1. Changes before the change: Perimenopausal Bleeding
World Menopause Day 2017
Changes before the change:
Perimenopausal Bleeding

2. IMS theme Series: Perimenopausal Bleeding
Abnormal Uterine Bleeding (AUB) - Definition
Bleeding that is unlike normal menstrual flow in terms of frequency, duration and quantity. It includes infrequent or frequent bleeding, heavy menstrual bleeding or intermenstrual bleeding
AUB is a leading cause for gynecological consultations in the peri- and post-menopausal age groups.
World Menopause Day 2017

3. IMS theme Series: Perimenopausal Bleeding
AUB subsets in the Perimenopause
Ovulatory AUB
Ovulatory bleeding may be heavy and can be associated with typical premenstrual symptoms and painful periods.
World Menopause Day 2017

4. IMS theme Series: Perimenopausal Bleeding
AUB subsets in the Perimenopause
Anovulatory AUB
Anovulatory bleeding, which is found more frequently during the perimenopause compared to the premenopause, is often linked to prolonged periods, heavier flow and an irregular cycle. If prolonged (e.g. in PCOS or associated with obesity), anovulatory bleeding has a stronger link to endometrial cancer and endometrial hyperplasia
World Menopause Day 2017

5. IMS theme Series: Perimenopausal Bleeding
Abnormal Uterine Bleeding - Etiology
1. Hormonal Changes
2. Benign Anatomic Changes
Uterine Polyps
Uterine Fibroids
Adenomyosis
Low Thyroid Function
Other medical conditions, i.e. coagulopathy
3. Cancer
Primarily endometrial, but also cervical.
World Menopause Day 2017

6. IMS theme Series: Perimenopausal Bleeding
Abnormal Uterine Bleeding - Diagnosis
The goal of diagnosis is to distinguish women with anatomic causes from women with normal anatomy.
Identifying endometrial malignancy, although uncommon among the AUB etiologies, is often the main purpose of the investigations.
World Menopause Day 2017

7. FIGO Nomenclature: PALM-COEIN
IMS theme Series: Perimenopausal Bleeding
FIGO Nomenclature: PALM-COEIN
Abnormal Uterine Bleeding
(AUB)
-Heavy menstrual bleeding (AUB/HMB)
-Intermenstrual bleeding (AUB/IMB)
PALM: Structural Causes
Polyp (AUB-P)
Adenomyosis (AUB-A)
Leiomyoma (AUB-L)
Submucosal myoma (AUB-Lsm)
Other myoma (AUB-Lo)
Malignancy & hyperplasia (AUB-M)
COEIN: Nonstructural Causes
Coagulopathy (AUB-C)
Ovulatory dysfunction (AUB-O)
Endometrial (AUB-E)
Iatrogenic (AUB-I)
Not yet classified (AUB-N)
World Menopause Day 2017
Adapted from Practice Bulletin No ACOG Obstet Gynecol 2012;120:197–206

8. IMS theme Series: Perimenopausal Bleeding
Before
Now
AUB
HMB
DUB
Menorrhagia
Menometrorrhagia
Oligomenorrhe
AUB-P
AUB-A
AUB-L
AUB-M
AUB-C
AUB-O
AUB-E
AUB-I
AUB-N
World Menopause Day 2017

9. IMS theme Series: Perimenopausal Bleeding
Assessment of abnormal uterine bleeding
General assessment
History and bleeding pattern
Physical, pelvic and speculum examination
Laboratory tests including:
Full blood count, iron studies, (thyroid, hCG – if indicated)
Disorders of hemostasis (if indicated)
Evaluate pelvic organs and endometrium
ultrasound scan
Hysteroscopy
MRI (if indicated)
World Menopause Day 2017

10. IMS theme Series: Perimenopausal Bleeding
Imaging Techniques
The primary imaging test for the evaluation of abnormal uterine bleeding is transvaginal ultrasound. This maybe more difficult in cases of co-existing myomas, previous surgery, marked obesity, axial uterus or adenomyosis. In such cases SIS - saline infusion sono-hysterography can be helpful.
Hysteroscopy as a diagnostic tool may also be employed if intra-uterine pathology is suspected. It can be done in an outpatients setting using small telescopes and usually requires no analgesia. An inpatient procedure will be required in 15-20%
World Menopause Day 2017

11. IMS theme Series: Perimenopausal Bleeding
Endometrial Sampling
Endometrial sampling is required to diagnose endometrial abnormality.
This can be done, usually after an ultrasound or hysteroscopy, with a vacuum aspiration system, e.g. Pipelle. However, this will only sample a small proportion of the cavity and there is a high incidence of false negative results, and cancer may be missed. AUB will often require further evaluation.
World Menopause Day 2017

12. IMS theme Series: Perimenopausal Bleeding
Treatment of abnormal uterine bleeding
Treatment goals for patients with AUB include regulation of menstrual cycles, minimization of blood loss and improvement in quality of life.
Treatment options include pharmacological approaches (either hormonal or non-hormonal), and surgical or radiological procedures.
Awareness, reassurance and keeping a healthy lifestyle will contribute to the treatment options for AUB.
World Menopause Day 2017

13. IMS theme Series: Perimenopausal Bleeding
Management of abnormal uterine bleeding (1)
Non-hormonal medical treatments
Non-steroidal anti-inflammatory drugs
Anti-fibrinolytic agents (ie, tranexamic acid)
Iron supplements, in case of anemia
Hormonal medical treatments
Cyclical or long-acting progestogens
Combined oral contraceptives
GnRH analogs (fibroid-associated)
Selective progesterone receptor modulators (fibroid-associated)
Levonorgestrel intrauterine system (LNG-IUS)
World Menopause Day 2017

14. IMS theme Series: Perimenopausal Bleeding
Management of abnormal uterine bleeding (2)
Endometrial ablation
Uterine artery embolization (fibroid-associated)
Hysterectomy
World Menopause Day 2017