ABNORMAL UTERINE BLEEDING TONY HOANG, MD

Abnormal uterine bleeding AUB accounts for approx. 70% of all gyn visits in the peri-menopause & post-menopausal years Menstrual disorders accounts for 20% of all gyn visits 2 millions visits per year Growing popularity of Bio-Identical hormones use

WHAT IS NORMAL BLEEDING AGE OF THE PATIENT (NON-PREGNANT) ADOLESCENCE REPRODUCTIVE MENOPAUSAL FLOW FREQUENCY DURATION

NORMAL BLEEDING FLOW (5 days) FREQUENCY DURATION 30 ml – 80 ml of bleeding FREQUENCY Every 21-35 days DURATION Bleeding for 2 – 8 days

TERMINOLOGY MENORRHAGIA – heavy menstrual bleeding METRORRHAGIA – bleeding btwn periods MENOMETRORRHAGIA - combo OLIGOMENORRHEA – bleeding less frequent than 35 days POLYMENORRHEA – bleeding more often than 21 day AMENORRHEA – cessation of periods for 6 months

INITIAL EVALUATION HISTORY MENSTRUAL PAST OR PRESENT ILLNESSES BLEEDING PATTERNS ASSOCIATED PAIN SYMPTOMS SEVERITY FAMILY HSTORY (20%) PAST OR PRESENT ILLNESSES USE OF MEDICATIONS / Herbal Products (Ginkgo Biloba/Ginseng/ motherwort) USE OF BIRTH CONTROL METHODS (IUDs / IMPLANTS / INJECTIONS) WEIGHT, EATING HABITS, EXERCISE, STRESS LEVEL PAP HISTORY

UNDERLYING BLEEDING DISORDER SCREEN QUESTION ABOUT BLEEDING AT MENARCHE HEMORRHAGE (ONE OF THE FOLLOWING) POSTPARTUM POST SURGICAL BLEEDING ASSOC. WITH DENTAL WORK HEMORRHAGE (TWO OF THE FOLLOWING) BRUISING ONE OR TWO TIMES PER MONTH EPISTAXIS ONE OR TWO TIMES PER MONTH FREQUENT GUM BLEEDING FAMILY HISTORY

MENSTRUAL CYCLE DIARY

Initial evaluation

Initial evaluation

Differential diagnosis PREGNANCY / MISCARRIAGE / ECTOPIC ENDOMETRIAL POLYPS ENDOMETRIAL ATROPHY FIBROIDS ADENOMYOSIS OVULATORY ANOVULATORY BIRTH CONTROL SIDE EFFECT (IMPLANTS/IUD) INFECTION (ENDOMETRITIS) BLOOD CLOTTING DISORDERS ENDOMETRIAL HYPERPLASIA UTERINE CANCERS PCOS IATROGENIC NOT YET CLASSIFIED

Differential diagnosis PREGNANCY / MISCARRIAGE / ECTOPIC ENDOMETRIAL POLYPS ENDOMETRIAL ATROPHY FIBROIDS ADENOMYOSIS OVULATORY ANOVULATORY BIRTH CONTROL SIDE EFFECT (IMPLANTS/IUD) INFECTION (ENDOMETRITIS) BLOOD CLOTTING DISORDERS ENDOMETRIAL HYPERPLASIA UTERINE CANCERS PCOS IATROGENIC NOT YET CLASSIFIED

PALM-COEIN

WHAT TO ORDER HCG test CBC vWF (IF INDICATED) Ristocetin cofactor (IF INDICATED) PT/INR/PTT (IF INDICATED) TSH CHLAMYDIA

WORK UP TOOLS TRANSVAGINAL ULTRASOUND SALINE INFUSION SONOHYSTEROGRAPHY MRI HYSTEROSCOPY PAP SMEAR ENDOMETRIAL BIOPSY 45 YRS OR OLDER OR RISK FACTORS: PCOS; OBESITY; FAILED RX; PERSISTENT

TREATMENT MEDICATIONS SURGICAL OPTIONS HORMONAL NON-HORMONAL DILATATION & CURETTAGE HYSTEROSCOPIC RESECTION UTERINE ARTERIAL EMBOLIZATION MYOMECTOMY ENDOMETRIAL ABLATION HYSTERECTOMY

MEDICATION HORMONAL NON-HORMAL OCP’S (Monophasic 35 mcg pills) 4 X 4 - 3 X 3 – 2 X 2 – 1X1 THEN STOP FOR ONE WEEK – RESUME 3 pills for Seven days OCP Q 6 HRS (48 HRS) ESTROGENS (CEE) 25-40 mg IV Q 4-6hrs PROGESTINS PROVERA 10 mg PO Q 4 hrs or 20 mg PO TID x 7 days PROVERA 60 -120 mg PO x 1 then 20 mg Daily x 9 days NORETHRINDRONE 5-10 mg PO Q 4hrs DMPA MIRENA IUD NON-HORMAL MOTRIN 800 mg PO TID x 5 days TRANEXAMIC ACID 500 mg – 1.3 gm PO TID x 5 days (FDA warning) DOXYCYCLINE 100 mg PO X 10 DAYS MEFEPREX 100 mg

SURGICAL UTERINE ARTERY EMBOLIZATOIN / UFE DILATATION & CURETTAGE HYSTEROSCOPIC RESECTION / SYMPHION ABLATION HTA / NOVASURE / MEA / HER OPTION / THERMACHOICE HYSTERECTOMY SUPRACERVICAL MYOMECTOMY LAVH LTH TVH TAH

UTERINE ARTERY EMBOLIZATION COMPLETE CHILD BEARING CATHERIZATION VIA FEMORAL ARTERY IV CONTRAST PVA (POLYVINYL ALCOHOL) 1- 3 HRS PROCEDURE TIME 6 HRS POST PROCEDURE BEDREST POST OP PAIN 6-12 HRS (POSSIBLE SEVERAL MONTHS) MAY REDUCE FIBROID BY 50% 20% RETREATMENT OR REQUIRED SURGERY S/E: INFECTION; PREMATURE MENOPAUSE; PERSISTENT PAIN; SCAR TISSUE; AMENORRHEA

ABLATIONS HTA MIA NOVASURE HER OPTION THERMACHOICE

MEA

HER OPTION

THERMACHOICE

NOVASURE

HYDROTHERMAL

DEMOSTRATION OF HTA ‪http://www.genesyshta.com

OBAMACARE??

“A HAPPY WIFE IS A HAPPY LIFE…” thoang@premierwomensmedical.com