Abnormal Uterine Bleeding: Not just OCPs or hysterectomy anymore Tony Ogburn MD Professor, Dept. of Ob/Gyn University of New Mexico

Objectives Discuss the classification of abnormal uterine bleeding Understand the evaluation of abnormal uterine bleeding in reproductive aged women List the non surgical treatment options of abnormal uterine bleeding Discuss the indications for surgical management for abnormal uterine bleeding

Disclosures Nexplanon trainer – no disclosure IUD devotee…

A lot of confusing terms! Dysfunctional uterine bleeding Epimenorrhagia Epimenorrhea Functional uterine bleeding Hypermenorrhea Hypomenorrhea Menometrorrhagia Menorrhagia (all usages: essential menorrhagia, idiopathic menorrhagia, primary menorrhagia, functional menorrhagia, ovulatory menorrhagia, anovulatory menorrhagia) Metrorrhagia Metropathica hemorrhagica Oligomenorrhea Polymenorrhagia Polymenorrhea Uterine hemorrhage

Common Terminology Descriptive Term Bleeding pattern Menorrhagia Regular cycles, prolonged duration, excessive flow Metrorrhagia Irregular cycles Menometorrhagia Irregular, prolonged, excessive Hypermenorrhea Regular, normal duration, excessive flow Polymenorrhea Frequent cycles Oligomenorrhea Infrequent cycles Amenorrhea No cycles

A new classification system PALM - COEIN Initial conference – 2005 Wide participation of stakeholders FIGO, ACOG, FDA, Researchers, Journals Focused on terminology, defining needs and resources Follow-up conference – 2009 Nomenclature and classification systems Approved by FIGO - 2011 Useful for clincians, researchers, and educators Provides a tool for structured history, evaluation

Nomenclature Acute AUB Chronic AUB “an episode of bleeding in a woman of reproductive age, who is not pregnant, that, in the opinion of the provider, is of sufficient quantity to require immediate intervention to prevent further blood loss.” Chronic AUB “bleeding from the uterine corpus that is abnormal in duration, volume, and/or frequency and has been present for the majority of the last 6 months.”

Suggested “norms” Clinical dimensions of menstruation and menstrual cycle Descriptive term Normal limits (5th-95th percentiles) Frequency of menses, d Frequent <24 Normal 24-38 Infrequent >38 Regularity of menses: cycle-to-cycle variation over 12 months, d Absent No bleeding Regular Variation ± 2-20 Irregular Variation >20 Duration of flow, d Prolonged >8.0 4.5-8.0 Shortened <4.5 Volume of monthly blood loss, mL Heavy >80 5-80 Light <5

PALM-COEIN 4 categories that are defined by visually objective structural criteria (PALM) Polyp Adenomyosis Leiomyoma Malignancy and hyperplasia 4 criteria that are unrelated to structural anomalies (COEI) Coagulopathy Ovulatory dysfunction Endometrial Iatrogenic 1 criterion that is reserved for entities that are not yet classified (N).

Causes of AUB Structural abnormalities (PALM) Polyps – AUB-P endocervical or endometrial Detected by ultrasound or sonohysterography Often irregular, light bleeding

Structural abnormalities (PALM) Adenomyosis –AUB-A Controversial as a cause of bleeding Diagnosed with ultrasound, MRI, pathology

Structural abnormalities (PALM) Leiomyoma – AUB-L Submucous Intramural Subserosal Diagnosed with exam, ultrasound, MRI, CT Heavy, regular bleeding

Structural abnormalities (PALM) Malignancy and hyperplasia – AUB-M Diagnosed by biopsy Irregular bleeding

Non Structural Causes - COEI Coagulopathy Usually suspected based on history Von Willebrands most common Heavy, regular bleeding Ovulation disorders Suspected on history Variable cycle length Can be confirmed with laboratory testing Wide range of bleeding patterns – usually irregular

Causes of AUB Anovulatory Most common cause of AUB Many reasons for anovulation Unknown PCOS Stress, weight change, exercise Endocrine Thyroid, PRL Secreting tumors

Non Structural Causes - COEI Endometrial A diagnosis of exclusion A wastebasket… Iatrogenic Hormone Use IUD, implant

Not Yet Classified - N “Other entities that may or may not contribute to or cause AUB but have not been identified or have been poorly defined, inadequately examined, and/or are extremely rare”

