Abnormal Uterine Bleeding By YANG FENG OBGYN Dept, Nanfang Hospital

Normal menstrual duration: 3-7d Normal menstrual cycle: 21-35d Normal blood loss<80ml

Abnormal uterine bleeding Menorrhagia: heavy menstrual bleeding,>80ml Metrorrhagia: bleeding between periods Oligomenorrhea: >35-day cycle length Polymenorrhea: <21-day cycle length Amenorrhea: lack of periods for 3-6m Bleeding after sex Bleeding after menopause

Classification—PALM COEIN

AUB-O AUB-O is the result of chronic unopposed estrogen on the endometrium. Abnormalities at any level of the HPO axis Rule-out diagnosis

HPO Axis and menstrual cycle

Evaluation

Evaluation General physical: Pelvic examination Vital signs signs of PCOS(excessive weight, hirsutism, acne) signs of thyroid disease(thyroid nodule) signs of insulin resistance (acathosis nigricans,BMI) signs of bleeding disorder (petechiae, ecchymoses, skin pallor, swollen joints) signs of immune disease(rash, photosensitivity) Pelvic examination Speculum: lesions, pap smear if indicated Bimanual examination

Laboratory testing Pregnency tests CBC LFT TSH TCT Clamydia trachomatis Targeted screening for bleeding disorders (when indicated) Determine ovulatory status: cycle charting, BBT

Imaging tests when indicated Transvaginal ultrasound Sonohysterography Hysteroscopy MRI

Tissue sampling methods (when indicated) Endometrial biopsy >45ys history of unopposed extrogen exposure risk factors for endometrial hyperplasia obesity, PCOS, chronic anovulation, breast cancer, tamoxifen use, family history of EMC,BC,CC failed medical treatment or persistent AUB Hysteroscopy directed endometrial sampling

Aged based differential diagnosis Neonates Premenarchal Early postmenarche Reproductive age Perimenopausal Postmenopausal

Aged based differential diagnosis Neonates: estrogen withdrawal Premenarchal: foreign body trauma, abuse cancer precocious puberty

Aged based differential diagnosis Early postmenarche pregnancy anovulation: HPO immaturity (90% of cases) stress: mental disorder or exercise induced infection coagulopathy

Aged based differential diagnosis Reproductive age pregnancy anovulation polyps/fibroids/adenomyosis medication related (oral contraceptives) infection cancer coagulopathy, endocrine disorder

Aged based differential diagnosis Perimenopausal Anovulation Hyperplasia and cancer Polyp/fibroid/adenomyosis Postmenopausal cancer atrophy polyp estrogen therapy selective extrogen receptor modulators

Acute menorrhagia Initial assessment of vital signs IV assess, blood transfusion if unstable Stop the bleeding estrogen, OCP or progestin, tranexamic acid Foley balloon catheter(tamponade) Surgical: D&C if persistent heavy bleeding hysterectomy/embolization as last resort Long-term maintenance therapy

Chronic menorrhagia Medical options Oral contraceptives Levonorgestrel intrauterine device GnRH-a Failed medical therapy or known surgical indication hysteroscopy hysterectomy endometrial ablation

Endometrial ablation

Case 1 Chief complaint: I’ve been bleeding from my vagina (58 year-old)

History of present illness 58yr obese woman, 6 month history of vaginal bleeding Menopause: 10 yrs ago Gyn history: clomiphene for ovulation induction Denies OCPs or history of STDs Pap smears: last was normal, 4 mo ago

Physical examination VS: BP 155/90 General exam: unremarkable Pelvic exam: unremarkable

Differential diagnosis Endometrial carcinoma Endometrial hyperplasia Endometrial atrophy Endometrial polyps

Initial diagnostic plan Next step? Result: Complex hyperplasia with atypia

Is it enough by just doing a D&C. NO Is it enough by just doing a D&C? NO!!! Always reassure there is no cancer

Treatment plan Surgical staging exploratory laparotomy TAH+BSO selective lymph node dissection

Case2 Chief complaint: I have heavy periods every few weeks or so (32yo)

HPI 32yr G4P4, irregular, heavy menses q3-4wks Tubal ligation 3yrs ago Denies bleeding disorders & easy bruising No vulvar, vaginal or cervical lesions Dark blood in the vagina with mucosa pink & moist but cervical mucus is thin & watery Uterus: asymmetric, minimally enlarged but nontener & mobile. No adnexal masses.

Differential diagnosis Pregnancy complications Anatomic uterine lesion Anovulation

Initial diagnostic plan Pregnancy test!!! negative rules out pregnancy related problems

Further diagnostic plan Transvaginal ultrasound Hysterosonography

Treatment plan

Case 3 Chief complaint: Spotting for a month (56yo)

HPI 56yr, G11P9, still have regular periods. spotting for a month. No vulvar, vaginal or cervical lesions. Uterus: symmetric enlarged, soft and nontender No adnexal masses. Ultrasound: a 6*5cm mass in the uterine cavity.

Initial diagnostic plan Diagnostic fractional curretage Hydatidiform mole

Initial diagnostic plan Pregnancy test!

Review Classification: PALM-COEIN Aged based differential diagnosis Management of acute menorrhagia

References ACOG Practice Bulletin Diagnosis of Abnormal Uterine Bleeding in Reproductive-Aged Women Management of Abnormal Uterine Bleeding Associated With Ovulatory Dysfunction ACOG Committee Opinion Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women

Thank You! Q&A Time