1. Abnormal Uterine Bleeding
Karen Carlson, M.D.
Assistant Professor
Department of Obstetrics and Gynecology
University of Nebraska Medical Center

2. Objectives Physiology Definitions Etiologies Evaluation Management
Medical
Surgical

3. Phases of Reproductive Cycle
Follicular phase
Onset of menses to LH surge
14 days (varies)
Dominant follicle
greatest number of granulosa cells and FSH receptors
Ovulation
Luteal phase

4. Phases of Reproductive Cycle
Follicular phase
Ovulation
30-36 hours after LH surge
Luteal phase
LH surge to menses
14 days (constant)

5. Menses Involution of corpus luteum Decrease progesterone and estrogen
20-60 cc of dark blood and endometrial tissue

6. Abnormal uterine bleeding
Change in frequency, duration and amount of menstrual bleeding

7. Case 1 12 year-old Regular menses Very heavy bleeding
Frequent nosebleeds and bruises easily
Workup??

8. Case 1
Labs?
PT/PTT
Platelet count
TSH
vWF
H and H
Treatment?

9. Systemic Etiologies Coagulation defects
Routine screening for coagulation defects
Reserved for heavy bleeding at menarche
Screen for inherited bleeding disorder
Coagulation defects
ITP
VonWillebrand’s

10. Harrison’s Principles of Internal Medicine, 14th edition
von Willebrand’s Disease is the most common inherited bleeding disorder with a frequency of 1/
Harrison’s Principles of Internal Medicine, 14th edition

11. Hypothyroidism can be associated with menorrhagia or metrorrhagia
Hypothyroidism can be associated with menorrhagia or metrorrhagia. The incidence has been reported to be %.
Wilansky, et al., 1989

12. Case 2
14 year-old
Irregular menses every 8-12 weeks
Moderate volume

13. Case 2 Normal Hgb What’s the menstrual irregularity?
Insufficient LH and FSH to induce follicular maturation and ovulation
Immaturity of the hypothalamic-pituitary axis
Anovulatory cycles
When should ovulatory bleeding be established?
2-3 years after menarche

14. Physiology of Abnormal Uterine Bleeding
Anovulation
No corpus luteum
No progesterone
Estrogen production continues
Endometrial proliferation
AUB

15. PCOS 12 or more follicles per ovary Follicles 2-9 mm in diameter
Ovarian volume over 10 ml
Cardiometabolic risk assessment
Androgenism signs
DHEAS
Total testosterone
Non-classic CAH
fasting17 hydroxyprogesterone
Confirmed by ACTH stim test

16. Definitions Normal menses Mean duration is 4 days.
Every 28 days +/- 7 days
Mean duration is 4 days.
More than 7 days is abnormal.

17. Normal Menses
Average blood loss with menstruation is 35-50cc. 95% of women lose <60cc.

18. Frequency of AUB Menorrhagia occurs in 9-14% of healthy women.
Most common Gyn disorder of reproductive age women

19. Heavy Periods Disrupt Women’s Lives
“How Often Does Your Period Cause You to Miss the Following Activities?”

20. Hormonal Therapy
Silent Sufferers
5 Million
Surgical Intervention

21. Definitions Menarche Menopause Ovulatory cycles for over 30 years
average age years
Menopause
average age 51.4 years
Ovulatory cycles for over 30 years

22. Definitions Amenorrhea:
Primary amenorrhea
Secondary amenorrhea
No menses for 3-6 months

23. Primary amenorrhea No menses by age 13 No menses by age 15
No secondary sexual development
No menses by age 15
Secondary sexual development present

24. Most Common Causes of Reproductive Tract AUB
Pre-menarchal
Foreign body
Reproductive age
Gestational event
Post-menopausal
Atrophy

25. FIGO System PALM-COEIN Polyp Adenomyosis Leiomyoma
Malignancy and hyperplasia
Coagulopathy
Ovulatory disorders
Endometrium
Iatrogenic
Not classified
Nine basic categories

26. Reproductive Tract Causes of Benign Origin
Uterine
Pregnancy
Leiomyomas
Polyps
Hyperplasia
Carcinoma

27. Proposed Etiologies of Menorrhagia with Leiomyoma
Increased vessel number
Increased endometrial surface area
Impeded uterine contraction with menstruation
Clotting less efficient locally
Wegienka, et al., 2003

28. Sonohysterogram

29. Hysterosalpingogram (HSG)

30. Reproductive Tract Causes of Benign Origin
Uterine
Vaginal or labial lesions
Carcinoma
Sarcoma
Adenosis
Lacerations
Foreign body

