1. ABNORMAL UTERINE BLEEDING IN REPRODUCTIVE AGED WOMEN August 2015 Hoa Nguyen Jodi Nagelberg John Joseph Kimberly Truong Rola Khedraki Sangeeta Kalsi

2. Definitions  Menorrhagia: heavy menstrual bleeding (>80 mL)  Metrorrhagia: bleeding between periods  Polymenorrhea: bleeding that occurs more often than every 21 days  Oligomenorrhea: bleeding that occurs less frequently than every 35 days

3. Classification: PALM-COEIN 1 International Federation of Gynecology and Obstetrics, 2011

4. Diagnosis: H&P  History  Menstrual bleeding hx (incl. severity and assoc pain)  FHx: AUB/ bleeding disorders  Meds: warfarin, heparin, NSAID, OCP, ginkgo, ginseng, motherwort  Physical  PCOS: obesity, hirsutism, acne  Thyroid dysfunction: cold/heat intolerance, dry skin, lethargy, proptosis  DM: acanthosis nigricans  Bleeding disorder: petechiae, pallor, signs of hypovolemia  Pelvic exam

5. Diagnosis: Labs and Imaging  Labs  Pregnancy test  CBC  Targeted screening for bleeding disorder (when indicated)  TSH  Gonorrhea/Chlamydia in high risk patients  Imaging:  TVUS  Sonohysterography  Hysteroscopy  MRI  Endometrial biopsy

6. Common Differential by Age 13-1819-3940-Menopause Anovulation OCP Pelvic infection Coagulopathy Tumor Pregnancy Structural Lesions (leiomyoma, polyp) Anovulatory cycles (PCOS) OCP Endometrial hyperplasia Endometrial cancer (less common) Anovulatory bleeding Endometrial hyperplasia/ carcinoma Endometrial atrophy Leiomyoma

7. Uterine Evaluation 1

8. Management  Medical management should be initial treatment for most patients  Need for surgery is based on various factors (stability of patient, severity of bleed, contraindications to med management, underlying cause)  Type of surgery dependent on above + desire for future fertility  Long term maintenance therapy after acute bleed is controlled

9. Management Continued  Determine acute vs. chronic  If acute, signs of hypovolemia/hemodynamic instability?  If yes, IV access with 1 to 2 large bore IV; prepare for transfusion and clotting factor replacement  Once stable, evaluate etiology (PALM-COEIN)  Determine Treatment

10. Medical Management  Conjugated Equine Estrogen  Combined OCPs  Medroxyprogesterone Acetate  Tranexamic Acid  Long term therapy: levonorgesterel IUD, OCPs, progestin (PO or IM); unopposed estrogen should not be used long term  Treatments differ for pts with bleeding disorders  Ex: desmopressin can help in vWF disease, etc  Avoid NSAIDs

11. Surgical Management Options  D&C  Endometrial Ablation  Uterine Artery Embolization  Hysterectomy

12. References 1. Practice bulletin no. 128: diagnosis of abnormal uterine bleeding in reproductive-aged women. Obstet Gynecol. 2012 Jul;120(1):197-206. doi: 10.1097/AOG.0b013e318262e320. 2. Committee Opinion no 557: management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Obstet Gynecol. 2013 Apr;121(4):891-6. doi: 10.1097/01.AOG.0000428646.67925.9a.

13. MKSAP Questions 1) A 35 year old female is evaluated for a 5 month history of heavy menstrual bleeding. She has been menstruating for the last 8 days and is still going through 10 pads or more daily with frequent clots. She has fatigue but no dizziness. She and her husband would like to conceive a 2 nd child next year. She does not smoke. Vitals: Afebrile, BP 138/71, HR 80. Neg orthostasis. Pelvic exam: moderate amount of blood in vaginal vault. Pelvic u/s shows a large submucosal fibroid. Hb 10.5. You consult ob/gyn for a myomectomy, scheduled in 2 weeks. Which of the following is the most appropriate next step in management? A. Levonorgestrel IUD (Mirena) B. IV estrogen C. Estrogen-progesterin oral contraceptive D. Re-evaluate in 2 weeks

14. Question 1: Answer  Correct Answer: C) Estrogen-progestin OCP  Estrogen-progestin OCP and IUD are effective treatments for heavy menstrual bleeding. Estrogen/progestin OCP is the better choice as pt is planning to conceive in the near future. Pt also does not have any contraindications to estrogen.  IV Estrogen (B) would be appropriate if pt was orthostatic or dizzy from blood loss. PE and DVT are complications of IV estrogen.  Monitoring (D) is not appropriate given her significant, ongoing blood loss.

