2. Abnormal Uterine Bleeding Anisa Ssengoba-Ubogu, M.D. BCM Kelsey- Seybold Clinic Family Medicine Residency Program

3. Goals Review causes of Abnormal uterine bleeding Management

4. Menstrual disorders accounted for 19.1% of 20.1 million visits to physician offices for gynecologic conditions over a two-year period 25% of gynecologic surgeries involve abnormal uterine bleeding

5. NORMAL MENSTRUAL CYCLES OCCUR AT 28 DAY INTERVALS 21-35 DAY RANGE IS NORMAL 400-500 CYCLES OCCUR BETWEEN THE FIRST AND LAST PERIODS 70% OF THE BLOOD LOSS FROM A MENSTRUAL CYCLE OCCURS IN THE FIRST TWO DAYS

6. Menorrhagia- Bleeding occurs at normal intervals (21 to 35 days) but with heavy flow (>=80 mL) or duration (>=7 days Metrorrhagia-Irregular, frequent uterine bleeding of varying amounts but not excessive Menometrorrhagia-Bleeding occurs at irregular, noncyclic intervals and with heavy flow (>=80 mL) or duration (>=7 days).

7. Polymenorrhea-Regular bleeding at intervals of less than 21 days Oligomenorrhea-Bleeding at intervals greater than every 35 days Amenorrhea-No uterine bleeding for at least 6 months Acute emergent abnormal uterine bleeding- significant blood loss that results in hypovolemia (hypotension or tachycardia) or shock.

8. Differential Diagnosis Medications Systemic Disease Infection Trauma Complications of Pregnancy Benign Pelvic Pathology Neoplasm

9. Medications/iatrogenic Anticoagulants Antipsychotics Corticosteroids Herbal and other supplements: ginseng, ginkgo, soy Hormone replacement Intrauterine devices OCPs, including progestin-only pill SSRI’s Tamoxifen (Nolvadex) Thyroid hormone replacement

10. Systemic disease Blood dyscrasias, including leukemia and thrombocytopenia Coagulopathies Hepatic disease Polycystic ovary syndrome Renal disease Adrenal hyperplasia and Cushing's disease Hypothalamic suppression (from stress, weight loss, excessive exercise) Pituitary adenoma or hyperprolactinemia Thyroid disease

12. Infection Cervicitis Endometritis Myometritis Salpingitis

13. Trauma Laceration Abrasion Foreign body Sexual Abuse/ Assault

14. Complications of Pregnancy Intrauterine pregnancy Ectopic pregnancy Spontaneous abortion Gestational trophoblastic disease Placenta previa

15. Benign pelvic pathology Cervical polyp Endometrial polyp Leiomyoma Adenomyosis

16. Endocervical polyp

17. Endometrial Polyp

18. Leiomyoma

21. Malignant neoplasm cervical squamous cell carcinoma endometrial adenocarcinoma estrogen-producing ovarian tumors testosterone-producing ovarian tumors leiomyosarcoma 1 IN 5 WOMEN OLDER THAN 45 WILL HAVE A MALIGNANT OR PREMALIGNANT CAUSE OF BLEEDING

22. Endometrial Cancer

23. Risk Factors for Endometrial Cancer Chronic anovulatory cycles Obesity Nulliparity Age > 35 years Diabetes Tamoxifen therapy H/o unopposed estrogen use

24. Labs Pregnancy test! Cbc- access anemia/ platelet dysfunction STD check (GC/CT/trich) PAP LFT’S/INR TSH Prolactin Blood glucose DHEA-S, free testosterone, 17alpha- hydroxyprogesterone

25. Imaging/ tissue sampling EMB TVUS Saline-infusion sonohysterography Hysteroscopy

26. Bleeding pattern Severe acute Ovulatory Anovulatory Related to contraception

27. Severe Acute Bleeding Premarin 2.5mg qid plus promethazine 25mg D &C if no response after 2-4doses of Premarin Switch to OCP (LoOval qid x 4d, tid x 3d, bid x 2d, qd x3wks, 1wk off then cycle for 3mo

28. Dysfunctional Uterine Bleeding Abnormal uterine bleeding not caused by pelvic pathology, medications, systemic disease or pregnancy. Can be ovulatory or anovulatory.

30. Causes of DUB Estrogen breakthrough bleeding Estrogen withdrawal bleeding Progesterone breakthrough bleeding

31. Medical Management Anovulatory- OCP’s/patch/ring or cyclic progestins if contraindication to OCP’s Ovulatory- NSAIDS, levonorgestrel- releasing intrauterine system (Mirena) OCPs, Depo, patch, ring, Implanon

32. Ortho Evra

33. Nuva Ring Implanon Mirena

34. Abnormal bleeding w/ OCPs Low dose OCPs – increase estrogen Necon 1/35, Demulen 1/35, Demulen 1/50, LoOvral -check STDs - imaging

35. Abnormal Bleeding with Depo 1 st 4-6mo? Observe, add OCP, inc injection freq q2mo Premarin 1.25mg qd x 7d, repeat if bleeding recurs OTHER OPTIONS: -Ethinyl estradiol (Estinyl)- 20 mcg per day for 1 to 2 weeks – Estradiol (Estrase)- 0.5 to 1 mg per day for 1 to 2 weeks

36. Abnormal Bleeding with IUD Observe if mild for 4-6mo OCP for one cycle if Mirena Provera 10mg for 7days if Paraguard

37. Surgical Management Hysterectomy Uterine artery embolization Endometrial ablation Myomectomy Operative hysteroscopy

38. Case #1 18 year old female h/o Depo x 4years, complains of heavy bleeding and cramping (give estradiol 1mg daily x 2wks, Motrin, check cbc,calcium+D, consider other birth ctl options)

39. Case #2 25 year old female with complaint of heavy menses lasting 10 days+ dysmennorhea, hct-30. (regulate with birth ctl, tx anemia, NSAIDS)

40. Case #3 59 year old widowed female with 2 episodes of spotting. (check cultures, refer to Gyn)

41. Case #4 30 year old female complains of lack of menses for 3months (trial of Provera 10mg daily x 10days for withdrawal bleeding)

42. Case #5 19 y/o female with severe bleeding, 1 tampon/hr. BP stable. (Premarin 2.5 qid with antiemetic, then OCP)