Abnormal Uterine Bleeding:Not just OCPs or hysterectomy

anymore

Tony Ogburn MDProfessor, Dept. of Ob/GynUniversity of New Mexico

Objectives

• Discuss the classification of abnormal uterine bleeding

• Understand the evaluation of abnormal uterine bleeding in reproductive aged women

• List the non surgical treatment options of abnormal uterine bleeding

• Discuss the indications for surgical management for abnormal uterine bleeding

Disclosures

• Nexplanon trainer – no disclosure

• IUD devotee…

A lot of confusing terms!Dysfunctional uterine bleeding

Epimenorrhagia

Epimenorrhea

Functional uterine bleeding

Hypermenorrhea

Hypomenorrhea

Menometrorrhagia

Menorrhagia (all usages: essential menorrhagia, idiopathic menorrhagia, primary menorrhagia, functional menorrhagia, ovulatory menorrhagia, anovulatory menorrhagia)

Metrorrhagia

Metropathica hemorrhagica

Oligomenorrhea

Polymenorrhagia

Polymenorrhea

Uterine hemorrhage

Common TerminologyDescriptive Term Bleeding patternMenorrhagia Regular cycles,

prolonged duration, excessive flow

Metrorrhagia Irregular cyclesMenometorrhagia Irregular, prolonged,

excessive

Hypermenorrhea Regular, normal duration, excessive flow

Polymenorrhea Frequent cyclesOligomenorrhea Infrequent cyclesAmenorrhea No cycles

A new classification systemPALM - COEIN

• Initial conference – 2005– Wide participation of stakeholders

• FIGO, ACOG, FDA, Researchers, Journals• Focused on terminology, defining needs and resources

• Follow-up conference – 2009• Nomenclature and classification systems– Approved by FIGO - 2011

• Useful for clincians, researchers, and educators• Provides a tool for structured history, evaluation

Nomenclature

• Acute AUB – “an episode of bleeding in a woman of reproductive

age, who is not pregnant, that, in the opinion of the provider, is of sufficient quantity to require immediate intervention to prevent further blood loss.”

• Chronic AUB – “bleeding from the uterine corpus that is abnormal

in duration, volume, and/or frequency and has been present for the majority of the last 6 months.”

Suggested “norms”Clinical dimensions of menstruation and menstrual cycle

Descriptive term Normal limits (5th-95th percentiles)

Frequency of menses, d

Frequent <24

Normal 24-38

Infrequent >38

Regularity of menses: cycle-to-cycle variation over 12 months, d

Absent No bleeding

Regular Variation ± 2-20

Irregular Variation >20

Duration of flow, d

Prolonged >8.0

Normal 4.5-8.0

Shortened <4.5

Volume of monthly blood loss, mL

Heavy >80

Normal 5-80

Light <5

PALM-COEIN• 4 categories that are defined by visually objective structural

criteria (PALM) – Polyp– Adenomyosis– Leiomyoma– Malignancy and hyperplasia

• 4 criteria that are unrelated to structural anomalies (COEI)– Coagulopathy– Ovulatory dysfunction– Endometrial– Iatrogenic

• 1 criterion that is reserved for entities that are not yet classified (N).

Causes of AUBStructural abnormalities (PALM)

• Polyps – AUB-P– endocervical or

endometrial

• Detected by ultrasound or sonohysterography

• Often irregular, light bleeding

Structural abnormalities (PALM)

• Adenomyosis –AUB-A• Controversial as a cause

of bleeding• Diagnosed with

ultrasound, MRI, pathology

Structural abnormalities (PALM)

• Leiomyoma – AUB-L– Submucous– Intramural– Subserosal

• Diagnosed with exam, ultrasound, MRI, CT

• Heavy, regular bleeding

Structural abnormalities (PALM)

• Malignancy and hyperplasia – AUB-M

• Diagnosed by biopsy• Irregular bleeding

Non Structural Causes - COEI

• Coagulopathy• Usually suspected

based on history• Von Willebrands most

common• Heavy, regular bleeding

• Ovulation disorders• Suspected on history– Variable cycle length

• Can be confirmed with laboratory testing

• Wide range of bleeding patterns – usually irregular

Causes of AUB

• Anovulatory– Most common cause of

AUB– Many reasons for

anovulation• Unknown• PCOS• Stress, weight change,

exercise• Endocrine

– Thyroid, PRL– Secreting tumors

Non Structural Causes - COEI

• Endometrial• A diagnosis of exclusion– A wastebasket…

• Iatrogenic– Hormone Use– IUD, implant

Not Yet Classified - N

• “Other entities that may or may not contribute to or cause AUB but have not been identified or have been poorly defined, inadequately examined, and/or are extremely rare”

Evaluation• History

– Acute• Stable?

