2. Abnormal Uterine Bleeding
District 1 ACOG Medical Student Education Module 2011

3. What is normal uterine bleeding?
Age of patient
Frequency
Duration
Flow

4. What is normal uterine bleeding?
Frequency of menses
21 days (0.5%) to 35 days (0.9%)
Age 25, 40% are between 25 and 28 days
Age 25-35, 60% are between 25 and 28 days
Teens and women over 40’s cycles may be longer apart
Munster K et al, Br J Obstet Gynaecology

5. What is normal uterine bleeding?
Duration of menses
2 days to 8 days
Usually 4-6 days
Hallberg L et al, Acta Obstet Gynecology Scandinavica

6. What is normal uterine bleeding?
Flow/amount of menses
Normal volume of menstrual blood loss is 30 cc
Hallberg L et al, Acta Obstet Gynecology Scandinavica

7. Traditional terminologies
Menorrhagia
Regular intervals, excessive menstrual blood loss
amount >80mL
Metrorrhagia
Irregular intervals, excessive flow and duration
Oligomenorrhea
Interval longer than 35 days
Polymenorrhea
Interval less than 21 days
Cohen BJB et al, Obstetrical and Gynecologic Survey

8. Differential diagnosis
Pregnancy related complications
ectopic, inevitable

9. Differential diagnosis
Disease of the cervix
Polyp, ectropian, dysplasia, invasive cancer

10. Differential diagnosis
Disease of the uterus
Infection: endometritis
Endometrial polyp, adenomyosis, hyperplasia, adenocarcinoma
Fibroids
One third of patients with symptoms
Correlation between the severity of the bleeding and the area of endometrial surface
Sehgal N, et al American Journal of Surgery
Histologic abnormalities of the endometrium, ranging from atrophy to hyperplasia
Deligdish, et al Journal of Clinical Pathology
Endometrial venule ectasia
Faulkner RL American J of Obstetrics and Gynecology; Farrer-Brown G, et al Journal of Obstetrics and Gynaecology Br Common W

11. Differential diagnosis
Disease of the ovary
Germ cell tumors
Choriocarcinomas
Embryonal carcinoma
Sex cord-stromal tumors
Granulosa cell tumors(1-2% of all ovarian tumors)
Peak incidence between 50 and 55 years of age

12. Differential diagnosis
Thyroid disease
Prolactinomas
Coagulation defects
Renal, liver failure

13. Differential diagnosis
Trauma
Foreign bodies

14. Differential diagnosis
Dysfunctional uterine bleeding
Anovulatory cycles
Loss of normal regulatory mechanism
Immaturity
Dysfunction
Psychiatric medications, stress, anxiety, exercise, rapid weight loss, anorexia nervosa
Ovarian failure
Obesity
PCOS

15. Evaluation History and physical Labs Pregnancy test CBC TSH Prolactin
(Liver function tests)
(Coagulation panels)
(Androgen profile)
Testosterone, DHEAS, Hydroxyprogesterone

16. Evaluation (cont) Cytopathology Imaging studies Surgical Pap
Endometrial biopsy
Imaging studies
Surgical
D&C hysteroscopy

17. Treatments Medical therapy Surgical therapy Radiologic therapy
Hormonal
Progestin, estrogen (IV), combination OCPs
GnRH agonist
Surgical therapy
D&C
Endometrial ablation
Myomectomy/hysterectomy
Radiologic therapy
Uterine artery embolization (UAE)

18. Anovulatory Bleeding: Adolescents (13-18 years)
Anovulatory bleeding may be normal physiologic process, with ovulatory cycles not established until 1-2 yrs after menarche (immature HPG axis)
Screen for coagulation disorders (PT/PTT, plts)
May be caused by leukemia, ITP, hypersplenism
Consider endometrial bx in adolescents with 2-3 year history of untreated anovulatory bleeding, especially if obese

