Management of Abnormal Uterine Bleeding Sonnie Kim-Ashchi, MD. FACOG

Patient No 1 Emily is 14 years old, started her first menses last year, irregular at the beginning , now regular monthly. But she reports heavy bleeding that soaks through her uniform. And very “ inconvenient” to have heavy bleeding during her soccer/ lacrosse/crew practices.

Patient No2. Laura is 26 years old trying to get pregnant for last 2 years. She has 4 to 5 periods a year. She is getting more hair in her face and darker in back of her neck. She is getting nervous about her future fertility.

Patient No. 3 Mrs. Robinson is 50 years old. Her last period was 6 months ago. Now bleeding heavily for 10 days passing clots.

Patient No. 4 Mrs. Hopkins is 70 years old. She has been postmenopausal since her early 50’s. She noticed pink spotting about three months ago. At that time, she was too embarrassed to her PCP during her routine checkup. But now, spotting changed to heavy bright red bleeding.

Abnormal Uterine Bleeding Associated with Ovulatory Dysfunction ( AUB-O) The most common cause for gyn visits and referrals. Ovulatory dysfunction presents with heavy irregular uterine bleeding due to the effects of chronic unopposed estrogen on the endometrium. Acute AUB Chronic AUB- topic today Acute AUB is a critical emergency. We need to stabilize the pt from hypovolemic shock. Possibly IV estrogen or even emergency hysterectomy.

Causes of Anovulation Physiologic Pathologic Adolescence Pregnancy Lactation Perimenopause Hypothalamic dysfunction (secondary to anorexia nervosa) Hyperprolactinemia Primary pituitary disease Premature ovarian failure Thyroid disease Hyper androgenic anovulation(PCOS, CAH, or Androgen-producing tumor) Iatrogenic(secondary to radiation or chemotherapy) Medication This is kind ofanovulation busy slides to tell you about the causes of

Causes of AUB by FIGO and ACOG PALM-Structural Causes COEIN-Nonstructural causes Polyp and Pregnancy Adenomyosis Leiomyoma Malignancy and hyperplasia Coagulopathy Ovulatory dysfunction Endometrial Iatrogenic Not yet classified With this system, the etiologies of chronic AUB are classified as “ related to uterine structural abnormalities and “ unrelated to structual abnormalities” and categorized following the acronym PALM-COEIN . You have to determine the most likely etiology of AUB to come up with the most effective and appropriate mgt for your pts. This is done by history, physical exam, lab and imaging tests. -----UP to 13% of women with heavy menses have some variant of vW disease and up to 12% of women may have an underlying coagulation disorders. Von willebrand-ristocetin cofactor activity, vW factor antigen, factor Viii8 International Federation of Gynecology and Obstetrics ( FIGO) American College of Ob/Gyn ( ACOG)

Age-Based Consideration in Differential Diagnosis 13-18 Years Differential diagnosis is similar to other age groups except endometrial hyperplasia and malignancy. 1. Anovulation; Hypothalamic immaturity ( 90%) 2.Stree-exercise-induced 3. Obesity 4. Coagulation disorder like Von Willebrand disease 5. Pregnancy, sexual trauma, STD regardless of her “reported “ sexual history 6. Look for PCOS such as acne, hirsutism,

Age-Based Consideration in Differential Diagnosis; 19-39 Years PCOS is one of the most common causes in this group. Anovulation Obesity is comorbid condition. Endocrine disorder eg. hypothyroidism Pregnancy Polyp, fibroids, adenomyosis Medication related esp. OCP Infection Premalignant or malignant endometrial pathology must be considered for high risk patients especially medical management is not successful.

Age-Based Considerations in differential diagnosis ;40 Years to Menopause Most likely normal perimenopausal changes with irregular sometimes heavy menses Anovulation-unppopsed estrogen and hyperplasia Mean age of menopause is 52 years. The average duration of the menopausal transition is 4 years. Polyp, fibroid, adenomyosis Hyperplasia or cancer Pregnancy must be excluded. Definition of Menopause-cessation of menses for 12 consecutive months, NOT blood hormone tests

Age-Based Considerations in differential diagnosis; Menopause and on 1.Vaginal atrophy 2.Cancer/polyp 3. Estrogen therapy

Basic information about your patients via,,,, History Physical Exam Pertinent medical and surgical history-- Surgery-related bleeding? Bleeding after dental work? Bruising easily? Frequent nose bleeding or gum bleeding? Family history of bleeding? Medication– anticoagulant? Chemo agents? Detailed gyn history-menarche? Current bleeding frequency, interval, duration, related symptoms such as vaginal discharge, pain, LMP General—signs of systemic illness, ecchymosis, thyromegaly, signs of hyperandrogenism such as hirsutism, acne, male pattern balding. Acanthosis nigricans Pelvic exam including speculum exam and bimanual exam to look for genital trauma, cervical tumor, uterine enlargement. Now keeping in the acronym PALM-COEIN, lets take Hand P UP to 13% of women with heavy menses have some variant of vW disease and up to 12% of women may have an underlying coagulation disorders. Von willebrand-ristocetin cofactor activity, vW factor antigen, factor Viii8

Based on patient’s history and physical examination,,,, Laboratory Testing Imaging Urine pregnancy test Complete Blood Counts and platelets TSH If indicated, von Willebrand-ristocetin cofactor activity, vW factor antigen and Factor VIII, Liver Function Test. Pap smear Endometrial biopsy if older than 45 years or “ high risk” patients Transvaginal or transabdominal ultrasound Sonohysterogram Hysteroscopy

Treatment approach to guide therapy for AUB-O The choice of treatment is according to the goals of therapy √ Age group, 13 ? 25? 50? 75? √ To stop acute bleeding? √ To avoid future irregular heavy bleeding? √ Need for contraception? √ Need for comorbidity such as anemia √ Need for surgical treatment? Only when medical therapy fails, is contraindicated, is not tolerated by the patient, or the patient has intracavitary lesions.