– Chronic– Characterize bleeding pattern

• Examination– Is it from the uterus?!

• Laboratory studies– Pregnancy test– Hct/CBC– Other labs only if indicated – e.g.

• TSH/PRL• Iron studies• Labs for disorders of hemostasis

Evaluation

• Other diagnostic procedures– EMB• Consider in all patients over 45 or refractory bleeding• Pipelle vs. D&C

– Ultrasound– Sonohysterogram– Hysteroscopy

Endometrial biopsy

Ultrasound- Abdominal or transvaginal- Inexpensive and readily available in most of the world

Sonohysterogram– Inject small amount

of fluid in uterine cavity

– Transvaginal ultrasound

– Endometrial thickness and evaluation of intrauterine structures

HysteroscopyExpensiveCan be used for treatment

MRI

• Very expensive

• Not readily available

• Rarely needed!

Treatment

• Acute or chronic?• If you find something in your evaluation– Treat it!– Thyroid disease, cervical polyp, pregnancy, etc.

• Structural – consider referral early on– Surgery, embolization, hormonal Rx

• Often left with no obvious cause– Now what?

Treatment - Acute

• Unstable?– High dose hormones vs D&C• IV estrogen – 25 mg IV q 4-6 hours

• Stable– Oral meds• Monophasic OCPs – One TID for seven days, then daily

for at least one cycle• Medroxyprogesterone (Provera) – 20 mg TID for seven

days, then daily for at least three weeks• Tranexamic acid (Lysteda) – 1.3 mg TID for five days

Treatment - ChronicConsiderations

• Etiology and severity of bleeding (eg, anemia, interference with daily activities)

• Associated symptoms (eg, pelvic pain, infertility)• Contraceptive needs or plans for future pregnancy• Contraindications to hormonal or other

medications• Medical comorbidities• Patient preferences regarding medical versus

surgical and short-term versus long-term therapy

Treatment Options

• Non-surgical – usually the first line of treatment– Expectant management– NSAIDs

• Reduce blood loss by ~50%

– Antifibrinolytic agents - Tranexemic acid (Lysteda)• Expensive

– Hormonal methods• Combination methods

– Reduce blood loss by ~50%– Regulate cycles in ~85%

• Levonorgestrel IUD – Reduce blood loss by ~85%– Less effective at regulating cycles but usually not an issue

• Cyclic progestin– Most appropriate for anovulatory bleeding if other methods contraindicated

• GnRH agonists (leuprolide) – Expensive for long term use but good for pre-procedure preparation

Levonorgestrel IUD

• FDA approved for treatment of abnormal bleeding– More effective than OCPs,

oral progestins, Depo-Provera, NSAIDs

• Cost effective • Few side effects• Reduces blood loss by up to

97%• Takes 3-6 months for

optimal effect

Combination Methods

• OCPs– Use monophasic at least

for first three months– Use 30-35 of estrogen– Continuous vs. cyclic

• Patch/Rings– No good trials about

efficacy for this indication

Other?

• Depo Provera• Implant

Surgical Treatment

• Two main approaches– Global endometrial ablation– Hysterectomy

• Future pregnancy contraindicated/impossible

Global Endometrial Ablation

• Outpatient procedure• Excellent safety profile• A variety of methods

– Balloon – Thermachoice– Radiofrequency electricity – Novasure– Freezing – Her Option– Circulating hot water – HTA

• Unclear which, if any, is best!– All have about 80% “success”– Less in younger patients…– Equal to IUD in efficacy

Thermachoice

• Eight minute cycle• Lots of cramping during

procedure

HTA- 10 minute cycle- Vaginal burns an early issue

Her Option

- Takes a long time…

Novasure- 1-2 minutes- Have to dilate cervix more We have it at CRH!!!

Hysterectomy

• Random facts…– 100% effective for AUB– A significant minority of women with

“conservative” management end up with a hyst eventually

– Satisfaction rates are very high– Major complications do happen– Expensive

Questions

?

Maria

• 32 yo G2P2 with post – coital spotting for several months

• History completely unremarkable

Cora

• 37 yo with longstanding history of regular, heavy menses now bleeding heavily for 16 days. Passed out at home and brought in by ambulance.

Erica

• 62 yo postmenopausal for 11 years with spotting for several months

Stephanie

• 24 yo G0 with very heavy menses and cramping increasing over one year

Jane

• 42 yo G3P3 presents with heavy, regular bleeding for 9-12 months.

• Bleeds 2-3 weeks each month with large clots and cramps.

Sara

• 46 yo G2P2 with heavy, irregular menses for two years. Now increasing in frequency and flow

• Previous C/S X 2