1. VAGINAL BLEEDING
Dr. Paul Chang
March 31, 2015

2. OUTLINE Normal menstrual cycle Definitions Approach Pre-Menopausal AUB
Post-Menopausal AUB
Early Pregnancy Related bleeding (First trimester)

3. Differentials that I will not cover
Trauma
Bowel
Neonatal, Pediatric causes
Antepartum causes

4. Abnormal Uterine Bleeding
In the absence of pregnancy…
Affects 11-13% of reproductive age women(up to 30% according to SOGC)
24% in women aged 36-40
Women generally present for care because the amount, timing, or other characteristics of the bleeding have changed from their individual norm

5. Regulation of Menstrual Bleeding
In the endometrial lining, rising levels of estradiol produced by the follicles stimulate proliferative growth of epithelial and stromal elements. The endometrium thickens and becomes rich in progesterone receptors.
Once the LH surges, the ovum is released, and the follicle collapses to become the corpus luteum. The corpus luteum lasts for approximately 10 days and produces large amounts of progesterone.
Under the progestagenic influence, the endometrium enters the secretory phase. Endometrial growth stops, and the stroma becomes more compact and stable.

6. Regulation of Menstrual Bleeding
If the egg is not fertilized, the corpus luteum degenerates and no longer produces progesterone, the estrogen level decreases, the top layers of the lining break down and are shed, and menstrual bleeding occurs

7. Normal Dimensions of Menses
Frequency of menses
Every days
Regularity of menses from cycle-to-cycle
+/- 2 to 20 days
Heaviness of flow
5-80mL per month (avg 35mL)
Duration of flow
4-8 days

8. Definitions
Menorrhagia: menstrual periods with abnormally heavy or prolonged bleeding (>80mL per month)
Oligomenorrhea: cycle length > 35 days
Polymenorrhea: cyclic length > 24 days
Metrorrhagia: irregular intervals with normal or reduced volume and duration of flow
Menometrorrhagia: irregular intervals with excessive volume and duration of flow
Postmenopausal bleeding: bleeding that occurs more than 12 months after the last menstrual cycle

9. FIGO Menstrual Disorders Working Group 2012
Suggested new nomenclature for Abnormal Uterine Bleeding (AUB)
Goal: Simplify
Eliminate terminology such as menorrhagia, metrorrhaiga, and dysfunction uterine bleeding
Terminology for AUB
Volume
Regularity
Frequency
Duration
Other
International Federation of Gynecology and Obstetrics

13. PALM side refers to structural causes that could be evaluated and diagnosed on imaging and/or biopsy. The COEIN side allows consideration of underlying medical disturbances

14. Menstrual History Age of menarche Volume Regularity Frequency Duration
Associated symptoms: Pain, Mittelschmerz, premenstrual symptoms

15. Bleeding History Timing in relationship to menses Other Locations:
Onset
Quantity
Pictorial blood assessment chart
Severity
How many pads?
Runs down legs?
Interfering with school, work?
Symptomatic
Black outs
SOB
Palpitations
Timing in relationship to menses
Other Locations:
Teeth
Bruising
Hemorrhage/transfusion hx
Associated symptoms:
vaginal discharge or odour
pelvic pain or pressure

17. Approach

18. History Menstrual History Bleeding History OB History Family History
Inherited coagulation disorders
PCOS
Endometrial or colon cancers
Meds including herbs
Anticoagulants
Antidepressants (SSRIs and tricyclics)
Hormonal contraceptives
Tamoxifen
Antipsychotics (first generation and risperidone)
Corticosteroids
Herbs: gensing, chasteberry, danshen

19. Physical Exam Vitals, weight, BMI Signs of anemia
Conjunctivae Hb 95
Hand Crease Hb 75
Ocular Bruits Hb 55
Signs of bleeding disorder
Petechiae, Ecchymoses, swollen joints
Thyroid exam
Gyn exam (bimanual and speculum)

20. Investigations CBC bHCG Ferritin INR, PTT TSH Blood group and type
vWF screen when indicated (factor VIII, vWF antigen, vWF functional assay)
Pap smear and cervical cultures when indicated
Pelvic ultrasound/ saline infusion ultrasound
Endometrial biopsy
D&C
Hysteroscopy

21. Saline Infusion Ultrasound
Sonohysterogram
Hysterosonogram

22. Saline Infusion Ultrasound

23. Acute Management ABCs Vitals Estimate stage of shock
IV, foley, pulse oximeter, O2
Bolus 1-2L of RL or NS
Ultrasound
Group and type & bHCG
Call for help
If pregnant, remember to assess the gestation (FHR), Rhogam if appropriate

24. DDx By Age 13-18 Hypothalamic-Pituitary-Ovarian access immature
Hormonal contraceptives
Pregnancy
Pelvic infection
Coagulopathies

25. DDx By Age 19-39 Pregnancy Polyp Leiomyoma Anovulation (PCOS)
Hormonal contraceptives
Endometrial hyperplasia/cancer

26. DDx By Age 40 and over Anovulatory bleeding Endometrial Hyperplasia
Endometrial Cancer
Vaginal atrophy
Use of anti-coagulants
Rarely leiomyoma

27. Medical Therapies NSAIDs Antifibrinolytics (Tranexamic Acid)
Combined Hormonal Contraceptives
Cyclical progestins for anovulatory bleeding
Continous high dose progestins
Depo medroxyprogesterone acetate
Levonorgestrel IUD
GnRHa