FIGO and ACOG recommends Abnormal Uterine Bleeding, NOT Dysfunctional Uterine bleeding, DUB which was used in the past for the bleeding with no systemic or structural cause. DUB

Treatment for AUB-O Progestin Therapy Medroxyprogesterone acetate( Provera) Megestrol acetate (Megace) Norethindrone acetate(Aygestin) Depo Medroxyprogesterone acetate (Depo Provera) Implanon/Nexaplanon Levonorgestrel-releasing intrauterine device ( Mirena or Skyla or Liletta)

Treatment for AUB-O Progesterone and Estrogen combination therapy Oral contraceptives (Monophasic vs. Triphasic vs. combination extended cycle) Transdermal patches Vaginal rings

Surgical Management of AUB-O, ONLY IF medical managements fail Hysteroscopy Dilatation and Curettage Endometrial ablation Hysterectomy

Lab tests- urine hCG, CBC, TSH, vWd factor Patient No 1 Lab tests- urine hCG, CBC, TSH, vWd factor Treatment – Iron supplements and/or Low dose OCP or Progesterone IUD ( Skyla) Consider CONTINOUS combined hormonal contraceptives e.g., Seasonale, Seasonique. 4 periods a year Emily is 14 years old, started her first menses last year, irregular at the beginning , now regular monthly. But she reports heavy bleeding that soaks through her uniform. And very “ inconvenient” to have heavy bleeding during her soccer/ lacrosse/swimming practices.

Patient No2. Any hyper androgenic signs? Obesity? Labs-CBC, TSH, Fasting Prolactin Pelvic ultrasound Endometrial biopsy for high risk patients for hyperplasia or even cancer Fertility desired? If yes, induce ovulation. If not, OCP or Levonorgestrel IUD (Mirena or Liletta) whose benefit includes reduction of endometrial cancer. Weight Loss and Exercise Laura is 34 years old Gravida 0, having noncyclic menses, 4 to 5 periods a year. She is not sure about her fertility.

Need to rule out endometrial hyperplasia and cancer with EMB! Patient No. 3 Mrs. Robinson is 50 years old, last period was 6 months ago. Now bleeding heavily for 10 days passing clots. Very frustrated. Need to rule out endometrial hyperplasia and cancer with EMB! Labs- B HCG, CBC, TSH, Prolactin Pelvic ultrasound Treatment- low dose OCP, cyclic progestin therapy, Mirena IUD or endometrial ablation. Remember perimenopausal women can get pregnant!!

Patient No. 4 Mrs. Hopkins is 70 years old. She has been postmenopausal since her early 50’s. She noticed pink spotting about three months ago. At that time, she was embarrassed to see her gynecologist. But now spotting changed to heavy bright red bleeding. EMDOMETRIAL BIOPSY!! Transvaginal ultrasound especially endometrial stripe

When is EMB indicated? § Purpose of EMB is to rule out hyperplasia and cancer. § Incidences of endometrial cancer in different age groups Younger than 20; 0.2 in 100, 000 Age 20-34; 1.6% Age 35-44; 6.2%, the incidence increases with aging, Age 70-74; 88 cases per 100,ooo § EMB is indicated for patients older than 45 years with AUB-O § Also indicated younger than 45, 1.if medical management failed and systemic diseases such as leukemia or liver disease were ruled out in young patients. 2.patients with h/o unopposed estrogen exposure such as obesity (BMI greater than 30) and PCOS, chronic anovulation, h/o breast cancer, Tamoxifen use, family h/o endometrial cancer.

Surgical management for AUB-O ONLY IF medical managements fail Saline infused sonohysterogram Hysteroscopy Dilation and Curettage Endometrial ablation Hysterectomy

Surgical management for AUB-O Hysteroscopy and Dilation and Curettage Saline infusion sonohysteroscopy

Surgical management for AUB Endometrial ablation “ Hysterectomy Alternative” Can be done in the office,= Just copay for the office visit Resectoscopic endometrial ablation since 1937 Global nonresectoscopic ablation Freeze-Cryotherapy Radiofrequency electricity-Novasure Heated fluid- Thermachoice, HydroThermAblator Microwave-Microsulis Treatment Goal is to “ normalize “ menses ( 70 to 90 % patient satisfaction rate) , NOT amenorrhea. Prerequisites -uterus less than 10 cm, no cavitary lesion, adequate contraception after the procedure Patient must be counseled about the risks of masking endometrial cancer in the future. Post ablation Asherman syndrome, synechiae, endometrial distortion/stricture

Surgical management for AUB Endometrial Ablation Therma Choice Resectoscopic ablation Hydro ThermAblator) Novasure MicroSulis

Surgical management for AUB; Hysterectomy ONLY indicated for medical management failure or patient’s desire for definitive treatment.

daVinci robot assisted total hysterectomy Advantages for the patients *Minimally invasive. *Less painful. *less blood loss, about 50 cc. *Less infection. *Less hospitalization days. *More cosmetically appealing. *Quicker recovery. *Faster return to normal life/work. Advantages for the surgeons *Much improved 3 D visualization *Less complication *Less ergonomically challenging,, Less tiring Single Site Entry

Last Note,,Health apps for Patients Objective data collection instead of “ I bleed a lot”

Thank you Questions about Abnormal Uterine Bleeding?