1. Abnormal Uterine Bleeding Dr Helen Barnes GPSI September 2014

2. Terminology Abnormal Uterine Bleeding: Any bleeding from the uterus that is either abnormal in volume, regularity or timing. Encompasses HMB, IMB, PCB* & PMB* Heavy Menstrual Bleeding: Excessive menstrual loss interfering with quality of life, can occur alone or with other symptoms. Intermenstrual Bleeding: Uterine bleeding that occurs between clearly defined predictable cycles. The timing of IMB can be regular (predictable) or irregular (random). PCB & PMB can be uterine in origin but they can also be caused by other genital tract pathology.

3. Terminology con’t Terms no longer preferred: Menorrhagia Dysfunctional uterine bleeding Polymenorrhoea Metrorrhagia AUB is best described according to four components: frequency, duration, volume, regularity.

4. Classification FIGO 2011: PALM- COEIN Structural vs non-structural Can have more than one pathology co-existing.

5. Risk factors for hyperplasia Age > 45yrs Obesity (BMI > 30) Anovulatory cycles (PCOS) Persistent IMB Medical treatment failure Unopposed oestrogen or tamoxifen use.

6. Assessment *Uterine evaluation: history +/- examination +/- cx smear +/- STI screen +/- bloods

7. Treatment of AUB No discrete structural or histological cause, or fibroids < 3cm 1 st line if acceptable to patient is IUS Medical Management (step 1): Tranexamic acid (decrease 30-50%) NSAIDS (decrease 20-40%) COC (decrease 40%) Oral progestogen (high dose) (decrease 60%)* IUS (decrease 70-100%) GnRH analogues (3-6m) (decrease 60-100%) Progestogen only implant or depot (decrease 30-100%) * norethisterone is metabolised to EE, 15mg a day equivalent to 30mcg COC!

8. Treatment continued Minimally invasive uterus conserving surgery (step 2): Endometrial Ablation (decrease 80%) Transcervical resection of endometrium (TCRE) (decrease 80- 100%) Major surgery (step 3): Hysterectomy (complete cure) Future consideration – EA vs hysterectomy

9. Treatment continued For AUB – L where fibroids are > 3cm with significant impact on QAL: Hysteroscopic Myomectomy (decrease 50-80%) Laparoscopic Myomectomy (0-30% decrease) Uterine artery emobolisation (60-80% decrease) Hysterectomy (100%)