Evaluation History Examination Laboratory studies Acute Chronic Stable? Chronic Characterize bleeding pattern Examination Is it from the uterus?! Laboratory studies Pregnancy test Hct/CBC Other labs only if indicated – e.g. TSH/PRL Iron studies Labs for disorders of hemostasis

Evaluation Other diagnostic procedures EMB Ultrasound Sonohysterogram Consider in all patients over 45 or refractory bleeding Pipelle vs. D&C Ultrasound Sonohysterogram Hysteroscopy

Endometrial biopsy

Ultrasound - Abdominal or transvaginal - Inexpensive and readily available in most of the world

Sonohysterogram Inject small amount of fluid in uterine cavity Transvaginal ultrasound Endometrial thickness and evaluation of intrauterine structures

Hysteroscopy Expensive Can be used for treatment

MRI Very expensive Not readily available Rarely needed!

Treatment Acute or chronic? If you find something in your evaluation Treat it! Thyroid disease, cervical polyp, pregnancy, etc. Structural – consider referral early on Surgery, embolization, hormonal Rx Often left with no obvious cause Now what?

Treatment - Acute Unstable? Stable High dose hormones vs D&C Oral meds IV estrogen – 25 mg IV q 4-6 hours Stable Oral meds Monophasic OCPs – One TID for seven days, then daily for at least one cycle Medroxyprogesterone (Provera) – 20 mg TID for seven days, then daily for at least three weeks Tranexamic acid (Lysteda) – 1.3 mg TID for five days

Treatment - Chronic Considerations Etiology and severity of bleeding (eg, anemia, interference with daily activities) Associated symptoms (eg, pelvic pain, infertility) Contraceptive needs or plans for future pregnancy Contraindications to hormonal or other medications Medical comorbidities Patient preferences regarding medical versus surgical and short-term versus long-term therapy

Treatment Options Non-surgical – usually the first line of treatment Expectant management NSAIDs Reduce blood loss by ~50% Antifibrinolytic agents - Tranexemic acid (Lysteda) Expensive Hormonal methods Combination methods Regulate cycles in ~85% Levonorgestrel IUD Reduce blood loss by ~85% Less effective at regulating cycles but usually not an issue Cyclic progestin Most appropriate for anovulatory bleeding if other methods contraindicated GnRH agonists (leuprolide) Expensive for long term use but good for pre-procedure preparation

Levonorgestrel IUD FDA approved for treatment of abnormal bleeding More effective than OCPs, oral progestins, Depo-Provera, NSAIDs Cost effective Few side effects Reduces blood loss by up to 97% Takes 3-6 months for optimal effect

Combination Methods OCPs Patch/Rings Use monophasic at least for first three months Use 30-35 of estrogen Continuous vs. cyclic Patch/Rings No good trials about efficacy for this indication

Other? Depo Provera Implant

Surgical Treatment Two main approaches Global endometrial ablation Hysterectomy Future pregnancy contraindicated/impossible

Global Endometrial Ablation Outpatient procedure Excellent safety profile A variety of methods Balloon – Thermachoice Radiofrequency electricity – Novasure Freezing – Her Option Circulating hot water – HTA Unclear which, if any, is best! All have about 80% “success” Less in younger patients… Equal to IUD in efficacy

Thermachoice Eight minute cycle Lots of cramping during procedure

HTA - 10 minute cycle - Vaginal burns an early issue

Her Option - Takes a long time…

Novasure 1-2 minutes Have to dilate cervix more We have it at CRH!!!

Hysterectomy Random facts… 100% effective for AUB A significant minority of women with “conservative” management end up with a hyst eventually Satisfaction rates are very high Major complications do happen Expensive

Questions ?

Maria 32 yo G2P2 with post – coital spotting for several months History completely unremarkable

Cora 37 yo with longstanding history of regular, heavy menses now bleeding heavily for 16 days. Passed out at home and brought in by ambulance.

Erica 62 yo postmenopausal for 11 years with spotting for several months

Stephanie 24 yo G0 with very heavy menses and cramping increasing over one year

Jane 42 yo G3P3 presents with heavy, regular bleeding for 9-12 months. Bleeds 2-3 weeks each month with large clots and cramps.

Sara 46 yo G2P2 with heavy, irregular menses for two years. Now increasing in frequency and flow Previous C/S X 2