Abnormal Uterine Bleeding P. Michael Kidder, DO, FACOOG Primrose OB/GYN Springfield, MO

Disclosure No disclosures to report. I have no financial relationships with any pharmaceutical or equipment manufacturers.

Question 1 Which imaging modality is considered first line for imaging the pelvic anatomy? A. Magnetic Resonance Imaging B. Computed Tomography C. Sonography D. Hysteroscopy

Question 2 Combined Estrogen/Progesterone containing birth control works by feedback inhibiting the production of FSH in the pituitary gland. True False

Question 3 Menopause is diagnosed by using the following criteria? A. The onset of climacteric symptoms, i.e, hot flashes and night sweats B. Absence of menstruation for a period of at least 12 months C. Follicle Stimulating Hormone level <20pcg/dL D. When a woman reaches the age of 55

Question 4 Treatment options for women with AUB can include all of the following except; A. Combined Oral Contraceptives B. Tranexemic Acid C. Saline infusion Sonohysterogram D. LnG52/5 Progesterone IUD E. Hysterectomy

Question 5 What is the genetic inheritance of Hemophilia A and B? Autosomal Dominant Autosomal Recessive X-Linked Recessive X-Linked Dominant

Dysfunctional (Abnormal) Uterine Bleeding Definition Background Differential Diagnosis Terminology Evaluation Physical Exam Laboratory Assessment Imaging Treatment and Management

Definition Abnormal uterine bleeding: Menstrual bleeding of abnormal quantity, duration, or schedule. So what is considered normal? Cycle Length: 24-38 days Average blood loss: ~80cc Clinical definition is subjective: volume that does not interfere with a woman's physical, social, emotional, and/or quality of life Days of bleeding: <8 days

Background- Uterine Anatomy

Background The Menstrual Cycle: More than you will ever want to know. Primary Hormones: GnRH, FSH, LH, E2, P4 Hypothalamic-Pituitary-Ovarian Axis Birth Control- How does it work?!?!

Background-Endometrial Anatomy

Differential Diagnosis of AUB There’s a lot! Different age groups and developmental stages!

Terminology Old terminology- Menorrhagia, Menometorrhagia, Oligomenorrhea 2011 – Federation of Obstetrics and Gynecology (FIGO) PALM-COEIN Polyps Coagulopathy Adenomyosis Ovulatory Dysfunction Leiomyoma Endometrial Malignancy/Hyperplasia Iatrogenic Not Yet Classifies AUB-P, AUB-A, AUB-E, etc…

Evaluation- History Gynecologic and obstetric history, including: Menstrual history There’s an App for that! Sexual history Assess risk for pregnancy or sexually transmitted infections History of obstetric or gynecologic surgery C-sections, Myomectomy Contraceptive history OCP’s, IUD, Implants

Evaluation- History Continued Is the uterus the source of the bleeding? Bleeding from the vulva, vagina, or cervix volume of bleeding Large Volume- Likely uterine  color of the blood  Dark = old blood  bleeding is consistently postcoital Suggests cervical pathology Urinary or gastrointestinal tract bleeding? Hemorrhoids, fistula, fissures Is the patient premenarchal or postmenopausal? average age of menarche is 12 years average age of menopause is 51 years Definition of menopause!!!

Evaluation- History Continued Other medical history Bleeding disorders VwB, anticoagulation, thrombocytopenia, hematologic malignancy Hemophilia? (Rare in women?) Thyroid disease 1-2% of women Galactorrhea Hyperprolactinemia

Evaluation- Continued Is the patient pregnant? Just do the pregnancy test!!! Look pretty dumb when radiologist calls you up!!!

Evaluation Gotta have algorythms!!!

Evaluation- Laboratory Initial tests: Serum or Urine HCG Sensitivity of Urine vs Serum CBC Additional tests TSH Prolactin Sex hormones FSH, LH, Estradiol, progesterone, free testosterone Coagualtion studies

Evaluation- Imaging Pelvic ultrasound MRI Hysteroscopy Transvaginal superior to Transabdominal Saline Infusion sonogram Good for intrauterine pathology MRI Further evaluation of fibroids/advanced disease Hysteroscopy Direct imaging

Evaluation- Pelvic Ultrasound

Evaluation Your detailed history will guide your work-up!