28. High Yield Diagnosis & Its Management

29. Endometrial Polyps
Overgrowth of cells in the lining of the uterus (endometrium) leads to the formation of uterine polyps, also known as endometrial polyps
Menstrual characteristic:
Intermenstrual spotting
Hysteroscopic resection

30. Adenomyosis Hormonal contraceptives NSAIDs Dienogest (Visanne©)
Endometrial tissue, which normally lines the uterus, exists within and grows into the muscular wall of the uterus
Often asymptomatic
Menstrual characteristic:
Heavy, prolonged periods
Dysmenorrhea
Dyspareunia
Inter-menstrual bleeding
O/E: Enlarged uterus
Hormonal contraceptives
NSAIDs
Dienogest (Visanne©)
Mirena©
GnRHa
Hysterectomy

31. Adenomyosis

32. Fibroids Monoclonal non-cancerous growth of the myometrium
As many as 3 out of 4 women have uterine fibroids sometime during their lives
Often asymptomatic
Menstrual characteristic:
Heavy prolonged periods
U/S: bulky uterus
Hormonal contraceptives (*personally do not recommend)
NSAIDs
Tranexamic acid
SPRMs (Fibristil©)
Mirena©
GnRHa
Myomectomy
Uterine artery embolization
mrHIFU
Hysterectomy

33. Fibroids

34. Fibristil© Ulipristal acetate
Selective Progesterone Receptor Modulator

35. Von Willebrand Disease
Most cases are autosomal dominant inherited disorders. Most severe form is autosomal recessive. May be acquired
Most common inherited bleeding disorder
The prevalence of vWD is about 1 in 100 individuals. However the majority of these people do not have symptoms. The prevalence of clinically significant cases is 1 per 10,000
Menstrual characteristic:
Heavy volume is more prevalent (57-93% vs. 10% in normal controls)
Special tests: vWF screen (factor VIII, vWF antigen, cWF functional assay)
Medical Management:
OCP
Depo-Provera
Mirena
GnRHa
Tranexamic Acid
DDAVP*
Replacement therapy (Humate-P, platelets, cryoppte, FFP)
Surgical Management: Endometrial Ablation
Contraindications: NSAIDs

36. Anovulatory Most common: PCOS Hypothalamic hypogonadism
Premature ovarian failure
Menstrual characteristic:
Irregular with variable frequency and duration
Hormonal contraceptives
Cyclical progestins

37. Iatrogenic: Breakthrough Bleeding
Non-menstrual bleeding while on hormonal contraceptives
The low dose of oestrogen in modern contraceptive pills is insufficient to maintain endometrial integrity and the opposing effect of progestogen promotes atrophy of glands and stroma. The resulting endometrium is thin, fragile and prone to bleeding
Menstrual characteristic:
Light and intermenstrual
Reassurance: continue CHC for up to 3 months
Change to a more estrogenic CHC
Consider vaginal ring
Refer to Dr. Nayot’s talk

38. Endometrial NSAIDs Hormonal contraceptives Progestins Mirena©
AUB can occur in women with normal ovulatory function, and without coagulopathies because of abnormalities that reside in the endometrium:
Abnormal prostaglandin synthesis
Prostaglandin receptor upregulation
Increased fibrinolytic activity
Increased tissue plasminogen activity
NSAIDs
Hormonal contraceptives
Progestins
Mirena©
Tranexamic acid
SPRMs (Fibristil©)
GnRHa
Endometrial ablation
Hysterectomy

39. Early Pregnancy
Remember to give Rhogam if mom is Rh-ve (unless certain that of paternity and that he is also Rh-ve)
<12 wk GA, 120mcg IM
12 wks and higher, 300mcg IM
DO NOT FORGET: Follow bHCG to zero if non-viable

40. Abortion
Expectant
Misoprostol
D&C

41. Ectopic
Send to hospital
MTX
Laparoscopic surgery

42. Molar Pregnancy Suction D&C Oxytocin during curettage MTX
In a complete molar pregnancy, all of the fertilized egg's chromosomes come from the father. Shortly after fertilization, the chromosomes from the mother's egg are lost or inactivated and the father's chromosomes are duplicated. The egg may have had an inactive nucleus or no nucleus.
In a partial or incomplete molar pregnancy, the mother's chromosomes remain but the father provides two sets of chromosomes. As a result, the embryo has 69 chromosomes instead of 46. This can happen when the father's chromosomes are duplicated or if two sperm fertilize a single egg.

43. Endometrial Hyperplasia
Risk factors:
Nulliparity
Late menopause
Obesity
Smoking
Anovulation (PCOS)
Unopposed estrogen
Tamoxifen
Endometrial biopsy or D&C
Pelvic ultrasound (≤4mm is low risk)
Hysteroscopy

44. Endometrial Hyperplasia
WHO
Progression to Cancer
Simple Hyperplasia 1%
Complex Hyperplasia 3%
Atypical Simplex Hyperplasia 8%
Atypical Complex Hyperplasia
29%
Medical Management
Progesterone therapy
Provera 10mg 14 days per month (x 3 months)
Megace
Mirena
Clomid (SERM)
Surgical Management: Hysterectomy

45. Endometrial cancer Most common gynecologic cancer in North America
Avg age for endometrial ca is 61
5-30% of cases occur in premenopause
HPNCC have a lifetime risk for endometrial ca of 40-60%
Refer to Gynecologic Oncologist

46. Summary Rule out pregnancy PALM COEIN (I = iatrogenic and infectious)
History (menstrual, bleeding)
Physical
Investigations
Acute management
On-going therapies
Refer if appropriate
Read the question. Breathe. You can do it!

47. Thank You