1. Abnormal Uterine Bleeding: Not just OCPs or hysterectomy anymore
Tony Ogburn MD
Professor, Dept. of Ob/Gyn
University of New Mexico

2. Objectives Discuss the classification of abnormal uterine bleeding
Understand the evaluation of abnormal uterine bleeding in reproductive aged women
List the non surgical treatment options of abnormal uterine bleeding
Discuss the indications for surgical management for abnormal uterine bleeding

3. Disclosures
Nexplanon trainer – no disclosure
IUD devotee…

4. A lot of confusing terms!
Dysfunctional uterine bleeding
Epimenorrhagia
Epimenorrhea
Functional uterine bleeding
Hypermenorrhea
Hypomenorrhea
Menometrorrhagia
Menorrhagia (all usages: essential menorrhagia, idiopathic menorrhagia, primary menorrhagia, functional menorrhagia, ovulatory menorrhagia, anovulatory menorrhagia)
Metrorrhagia
Metropathica hemorrhagica
Oligomenorrhea
Polymenorrhagia
Polymenorrhea
Uterine hemorrhage

5. Common Terminology Descriptive Term Bleeding pattern Menorrhagia
Regular cycles, prolonged duration, excessive flow
Metrorrhagia
Irregular cycles
Menometorrhagia
Irregular, prolonged, excessive
Hypermenorrhea
Regular, normal duration, excessive flow
Polymenorrhea
Frequent cycles
Oligomenorrhea
Infrequent cycles
Amenorrhea
No cycles

6. A new classification system PALM - COEIN
Initial conference – 2005
Wide participation of stakeholders
FIGO, ACOG, FDA, Researchers, Journals
Focused on terminology, defining needs and resources
Follow-up conference – 2009
Nomenclature and classification systems
Approved by FIGO
Useful for clincians, researchers, and educators
Provides a tool for structured history, evaluation

7. Nomenclature Acute AUB Chronic AUB
“an episode of bleeding in a woman of reproductive age, who is not pregnant, that, in the opinion of the provider, is of sufficient quantity to require immediate intervention to prevent further blood loss.”
Chronic AUB
“bleeding from the uterine corpus that is abnormal in duration, volume, and/or frequency and has been present for the majority of the last 6 months.”

8. Suggested “norms”
Clinical dimensions of menstruation and menstrual cycle
Descriptive term
Normal limits (5th-95th percentiles)
Frequency of menses, d
Frequent
<24
Normal
24-38
Infrequent
>38
Regularity of menses: cycle-to-cycle variation over 12 months, d
Absent
No bleeding
Regular
Variation ± 2-20
Irregular
Variation >20
Duration of flow, d
Prolonged
>8.0
Shortened
<4.5
Volume of monthly blood loss, mL
Heavy
>80
5-80
Light
<5

9. PALM-COEIN
4 categories that are defined by visually objective structural criteria (PALM)
Polyp
Adenomyosis
Leiomyoma
Malignancy and hyperplasia
4 criteria that are unrelated to structural anomalies (COEI)
Coagulopathy
Ovulatory dysfunction
Endometrial
Iatrogenic
1 criterion that is reserved for entities that are not yet classified (N).

10. Causes of AUB Structural abnormalities (PALM)
Polyps – AUB-P
endocervical or endometrial
Detected by ultrasound or sonohysterography
Often irregular, light bleeding

11. Structural abnormalities (PALM)
Adenomyosis –AUB-A
Controversial as a cause of bleeding
Diagnosed with ultrasound, MRI, pathology

12. Structural abnormalities (PALM)
Leiomyoma – AUB-L
Submucous
Intramural
Subserosal
Diagnosed with exam, ultrasound, MRI, CT
Heavy, regular bleeding

13. Structural abnormalities (PALM)
Malignancy and hyperplasia – AUB-M
Diagnosed by biopsy
Irregular bleeding

14. Non Structural Causes - COEI
Coagulopathy
Usually suspected based on history
Von Willebrands most common
Heavy, regular bleeding
Ovulation disorders
Suspected on history
Variable cycle length
Can be confirmed with laboratory testing
Wide range of bleeding patterns – usually irregular

15. Causes of AUB Anovulatory Most common cause of AUB
Many reasons for anovulation
Unknown
PCOS
Stress, weight change, exercise
Endocrine
Thyroid, PRL
Secreting tumors

16. Non Structural Causes - COEI
Endometrial
A diagnosis of exclusion
A wastebasket…
Iatrogenic
Hormone Use
IUD, implant

17. Not Yet Classified - N
“Other entities that may or may not contribute to or cause AUB but have not been identified or have been poorly defined, inadequately examined, and/or are extremely rare”

