1. Abnormal Uterine Bleeding
Anne Whitworth, M.D.

2. Learning Objectives Identify the causes of abnormal uterine bleeding
Demonstrate a knowledge of the evaluation of abnormal uterine bleeding
Describe the treatments for the different causes of abnormal uterine bleeding

3. Abnormal Uterine Bleeding
Definition:
Bleeding outside of normal physiologic menstruation
Includes both dysfunctional uterine bleeding & structural bleeding

4. Normal Menstrual Cycle
Proliferative Phase/Follicular (8-14 d)
Predominance of estrogen over progesterone and a build up of endometrium
Secretory Phase/Luteal(14 d)
Begins after ovulation triggers progesterone production
Marked by a reaction to the combination of estrogen and progesterone and stabilization in the thickness of the endometrium

5. Normal Menstrual Cycle
Pituitary gonadotropin secretion is stimulated by the GnRH
Estradiol results in increased secretion of LH and decreased secretion of FSH
Leading to release of the egg
Corpus luteum has negative feedback on LH and FSH

6. Normal Menstrual Cycle

7. Normal Menstrual Cycle
Interval
28 days +/- 7 days
Duration
4-6 days (3-5 pads/tampons per day)
Blood loss
25-69 ml (average 35 to 40 ml)
no clots, no mid cycle bleeding

8. Normal Menstrual Cycle
The average female will have around 400 menstrual cycles in her life
Up to 20% of women will present to the office with the complaint of excessive blood loss

9. Definitions of Abnormal Uterine Bleeding
Menorrhagia
Prolonged or excessive uterine bleeding at regular intervals
Metrorrhagia
Uterine bleeding at irregular but frequent intervals, amount is variable
Menometrorrhagia
Prolonged uterine bleeding at irregular intervals

10. Definitions of Abnormal Uterine Bleeding
Intermenstrual bleeding
Bleeding of variable amounts between regular menstrual periods
Polymenorrhea
Uterine bleeding at regular intervals of less than 21d
Oligomenorrhea
Uterine bleeding in which the interval between bleeding episodes may vary from 35 days to 6 months
Amenorrhea
No uterine bleeding for at least 6 months

11. Causes of Abnormal Uterine Bleeding
Disruption of regularity, frequency, volume and duration of menstrual flow
The cause can be physiologic, pathologic or pharmocologic

12. Causes of Abnormal Uterine Bleeding Differential
Complications of Pregnancy
Pelvic Pathology
Systemic
Ovulatory vs. anovulatory
Iatrogenic (pharmacologic)

13. Causes of Abnormal Uterine Bleeding Differential
1. Complications of Pregnancy
Ectopic pregnacy
Miscarriage
Placenta previa
Gestational trophoblastic disease

14. Causes of Abnormal Uterine Bleeding Differential
2. Pelvic Pathology
Benign
Pregnancy, myoma, adenomyosis, endometriosis,endometrial/cervical polyp, PID, infection,trauma, vascular abnormality, foreign body
Malignant
Carcinoma of the reproductive tract
Endometrial hyperplasia (pre- malignant changes)

15. Uterine Fibroids

16. Causes of Abnormal Uterine Bleeding Differential
3. Systemic
Ovulatory
Coagulation disorder
Thrombocytopathy, von Willibrand’s disease, Leukemia
Systemic Lupus erythematosus
Cirrhosis
Anovulatory
Hypothyroid, hyperprolactenemia, PCOD, hypothalamic dysfunction

17. Causes of Abnormal Uterine Bleeding
4. Iatrogenic
Hormone therapy
Contraceptive devices and injections
Medications
Antidepressants, anticoagulants, steroids

18. Causes of Abnormal Uterine Bleeding
If no etiology in above categories then by exclusion the diagnosis is dysfunctional uterine bleeding--it applies not only to menorrhagia but also menometrorrhagia

19. Causes of Abnormal Uterine Bleeding
Dysfunctional Uterine Bleeding
Causes 80% of menorrhagia
Bleeding is UTERINE and mechanism is HORMONAL