31. Reproductive Tract Causes of Benign Origin
Uterine
Vaginal or labial lesions
Cervical lesions
Polyps
Condyloma
Cervicitis
Neoplasia

32. Causes of Benign Origin
Uterine
Vaginal or labial lesions
Cervical lesions
Urethral
Caruncle
Diverticulum GI
Hemorrhoids

33. Iatrogenic Causes of AUB
Intra-uterine device
Oral and injectable steroids
Psychotropic drugs
MAOI’s

34. Evaluation and Work-up: Early Reproductive Years/Adolescent
Thorough history
Screen for eating disorder
Labs:
CBC, PT, PTT, FSH, TSH, prolactin, HCG ,VWF

35. Evaluation and Work-up: Women of Reproductive Age
hCG, FSH, CBC, TSH, FSH, Prolactin
Cervical cultures
U/S
Hysteroscopy
EMB

36. Evaluation and Work-up: Post-menopausal Women
Transvaginal U/S
EMB

37. Causes of Postmenopausal Bleeding
60% atrophy
Karlsson, et al., 1995

38. Not a single case of endometrial CA was missed when a <4mm cut-off for the endometrial stripe was used in their 10 yr follow-up study. Specificity 60%, PPV 25%, NPV 100%
Gull, et al., 2003

39. Case 3 28 yo with regular but heavy menses Diagnostic tests?
No pathology
Desires pregnancy
Treatment?

40. Case 4 26 yo with irregular menses. Desires pregnancy
Trying for 2 years. Recent weight gain
Labs?
TSH, prolactin, H and H, hgb a1c
Treatment?
Weight loss, exercise
Clomid

41. Case 5 42 yo with heavier menses. Slightly enlarged uterus on exam
Evaluation?
1.5 cm Fibroid
Treatment options?
Desires pregnancy versus done with childbearing

42. Comprehensive Gynecology, 4th ed.
EMB
Complications rare. Rate of perforation 1-2/1,000. Infection and bleeding rarer.
Comprehensive Gynecology, 4th ed.

43. EMB Sensitivity 90-95% Easy to perform
Numerous sampling devices available

44. Possible findings on EMB
Proliferative, secretory, benign, or atrophic endometrium
Inactive endometrium
Chronic endometritis
Tissue insufficient for analysis
No endometrial tissue seen
Simple or complex (adenomatous) hyperplasia without atypia
Simple or complex (adenomatous) hyperplasia with atypia
Endometrial adenocarcinoma

45. Endometrial Hyperplasia
*EMB path report
simple hypersplasia WITHOUT atypia.
*Progesterone therapy
Provera® 5-10 mg daily
Mirena IUD
*Repeat EMB in 3-6 months

46. 10% of women with postmenopausal bleeding will be diagnosed with endometrial cancer
Karlsson, et al., 1995

47. Menstrual bleeding stops IF:
Prostaglandins cause contractions and expulsion
Endometrial healing and cessation of bleeding with increasing estrogen

48. AUB Management Options:
Progesterone
Estrogen
OCP’s
NSAIDs
Surgical

49. Medical Treatments Iron Antifibrinolytics Cyclooxygenase inhibitors
Tranexamic Acid (Lysteda)
Cyclooxygenase inhibitors
Progestins
Estrogens + progestins (OCs, vaginal ring and contraceptive patches)
Parenteral estrogens (CEEs)
Androgens (Danazol)
GnRH agonists and antagonists
Antiprogestational agents

50. AUB Management: NSAIDs
Arachidonic Acid
cyclic endoperoxides are inhibited X
Prostaglandins
Thromboxane
Prostacyclin*
*Causes vasodilation and inhibits platelet aggregation

51. Progestins: Mechanisms of Action
Inhibit endometrial growth
Inhibit synthesis of estrogen receptors
Promote conversion of estradiol  estrone
Inhibit LH
Organized slough to basalis layer
Stimulate arachidonic acid formation

52. Progestational Agents
Cyclic Provera mg daily for days
Continuous Provera 2.5-5mg daily
DepoProvera® 150mg IM every 3 months
Levonorgestrel IUD (5 years)

53. Management acute Bleeding: Estrogen
IV Estrogen 25mg q6 hours OR
Premarin® 1.25mg, 2 tabs QID

54. Surgical Options:
Endometrial Ablation
Hysterectomy

55. Endometrial Ablation Economics Indirect costs Direct costs
50% less than hysterectomy
Indirect costs
Savings may be even greater
Includes
Reduced mortality
Quicker return to work

56. NovaSure ThermaChoice

57. The End