Abnormal Uterine Bleeding Cullen Archer, MD Assistant Professor Obstetrics and Gynecology UT Health Science Center at San Antonio

Definitions Menses: cyclic regular uterine bleeding occurring every 28 days with 4 days duration Menometrorrhagia: prolonged uterine bleeding occurring at irregular intervals Menorrhagia (hypermenorrhea): prolonged (more than 7 days) or excessive (greater than 80 cc) uterine bleeding occurring at regular intervals. Polymenorrhea: uterine bleeding occurring at regular intervals of less than 21 days Oligomenorrhea: infrequent uterine bleeding occurring at irregular intervals from every 35 days to 6 months Amenorrhea: no menses for at least 6 months Dysfunctional Uterine Bleeding: excessive uterine bleeding with no demonstrable organic cause. It is most frequently due to abnormalities of endocrine origin, particularly anovulation.

How much is too much? 40% of women with blood loss > 80 cc considered their menstrual flow to be small or moderate in amount (Halberg, et. al.) 14% of women with blood loss < 20 cc thought menses was too heavy. Blood loss > 80 cc per cycle is associated with significantly lower hemoglobin, hematocrit, and serum iron levels than women with less menstrual blood loss (Halberg).

Classification Organic Inorganic (Dysfunctional) –Diagnosis of exclusion –Anovulatory –Ovulatory

Organic AUB Systemic Disease –Coagulopathy –Hypothyroidism –Cirrhosis Genital tract disease

Coagulopathies Von Willebrand’s disease Prothrombin deficiency Leukemia Sepsis ITP Hypersplenism

Hypothyroidism Frequently associated with menorrhagia as well as intermenstrual spotting Incidence 0.3% to 2.5% among women with menorrhagia

Organic AUB Systemic Disease –Coagulopathy –Hypothyroidism –Cirrhosis Genital tract disease

Genital Tract Disease Pregnancy Malignancy Infection Anatomic uterine abnormalities Foreign bodies (IUD) Oral and injectable steroids (OCPs and HRT)

Pregnancy Intrauterine pregnancy –Threatened abortion –Incomplete abortion –Complete abortion –Missed abortion Ectopic

Malignancy Cervical cancer Endometrial cancer Estrogen producing ovarian tumors

Infection Endometritis Cervicitis –Postcoital bleeding

Anatomic Abnormalities Leiomyomata –Submucosal –Intramural Endometrial polyps Adenomyosis

Dysfunctional (inorganic) Anovulatory DUB Ovulatory DUB

Anovulatory DUB Predominant in the postmenarchal and premenopausal years Continuous estradiol production without corpus luteum formation and progesterone production steady state of estrogen stimulation leads to a continuously proliferating endometrium, which may outgrow its blood supply or lose nutrients with varying degree of necrosis In contrast to normal menses, uniform slough to the basalis layer does not occur, which produces excessive uterine blood flow

Ovulatory DUB occurs most commonly after adolescent years and before perimenopausal years incidence ~ 10% of ovulatory women

Management Hypothyroidism – mcg LT4 daily resulted in disappearance of menorrhagia within 3-6 months

Management Leiomyomata –OCPs –Myomectomy –Leuprolide acetate 3.75 mg IM qmonth x3 –Hysterectomy –Uterine artery embolization Endometrial polyps –Hysteroscopy, D+C Adenomyosis –OCPs –GnRH analog –Hysterectomy

Acute DUB Estrogens –In pharmacologic doses causes rapid groth of the endometrium over denuded tissue –CEE 10 mg/d po in 4 divided doses should control within 24 hours (if not, 20 mg) –IV route for acute menorrhagia (25mg IV q 3hr x2; 3-6 hours for effect) Progestins –Because most women with acute menorrhagia bleed because of anovulation, progestin therapy is also indicated –MPA 10 mg daily with estrogen x 7-10 days OCP taper (or high dose) x 7 days

Progestins Stop endometrial growth Support and organize the endometrium Organized slough to the basalis layer occurs after withdrawal allowing a rapid cessation of bleeding Long-term treatment of choice for anovulatory DUB Not as effective for acute bleeding