19. Anovulatory Bleeding: Management in Adolescents
High dose estrogen therapy for acute bleeding episodes (promotes rapid endometrial growth to cover denuded endometrial surfaces): conjugated equine estrogens PO up to 10 mg/d in 4 divided doses or IV 25 mg q 4 hrs for 24 hrs
Treat pts with blood dyscrasias for their specific diseases, r/o leukemia
Prevent recurrent anovulatory bleeding with:
cyclic progestin (i.e. Provera) or
low dose (≤ 35 μg ethinyl estradiol) oral contraceptive
suppresses ovarian and adrenal androgen production and increases SHBG  decreasing bioavailable androgens

20. Anovulatory Bleeding: Reproductive Age (19-39 years)
Anovulatory bleeding not considered physiologic, evaluation required
6-10% of women have hyperandrogenic chronic anovulation (i.e. PCOS), characterized by noncyclic bleeding, hirsutism, obesity (BMI ≥ 25)
Underlying biochemical abnormalities: noncyclic estrogen production, elevated serum testosterone, hypersecretion of LH, hyperinsulinemia.
h/o rapidly progressing hirsutism with virilization suggests tumor
Lab testing: HCG, TSH, fasting serum prolactin
If androgen-producing tumor is suspected, serum DHEAS and testosterone levels
If POF suspected, serum FSH
Chronic anovulation resulting from hypothalamic dysfunction (dx’d by low FSH level) may be due to excessive psychologic stress, exercise, or weight loss

21. Anovulatory Bleeding: Reproductive Age (19-39 yrs)
When is endometrial evaluation indicated?
Sharp increase in incidence of endometrial CA from 2.3/100,000 ages yrs  6.1/100,000 ages yrs
Therefore, endometrial bx to exclude CA is indicated in any woman > 35 yrs old with suspected anovulatory bleeding
Pts who don’t respond to medical therapy or have prolonged periods of unopposed estrogen 2/2 anovulation merit endometrial bx

22. Anovulatory Bleeding: Reproductive Age (19-39 yrs)
Medical therapies
Can be treated safely with either cyclic progestin or OCPs, similar to adolescents.
Estrogen-containing OCPs
relatively contraindicated in women with HTN or DM
contraindicated for women > 35 who smoke or have h/o thromboembolic dz
If pregnancy is desired, ovulation induction with clomid is initial tx of choice
Can induce withdrawal bleed with progestin (i.e. provera), followed by initiation of therapy with Clomid, 50 mg/d for 5 days, starting b/t days 3 and 5 of menstrual cycle

23. Anovulatory Bleeding: Later Reproductive Age (40-Menopause)
Incidence of anovulatory bleeding increases toward end of reproductive years
In perimenopausal women, onset of anovulatory cycles is due to declining ovarian function.
Can initiate hormone therapy for cycle control
When is endometrial evaluation indicated?
Incidence of endometrial CA in women years: 36.2/100,000
All women > 40 yrs who present with suspected anovulatory bleeding merit endometrial bx after excluding pregnancy

24. Anovulatory Bleeding: Later Reproductive Age (40-Menopause)
Medical therapy
Cyclic progestin, low-dose OCPs, or cyclic HRT are all options
Women with hot flashes secondary to decreased estrogen production can have symptomatic relief with ERT in combination with continuous or cyclic progestin

25. Anovulatory Bleeding: Later Reproductive Age (40-Menopause)
Surgical therapy
Surgical options include: hysterectomy and endometrial ablation
Surgical tx only indicated when medical mgmt has failed and childbearing complete
Some studies suggest hysterectomy may have higher long-term satisfaction than ablation
Endometrial ablation: NovaSure, thermal balloon
YAG laser and rollerball less widely-used currently
45% of women achieve amenorrhea after YAG laser or resectoscope. 12 month post-op satisfaction is 90%. Only 15% of women achieve amenorrhea after thermal balloon ablation, and 1 yr satisfaction rate still 90%
Long-term satisfaction with ablation may be lower:
in 3-year f/u study, 8.5% of women who had undergone ablation were re-ablated, an additional 8.5% had hyst
In a 5-year follow up study, 34% of women who underwent ablation later had a hyst.