18. Evaluation History Examination Laboratory studies Acute Chronic
Stable?
Chronic
Characterize bleeding pattern
Examination
Is it from the uterus?!
Laboratory studies
Pregnancy test
Hct/CBC
Other labs only if indicated – e.g.
TSH/PRL
Iron studies
Labs for disorders of hemostasis

19. Evaluation Other diagnostic procedures EMB Ultrasound Sonohysterogram
Consider in all patients over 45 or refractory bleeding
Pipelle vs. D&C
Ultrasound
Sonohysterogram
Hysteroscopy

20. Endometrial biopsy

21. Ultrasound - Abdominal or transvaginal
- Inexpensive and readily available in most of the world

22. Sonohysterogram Inject small amount of fluid in uterine cavity
Transvaginal ultrasound
Endometrial thickness and evaluation of intrauterine structures

23. Hysteroscopy
Expensive
Can be used for treatment

24. MRI
Very expensive
Not readily available
Rarely needed!

25. Treatment Acute or chronic? If you find something in your evaluation
Treat it!
Thyroid disease, cervical polyp, pregnancy, etc.
Structural – consider referral early on
Surgery, embolization, hormonal Rx
Often left with no obvious cause
Now what?

26. Treatment - Acute Unstable? Stable High dose hormones vs D&C Oral meds
IV estrogen – 25 mg IV q 4-6 hours
Stable
Oral meds
Monophasic OCPs – One TID for seven days, then daily for at least one cycle
Medroxyprogesterone (Provera) – 20 mg TID for seven days, then daily for at least three weeks
Tranexamic acid (Lysteda) – 1.3 mg TID for five days

27. Treatment - Chronic Considerations
Etiology and severity of bleeding (eg, anemia, interference with daily activities)
Associated symptoms (eg, pelvic pain, infertility)
Contraceptive needs or plans for future pregnancy
Contraindications to hormonal or other medications
Medical comorbidities
Patient preferences regarding medical versus surgical and short-term versus long-term therapy

28. Treatment Options Non-surgical – usually the first line of treatment
Expectant management
NSAIDs
Reduce blood loss by ~50%
Antifibrinolytic agents - Tranexemic acid (Lysteda)
Expensive
Hormonal methods
Combination methods
Regulate cycles in ~85%
Levonorgestrel IUD
Reduce blood loss by ~85%
Less effective at regulating cycles but usually not an issue
Cyclic progestin
Most appropriate for anovulatory bleeding if other methods contraindicated
GnRH agonists (leuprolide)
Expensive for long term use but good for pre-procedure preparation

29. Levonorgestrel IUD FDA approved for treatment of abnormal bleeding
More effective than OCPs, oral progestins, Depo-Provera, NSAIDs
Cost effective
Few side effects
Reduces blood loss by up to 97%
Takes 3-6 months for optimal effect

30. Combination Methods OCPs Patch/Rings
Use monophasic at least for first three months
Use of estrogen
Continuous vs. cyclic
Patch/Rings
No good trials about efficacy for this indication

31. Other?
Depo Provera
Implant

32. Surgical Treatment Two main approaches
Global endometrial ablation
Hysterectomy
Future pregnancy contraindicated/impossible

33. Global Endometrial Ablation
Outpatient procedure
Excellent safety profile
A variety of methods
Balloon – Thermachoice
Radiofrequency electricity – Novasure
Freezing – Her Option
Circulating hot water – HTA
Unclear which, if any, is best!
All have about 80% “success”
Less in younger patients…
Equal to IUD in efficacy

34. Thermachoice
Eight minute cycle
Lots of cramping during procedure

35. HTA
- 10 minute cycle
- Vaginal burns an early issue

36. Her Option
- Takes a long time…

37. Novasure
1-2 minutes
Have to dilate cervix more
We have it at CRH!!!

38. Hysterectomy Random facts… 100% effective for AUB
A significant minority of women with “conservative” management end up with a hyst eventually
Satisfaction rates are very high
Major complications do happen
Expensive

39. Questions ?

40. Maria 32 yo G2P2 with post – coital spotting for several months
History completely unremarkable

41. Cora
37 yo with longstanding history of regular, heavy menses now bleeding heavily for 16 days. Passed out at home and brought in by ambulance.

42. Erica
62 yo postmenopausal for 11 years with spotting for several months

43. Stephanie
24 yo G0 with very heavy menses and cramping increasing over one year

44. Jane 42 yo G3P3 presents with heavy, regular bleeding for 9-12 months.
Bleeds 2-3 weeks each month with large clots and cramps.

45. Sara
46 yo G2P2 with heavy, irregular menses for two years. Now increasing in frequency and flow
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