15. 49 year old women presents to your primary care clinic with a 3 day history of heavy menstrual bleeding. She denies dysmenorrhea but reports that her menstruation cycle have been increasingly irregular over the past couple years. She is not sexually active and had a bilateral tubal ligation 10 years ago. Her physical exam demonstrated normal vital signs, no signs of hypovolemia, no bruises. Pelvic exam was unremarkable for tenderness, nodularities, or abnormal size uterus. Cervix was normal with blood in the os. Pregnancy test is negative and pap smear was performed. Which of the following is the most appropriate next step in management of this patient? A.Endometrial biopsy B.Measure serum LH and FSH C.Pelvic U/S D.Oral contraceptives Question 2

16. Question 2: Answer A. Endometrial biopsy—Need rule out endometrial cancer in patients older than 35 with AUB B. Measuring LH and FSH can confirm menopause, but does not rule out endometrial cancer. C. Pelvic ultrasound– good with uncertain findings on pelvic exams D. Oral contraceptives are appropriate for patients with anovulatory bleedings. But endometrial carcinoma needs to be ruled out first

17. 26 year old female presents with 4 days of history of light vaginal bleeding after intercourse. Prior to this incident, she reports regular menstruation cycle and no vaginal discharge. She is in a monogamous relationship with her husband. Her physical exam was unremarkable. Her pelvic exam was unremarkable except small amount of blood in the cervical os. What is the next best step in management? A. Perform endometrial biopsy B. Start oral contraceptive C. Perform pelvic ultrasound D. Check HCG levels Question 3

18. Question 3: Answer A. Endometrial biopsy is important to rule of endometrial cancer. In this younger patient, need to rule out more common causes initially B. Oral contraceptives are appropriate in anovulatory women. However, need to rule out endocrine and pregnancy first C. Pelvic ultrasound important for the identification of anatomical abnormalities or staging of pregnancy. However, pelvic exam was unremarkable and screening of pregnancy with serum markers has not been performed yet D. Serum HCG– Pregnancy is a common cause of abnormal uterine bleeding and needs to be ruled out in all women who have not gone through menopause

19. Question 4 A 44 year old woman presents to your office with a complaint of intermenstrual bleeding. Her last menstrual period ended 10 days ago, however for the past 3 days she noticed bleeding requiring 3-4 pads/daily. She reports that prior to this her periods were regular, lasting 5 days with occasional light intermenstrual bleeding over the last 6 months. She is sexually active only with her husband and uses barrier contraception. On physical exam she was afebrile, BP 134/86, HR 74, negative orthostasis. Pelvic exam demonstrated slightly enlarged, globular uterus, with blood noted in cervical os. Pregnancy test is negative. Which of the following is the most appropriate next step in the evaluation of this patient? A. Magnetic resonance imaging B. Transvaginal ultrasound C. Hysteroscopy D. Reassurance and monitoring

20. Question 4: Answer A. MRI is not the primary imaging modality to evaluate AUB, however may be used as a follow-up test after ultrasonography B. Transvaginal ultrasound is important in this patient with AUB and exam findings suggestive of structural abnormality C. Hysteroscopy/SIS should be done in patients with concerning uterine cavity findings on TVUS D. Monitoring would not be appropriate in the setting of abnormal bleeding and concerning physical exam findings

21. Question 5 A 29 year old woman presents to your office with a complaint of heavy menstrual bleeding. She has been menstruating for the last week with persistent heavy bleeding and passage of clots. She denies being sexually active. She is a current smoker (1-2 pack/day) and her only medications are metformin and lisinopril. On physical exam she was afebrile, BP 154/102, HR 62, negative orthostasis. BMI 31. Pelvic exam demonstrated moderate amount of blood in vault. Pregnancy test negative. Endometrial biopsy was performed and results are negative for malignant or hyperplastic disease. Which of the following is the most appropriate next step in the management of this patient? A. Estrogen-progestin oral contraceptive B. Endometrial ablation C. Levonorgestrel (Mirena) IUD D. Hysterectomy

22. Question 5: Answer A. Estrogen-progestin OCPs are effective in the treatment of heavy menstrual bleeding, however this patient has several risk factors for thrombosis B. Endometrial ablation is a minimally invasive option in patients in which medical therapy has failed. Medical therapy should be initiated, also it is unknown whether the patient wants to maintain fertility C. Levonorgestrel IUDs are effective in the treatment of heavy menstrual bleeding and would be an appropriate choice in this patient with contraindications to estrogen use D. Hysterectomy is curative in the treatment of uterine bleeding, however medical therapy and less invasive treatments are preferred initially