20. Causes of DUB
DUB is usually related to one of four hormonal-imbalance conditions
Estrogen breakthrough bleeding
Estrogen withdrawl bleeding
Progesterone breakthrough bleeding
Progesterone withdrawl bleeding

21. Causes of DUB Estrogen breakthrough bleeding:
This occurs when excess estrogen stimulates the endometrium to proliferate in an undifferentiated manner--if there is insufficient progesterone to provide structural support the endometrium will slough at irregular intervals

22. Causes of DUB Estrogen withdrawl bleeding:
This results from a sudden decrease in estrogen levels, such as occurs after bilateral oophorectomy, cessation of exogenous estrogen therapy or just before ovulation in the normal menstrual cycle

23. Causes of DUB Progesterone breakthrough bleeding:
This occurs when the progesterone:estrogen ratio is high. (progesterone only contraception)
The endometrium becomes atrophic and is prone to frequent, irregular bleeding.

24. Causes of DUB Progesterone Withdrawl Bleeding:
This occurs only if the endometrium is initially proliferated by exogenous or endogenous estrogen

25. Evaluation of Abnormal Uterine Bleeding
Obtain a History
Menstrual history
Recent cycle length and duration, blood flow, and pattern
Color and character of flow (pain, discharge, odor)
Estimate of amount of blood loss
Use of contraception
Medical history
Thyroid disorder
Current medications

26. Evaluation of Abnormal Uterine Bleeding
Physical Exam
Height, weight, vital signs
Body fat distribution
Tanner staging
Pelvic examination
External-bruising, laceration, discharge, cervix
Bimanual exam- uterine size, adnexal mass or pain

27. Evaluation of Abnormal Uterine Bleeding
Laboratory assessment
Rule out pregnancy!
CBC, PAP, cultures
Maybe TSH, Prolactin level
Maybe coagulation studies

28. Evaluation of Abnormal Uterine Bleeding
Further evaluation is based on menopausal status
Premenopausal--look for cause of anovulatory bleeding
Peri and postmenopausal--need to evaluate for endometrial hyperplasia or cancer

29. Evaluation of Abnormal Uterine Bleeding
Tests to rule out endometrial hyperplasia or carcinoma
Endometrial Biopsy
Ultrasound
Hysteroscopy

30. Evaluation- Endometrial Biopsy

31. Treatment
Goal of treatment is to control bleeding, prevent recurrence, and preserve fertility (if desired)

32. Treatment Acute, heavy bleeding
Hemodynamically unstable: High dose IV estrogen, or D& C
Hemodynamically stable: oral estrogen

33. Treatment Chronic abnormal bleeding—medical Rx observation NSAIDS
Oral contraceptives
Progesterones
Hormone replacement
Inhibit GnRH stimulation
Danazol

34. Treatment-Medical NSAIDs 20-30% GI upset OCPs 50% Progestins 15% Same
Drug/
Class
Efficacy
Side effects
Mechanism/other
NSAIDs
20-30%
GI upset
Decrease cyclooxygenase and increase thromboxane to prostaglandin
OCPs
50%
H/A, nausea, edema, wt gain, mood changes,
50 micrograms ethinyl estradiol
Progestins
15%
Same
Days 15-26, blood loss reduction 88% with IUD by month 3

35. Treatment –Merina IUD

36. Treatment- Medical Danazol 60% Androgenic, endometrial atrophy
Drug/class
Efficacy
Side effects
Mechanism/other
Danazol
60%
Androgenic, endometrial atrophy
Alters pulsitile gonadotropin release, higher doses inhibits ovulation
GnRH Agonists
100%
Hypoestrogenic/ bone loss
deplete further pituitary of bioactive goanadotropins and desensitize it to further GnRh stimulation
Antifibrin-olytic agents
80%
H/A, Gi upset, vertigo, possible increased thrombotic activity
Decrease blood loss by 84% by preventing the activation of plasminogen