Levonorgestrol IUD 80% reduction in menstrual blood loss at 3 months and 100% at one year Particularly effective in women with ovulatory DUB

Levonorgestrol IUD is contraindicated when one or more of the following conditions exist: Pregnancy or suspicion of pregnancy Congenital or acquired uterine anomaly, including fibroids if they distort the uterine cavity Acute pelvic inflammatory disease or a history of pelvic inflammatory disease, unless there has been a subsequent intrauterine pregnancy Postpartum endometritis or infected abortion in the past 3 months Known or suspected uterine or cervical neoplasia, or unresolved abnormal Pap smear Genital bleeding of unknown etiology Untreated acute cervicitis or vaginitis, including bacterial vaginosis or other lower genital tract infections, until infection is controlled Acute liver disease or liver tumor (benign or malignant) Woman or partner has multiple sexual partners Conditions associated with increased susceptibility to infections with microorganisms. Such conditions include, but are not limited to, leukemia, acquired immune deficiency syndrome (AIDS), and I.V. drug abuse Genital actinomycosis A previously inserted IUD that has not been removed Hypersensitivity to any component of this product Known or suspected carcinoma of the breast History of ectopic pregnancy or condition that would predispose to ectopic pregnancy

NSAIDs Reduce MBL particularly in women who ovulate by 20-50% A complete understanding of MOA not known Mefenamic acid 500mg TID Ibuprofen 400mg TID Meclofenamate 100mg TID Naproxen-Na 275mg q6hr after 550mg load

Endometrial Ablation Rollerball Thermachoice Balloon Novasure Contraindications –Desires future fertility Complications –Fluid overload –Uterine perforation –Thermal damage to adjacent organs

INDICATIONS The GYNECARE THERMACHOICE UBT System is a thermal balloon ablation device intended to ablate the endometrial lining of the uterus in premenopausal women with menorrhagia (excessive uterine bleeding) due to benign causes for whom childbearing is complete. CONTRAINDICATIONS The device is contraindicated for use in: A patient with known or suspected endometrial carcinoma (uterine cancer) or premalignant change of the endometrium, such as unresolved adenomatous hyperplasia. A patient with any anatomic or pathologic condition in which weakness of the myometrium could exist, such as history of previous classical cesarean sections or transmural myomectomy. A patient with active genital or urinary tract infection at the time of procedure (e.g., cervicitis, vaginitis, endometritis, salpingitis, or cystitis). A patient with an intrauterine device (IUD) currently in place. A patient who is pregnant or who wants to become pregnant in the future.

Indications: NovaSure Endometrial Ablation is intended to ablate the endometrial lining of the uterus in premenopausal women with menorrhagia (heavy menstrual bleeding) due to benign causes for whom childbearing is complete. Contraindications: NovaSure Endometrial Ablation is contraindicated for use in patients who: Are pregnant or want to become pregnant in the future; pregnancies following ablation can be dangerous for both mother and fetus. Have known or suspected endometrial carcinoma (uterine cancer) or pre-malignant conditions of the endometrium, such as unresolved hyperplasia. Have any anatomic or pathologic condition in which weakness of the myometrium could exist, such as history of previous classical cesarean section or transmural myomectomy. Have active genital or urinary tract infections at the time of the procedure (e.g., cervicitis, vaginitis, endometritis, salpingitis, or cystitis). Have an intrauterine device (IUD) in place. Have a uterine cavity length less than 4 cm. (The minimum length of the electrode array is 4 cm; treatment of a shorter uterine cavity will result in thermal injury to the endocervical canal). Have active pelvic inflammatory disease.

Hysterectomy History of –Excessive bleeding evidenced by Menorrhagia or polymenorrhea Anemia due to chronic blood loss –Failure of hormonal treatment or contraindication to its use –No current medication that can cause bleeding, or contraindication to stopping –Endometrial sampling performed –No evidence of remediable pathology by one of the following: SHG Hysteroscopy HSG Consideration of alternate therapies Assessment of surgical risk from anemia and need for treatment