Treatment and Management Choosing a treatment — Management of reproductive-age women with AUB with a benign etiology is based upon the following factors: Etiology Severity of bleeding (eg, anemia, interference with daily activities) Associated symptoms and issues (eg, pelvic pain, infertility) Contraceptive needs and plans for future pregnancy Medical comorbidities Underlying risk for venous thromboembolic disease and/or arterial thrombotic events

Treatment and Management Medical vs Surgical treatment Medical Oral Contraceptives (varying dose) vs LnG52/5 (Progesterone IUD) Progestins- cyclical and long term therapy Estrogen Tranexemic Acid Surgical Endometrial ablation Hysterectomy Myomectomy 58% of women that were medically treated for AUB underwent surgery within 2 years

Case #1: “Millie” 19 yr old college student presents complaining of heavy bleeding for the past 4 days- markedly heavier than her normal period. She also has nausea, vomiting for the past week. Her bleeding is bright red, and she notes passing some quarter sized clots. She is sexually active with one partner. She has been using the vaginal ring for contraception. PMH: Treated for URI 6 weeks ago with Azithromycin PSH: No surgeries What else do you want to know? Millenial

Case #1: “Millie” More History Physical Exam Labs Large amount of blood in the vault, uterus is difficult to palpate due to tenderness, no adnexal masses, cervix is clear. Labs

Case #1: “Millie” Urine HCG: Positive CBC Serum HCG?

Case #1: “Millie” Serum HCG: 198,000 What next? Ultrasound!

Case #1: “Millie” Ultrasound results: Numerous discrete anechoic (cystic) spaces with central area of heterogeneous echotexture 

Case #1: “Millie” Diagnosis??? Molar Pregnancy

Case #1: “Millie” Treatment Course… Transfusion, D&C, Follow HCG levels… Wait at least a year to get pregnant!

Case #2: “Alice” 47 yr old morbidly obese woman comes to your office complaining of vaginal bleeding for the past 6 weeks. She reports having irregular periods for the past 20 years- after the birth of her child (G2P1011). Husband had a vasectomy 18 years ago. Menarche at age 9. Her last period prior to her current bleeding was 4 months ago. What else do you want to know?

Case #2: “Alice” More History Physical Exam Labs Imaging

Case #2: “Alice” Ultrasound: Endometrial thickness of 2.16cm

Case #2: “Alice” What is your next step to make a diagnosis? Hysteroscopy, Dilation and Currettage!

Case #2: “Alice” Hysteroscopy Results: Endometrial Currettings Pathology: Complex Endometrial Hyperplasia with Atypia

Case #2: “Alice” So… what’s next for Alice?

Case #2: “Alice” Surgical video – Robotic Assisted Total Laparoscopic Hysterectomy with Bilateral Salpingoopherectomy

AUB- Huge Topic Main points Have a broad understanding of the differential diagnosis Low threshold to refer to specialist

Question 1 Which imaging modality is considered first line for imaging the pelvic anatomy? A. Magnetic Resonance Imaging B. Computed Tomography C. Sonography D. Hysteroscopy

Question 2 Combined Estrogen/Progesterone containing birth control works by feedback inhibiting the production of FSH in the pituitary gland. True False

Question 3 Menopause is diagnosed by using the following criteria? A. The onset of climacteric symptoms, i.e, hot flashes and night sweats B. Absence of menstruation for a period of at least 12 months C. Follicle Stimulating Hormone level <20pcg/dL D. When a woman reaches the age of 55

Question 4 Treatment options for women with AUB can include all of the following except; A. Combined Oral Contraceptives B. Tranexemic Acid C. Saline infusion Sonohysterogram D. LnG52/5 Progesterone IUD E. Hysterectomy

Question 5 What is the genetic inheritance of Hemophilia A and B? Autosomal Dominant Autosomal Recessive X-Linked Recessive X-Linked Dominant