/year • 25% of visits to gynecologists

17. Old Terminology • Menorrhagia • Metrorrhagia • Menometrorrhagia • Polymenorrhea • Dysmenorrhea • Amenorrhea • Oligomenorrhea • Hypomenorrhea

18. New Terminology • Heavy Menstrual Bleeding • Acute • Chronic • Intermenstrual Bleeding Munro MG, FIGO Classification of AUB 2011

20. HPI Onset Quantity : Spotting or heavy daily or intermittent Duration History for AUB Ask lots of questions!

21. History for AUB • Associated Symptoms • Pain • Nausea • Fatigue • Headache • Mastalgia • Gender Specific • Menstrual • Contraception • Gynecologic • Obstetric • Sexual • Genital Infections

22. Other Important Details • Family History • Anyone else? • Von Willebrand's • PCOS • PSH • Nutrition and exercise • Weight changes • Exercise habits • Diet • PMH • Chronic conditions • Liver disease • Kidney disease • Anemia • Drugs /medications • Psychiatric medications • Thyroid Disorders • Blood thinners

23. Case Three • 48 year old G2P2, S/P Bilateral Tubal Ligation 14 years ago, referred from her primary care office with RLQ pain of 3 months duration. LMP 5 weeks ago has had many years of irregular menses thought to be menopause transition. • Ultrasound shows an 8 cm adnexal cyst with CA 125 normal.

24. The next step is: • Get her on the schedule for surgery • MRI • Order Follicle Stimulating hormone(FSH) • Urine Pregnancy Test • Estradiol

25. Pregnancy Never forget pregnancy Age is not an issue! Prove it! Assumption can lead to death

26. Differential Diagnosis Of AUB • Structural: PALM-COEIN (Non Gravid Women) • Life Cycles: Pre-menarche Menarche Reproductive Post-Menopause • Anatomic: “Bottoms Up”

27. PALM-COEIN • FIGO Classification System (PALM-COEIN) for causes of AUB in non gravid women of reproductive age • Structural vs. Non-Structural • Developed to create a universally accepted nomenclature

28. PALMStructural Causes P- Polyp (AUB-P) A- Adenomyosis(AUB-A) L- Leiomyoma (AUB-L) Submucosal myoma (AUB-LSM)M- Malignancy & hyperplasia (AUB-M)

29. COEINNon-Structural Causes C- Coagulopathy (AUB-C) O-Ovulatory dysfunction (AUB-O) E- Endometrial (AUB-E) I- Iatrogenic (AUB-I) N- Not yet classified (AUB-N)

30. Case Four • 42 year old G3P3 who is in your civic group presents with heavy, cyclic uterine bleeding. You note spider angioma across her chest & down her arms. She has a slightly protuberant abdomen. Her husband had a vasectomy 7 years ago, and her pregnancy test is negative.

31. The best next step in evaluating her heavy uterine bleeding: • Fasting Blood Glucose • Thyroid Stimulating Hormone • Liver Function Test • Follicle Stimulating Hormone • Estradiol

32. What FIGO nomenclature would you use to label her AUB? • AUB-C • AUB-O • AUB-E • AUB-I • AUB-N

33. Liver Disease • Patients known to have liver disease manifest additional symptomatology because of abnormal hepatic function. • Evaluate patients for spider angioma, palmar erythema, splenomegaly, ascites, jaundice, and asterixis.

34. Differential Diagnosis of AUB Post-Menopausal Menarche Reproductive Pre-menarche

35. Differential Diagnosis of AUB: Anatomical • “Bottoms Up” • Vulva • Vagina • Cervix • Ovary • Brain • Contiguous Anatomy • GU • GI • Non-Pelvic Etiology • Endogenous • Iatrogenic

36. EVALUATION OF AUB NO YES Acute * Sub-Acute * Chronic

37. AUB Initial Assessment Evaluation Evaluation of the Uterus & Endometrium Endometrial Biopsy Transvaginal &/or abdominal Ultrasound (TVS/AUS) Saline Sono-hysteroscopy (SIS) Hysteroscopy • History & Physical • Vital Signs • Shock Signs • Laboratory • Pregnancy Test • Complete Blood Count

38. Endometrial Biopsy (EMB) • Evaluation of the Endometrium • Pipelle

39. TVS & SIS TVS SIS

40. Evaluation Hysteroscopy MRI Precisely localizes sub-mucosal fibroids MRI is not superior to TVS & SIS in overall diagnostic potential Dueholm M, et al. FertilSteril. 2001;76(2):350357

41. Treatment of AUB • Observation • Medical • Minimally invasive surgery • Major surgery

42. Medical Management • Iron • Anti-fibrinolytics • Anti-prostiglandin • Progestins • Estrogen + progestins (OCP) • Parenteral estrogens • Androgens • GnRH agonists • Anti-progestational agents

43. Surgical Approach Minimally Invasive Surgery Major Surgery Myomectomy Total Abdominal Hysterectomy (TAH) Total Vaginal Hysterectomy (TVH) Laparoscopic Hysterectomy LSH (laparoscopic supra-cervical) TLH (total laparoscopic) LAVH (laparoscopically assisted vaginal hysterectomy) Robotic (TLH or LSH) • Intrauterine Device (IUD) with progesterone • Dilation & Curettage • Endometrial Ablation

44. Final Case • 32 year old G2P2002 presents to the ER with 10 day history of heavy uterine bleeding. She is pale and appears frightened. Pulse is 120, BP is 90/60. Hemoglobin is 6, Hematocrit is 18. Pregnancy test is negative. How do you manage this patient?

45. The Best Next Step? • Oxygen & IV Fluids • Type and Cross 2 units of blood • Order a pelvic ultrasound • Order TSH, CBC, Coagulation panel • IV Conjugated Equine Estrogen • Consent for surgery

46. Management Acute AUB Chronic, Stable AUB Combined Oral Contraception AUB-O progestin therapy Levonorgestrel IUD Endometrial sampling is indicated prior to starting hormones in older women Medical failures have the surgical options • Can be a life-threatening emergency • Monitor vital signs, Start oxygen • IV fluids (wide bore IV catheter) • Type and Cross 2-4 units of blood • IV Estrogen • IM Progesterone • NSAIDS (Anti-prostaglandins vs.Anti-fibrinolytics) • Emergency D&C

47. Clinical Pearls Never Forget Pregnancy! PROVE IT! Age is Not an Issue! Assumptions Can Lead to Death!

48. References • ACOG Practice Bulletin No. 136, July 2013 • Beckmann, et al., Obstetrics & Gynecology, 7th ed., Chapters 37, 39 • Clinical Management of Abnormal Uterine Bleeding: APGO Educational Series, May 2002 • Dueholm M, et al. FertilSteril. 2001;76(2):350357 • Fritz, MA, Speroff et al, Clinical and Gynecologic Endocrinology and Infertility, 8th ed. 2011. • Manting M., AUB Lecture 2008 • Munro, MG, et al, FIGO Classification System (PALM-COEIN) for causes of AUB in non gravid women of reproductive age. Int J Gynaecol Obstet 2011; 113:3-13