Approach to Abnormal Uterine Bleeding Brent E. Seibel, MD Chief, Benign Gynecology Medical Director, UF Health North Jacksonville Associate Professor of Obstetrics and Gynecology University of Florida College of Medicine-Jacksonville

Disclosures I have no conflicts to disclose

Objectives Describe nomenclature, work up and management of abnormal uterine bleeding Illustrate treatment plan options for the PCP

Resources Committee on Practice Bulletins-Gynecology. Practice Bulletin no. 128: diagnosis of abnormal uterine bleeding in reproductive-aged women. Obstet Gynecol 2012; 120:197 Munro MG, Critchley HO, et al. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet 2011; 113:3 UpToDateR : Approach to abnormal uterine bleeding in nonpregnant reproductive-age women. www.uptodate.com

Introduction Abnormal uterine bleeding (AUB) Menstrual bleeding of abnormal quantity, duration, or schedule AUB terminology more descriptive than menorrhagia, metrorrhagia, etc. Accounts for 1/3 outpatient visits to gynecologists Wide variety of local and systemic diseases or medications Annual prevalence of 53 per 1000 women Common etiologies Structural, anovulation, disorders of hemostasis or neoplasia

Abnormal Uterine Bleeding Heavy Menstrual Bleeding (AUB-HMB) Intermenstrual Menstrual Bleeding (AUB-IMB) PALM: Structural Polyp (AUB-P) Adenomyosis (AUB-A) Leiomyoma (AUB-L) Malignancy and Hyperplasia (AUB-M) COEIN: Non-Structural Coagulopathy (AUB-C) Ovulatory Dysfunction (AUB-O) Endometrial (AUB-E) Iatrogenic (AUB-I) Not Yet Classfied (AUB-N)

PALM: Structural Polyps

PALM: Structural Adenomyosis

PALM: Structural Leiomomas

PALM: Structural Malignancy and Hyperplasia

COEIN: Non-structural Coagulopathy Inherited and acquired May occur in up to 20% of patients with HMB Indications for evaluation HMB since menarche Postpartum hemorrhage, excessive surgical bleeding or bleeding with dental work, or any two of the following Bruising 1-2 times per month Epitaxis 1-2 times per month Frequent gum bleeding Family history of bleeding symptoms

COEIN: Non-structural Ovulatory Dysfunction (From amenorrhea and oligomenorrhea to frequent irregular menses) Hypothalimic hypogonadotropic hypogonadism Thyroid dysfunction Hyperprolactinemia Hyperandrogenemia/PCOS Premature ovarian insufficiency Idiopathic anovulation Chronic illness

COEIN: Non-structural Endometrial Abnormalities Abnormal endometrial angiogenesis Prostaglandin production Vasoconstriction Increased fibrinolysis

COEIN: Non-structural Iatrogenic Contraceptives OCPs, patch or ring Depo Provera (DMPA) Contraceptive implant (Nexplanon) Intrauterine device (IUD) Other medications Antipsychotics Anticoagulants other

Evaluation: History Age of menarche Menstrual bleeding pattern Severity of bleeding Pain Medical history Surgical history Family history Bleeding disorders, PCOS, diabetes, cancer

Evaluation: Medications Anticoagulants Hormonal medications NSAIDS Antipsychotics Supplements

Evaluation: Physical Exam Weight extremes Skin Acanthosis nigrans Hirsuitism Acne Pallor Petechiae or echymosis Thyroid Abdomen Pelvic

Evaluation: Labs Pregnancy test STD testing if indicated Pap smear CBC TSH

Evaluation: Labs Bleeding disorder Hyperandrogenism/PCOS PT/PTT/INR Platelet function Fibrinogen Hyperandrogenism/PCOS Testosterone DHEAS 17-OHP HgbA1C, lipids, CMP

Evaluation: Labs Amenorrhea/Oligomenorrhea Prolactin FSH/LH Estradiol

Evaluation: Imaging Transvaginal ultrasound Saline Infusion Sonohysterogram (SIS) Excellent for cavity assessment MRI Fibroid mapping Mullerian anomalies Adenomyosis

Evaluation: Tissue Sampling Endometrial biopsy Women > age 45 with AUB Women < age 45 with chronic anovulation Obese PCOS Unopposed estrogens Hysteroscopy D&C

Treatment: Medical Combined oral contraceptives Progesterone therapy Intramuscular Levonorgestrel intrauterine system (IUD) Tranexamic acid NSAIDs

Treatment: Surgical Dilation and Curettage (D&C) Hysteroscopy Diagnostic Operative (polypectomy, myomectomy) Endometrial ablation Uterine artery embolization (UAE) Myomectomy Hysterectomy

Adolescent with AUB (HMB or IMB) History and physical exam *Pelvic ultrasound Peripubertal anovulatory bleeding Bleeding disorder Expectant management Treatment with OCPs or cyclic MPA Refer Ped/Ad Gyn or Hematology

Reproductive Age with AUB-HMB History, Physical exam and labs *Pelvic ultrasound Abnormal pelvic exam Normal pelvic exam Success! No further workup Pelvic ultrasound Treat abnormality Treat: OCPs Progesterone LngIUD Tranexamic acid NSAIDs Pelvic ultrasound Refer to GYN

Reproductive Age with AUB-IMB History, Physical exam and labs *Pelvic ultrasound Short-term IMB Long-standing IMB Expectant management or Treatment: OCPs Progesterone Pelvic ultrasound (TVS) Cavity evaluation* GYN referral EmBx* Treatment failure TVS/Cavity evaluation GYN referral Success! No further workup

Summary AUB a common condition among reproductive age women Evaluation and initial management by PCP Differentiate between structural and non- structural causes PALM – COEIN terminology

Thank you! Questions?