·:{iC0Fp'16 ACOFP 53rd Annual Convention & Scientific Seminars

Dysfunctional Uterine Bleeding

Michele Tartaglia, DO

3/17/2016

Michele Tartaglia, DO, FACOOG, CS Assistant Professor and Residency Program Director Rowan University School of Osteopathic Medicine Department of Obstetrics & Gynecology

Objectives  1. Define normal and abnormal uterine bleeding (AUB) 2. Describe a patterns based approach to AUB 3. Understand the diagnostic modalities commonly used in the workup of AUB 4. Describe the different options for both the medical and surgical management of AUB

Financial Disclosure 

 No financial disclosures to report

1 3/17/2016

Misc. Disclosure   Entire talk based on one article with some evidence based updating and commentary from me

I’m not the only author of this talk!!!

JABFM Article  • Authors = 2 family docs and 2 gynecologists • MEDLINE search for algorithms for clinical management AUB • Also examined care of 100 random women in university gyn clinic • Then honed own clinically based algorithm • Noticed that gyns usually immediately group all AUB patients into one of 4 groups

2 3/17/2016

JABFM Article  1. Severe acute bleeding 2. Irregular bleeding 3. Menorrhagia 4. Abnormal bleeding associated with contraceptive use • Oral contraceptives • Depo-medroxyprogesterone • Intrauterine devices

Normal Uterine Bleeding   Normal interval is 21-35 days  Normal duration is 1-7 days  Gyn textbook answer – two to eight days  Normal amount is less than 1 pad or every 3 hours

3 3/17/2016

Severe Acute Bleeding 

Severe Acute Bleeding   Bleeding that requires more than one pad/tampon per hour AND/OR  Vital signs indicating hypovolemia

Severe Acute Bleeding   Common causes:  Adolescents – coagulopathy (vonWillebrand disease, leukemia)  Fibroids – especially submucosal  People on anticoagulants  Obesity – anovulatory cycles and  Trauma  Tailor your lab workup to the individual patient  Ultrasound NOT as helpful in the adolescent

4 3/17/2016

Severe Acute Bleeding 

“Cycle Provera” – consider starting high dose (10mg BID-TID) with taper then standard dose (10mg qHS x 10-21 days) next two cycles

Severe Acute Bleeding   Alternative medical therapies  Tranexamic acid  Antifibrinolytic agent  Not studied for acute AUB  IV and PO options  Foley catheter placed into  Tamponade  26F with 30mL saline – case reports proving efficacy  Desmopressin or recombinant Factor VIII in patients with vonWillebrand disease

5 3/17/2016

Severe Acute Bleeding   Surgical options  D&C  Endometrial Ablation  Uterine artery embolization  Hysterectomy

Severe Acute Bleeding Summary 

Irregular Bleeding 

6 3/17/2016

Irregular Bleeding   Includes:  Metrorrhagia   Prolonged bleeding   Any other irregular pattern

Irregular Bleeding   Not every patient needs evaluation!  Adolescent in the first 2 yr after  immaturity HPO axis  However may request intervention  Perimenopausal patient  Some shortening or lengthening of the cycle is expected  Repeated cycles outside the normal range or other AUB requires  Reproductive age woman  Some spotting just before, just after, or at can be normal  However, ANY midcycle bleeding in an older patient should be worked up

HCG, TSH,

7 3/17/2016

Endometrial Biopsy   Paper: Age >35 with irregular bleeding REQUIRE biopsy  ACOG  >45yo as first line test  <45yo if hx unopposed estrogen (PCOS, obesity), failed medical management, persistent AUB  Sensitivity of EMB in studies that use hysterectomy: 68%, used D&C: 78%  Samples an average of 4% of the  Still a good test – just consider further eval if no response to therapy in the face of a normal EMB

Transvaginal Ultrasound   Identify polyps, fibroids, very thick EMS  EMS < 5mm = VERY low likelihood of endometrial hyperplasia or carcinoma  Large meta-analysis: intrauterine abnormalities found in 46.6% of women with AUB  Try to schedule day 4-6 of cycle (EMS thin)  Proliferative phase EMS usually 4-8mm  Secretory phase EMS usually 8-14mm  Saline infusion sonohysterography even more accurate

8 3/17/2016

Systemic Causes   Chronic – treat w doxy 100mg BID x 10d  Medications – eg. TCAs, corticosteriods, antipsychotics  Systemic disease – liver or kidney failure, thyroid d/o  Hyperandrogenic syndromes  PCOS  Congenital adrenal hyperplasia  Androgen secreting tumors  Hyperprolactinemia

9 3/17/2016

Menorrhagia 

Menorrhagia   Heavy but regular, cyclic bleeding  Blood loss greater than 80mL per cycle or patient perception of very heavy bleeding  Large clots  Iron deficiency

 If the bleeding lasts > 12 days (arbitrary set by authors) follow irregular bleeding algorithm

Menorrhagia   Up to 20% of women have an underlying bleeding disorder – MUST SCREEN  YES answer to any of the following is a +screen  HMB since menarche  One of the following:  PP hemorrhage  Surgery related bleeding  Bleeding assoc w dental work  Two or more of the following:  Bruising 1-2x a month  Epistaxis 1-2x a month  Frequent gum bleeding  Family hx bleeding symptoms

10 3/17/2016

11 3/17/2016

Tranexamic Acid   Oral antifibrinolytic FDA approved for treatment of HMB of greater than 80mL per cycle  Few case reports of arterial and venous thrombosis  NO REPORTS of VTE  Contraindicated in those w hx or high risk VTE  No data on use with COCs - contraindicated  Reduces blood loss by 40-65%  TID dosing only on days of heaviest bleeding – max 5 days

12 3/17/2016

AUB from

13 3/17/2016

References  • Ely JW, Kennedy CM, Clark EC, Bowdler NC. Abnormal Uterine Bleeding: a management algorithm. J Am Board Fam Med. 2006. 19(6):590-602. • ACOG Practice Bulletin Number 557. Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women. April 2013 (Reaffirmed 2015). • ACOG Practice Bulletin Number 128. Diagnosis of Abnormal Uterine Bleeding in Reproductive Aged Women. July 2012 (Reaffirmed 2014). • ACOG Practice Bulletin Number 136. Management of Abnormal Uterine Bleeding Associated with Ovulatory Dysfunction. July 2013 (Reaffirmed 2015). • Curtis M, Overholt S, Hopkins M. Glass’ Office Gynecology. 6th Edition. Lippincott Williams & Wilkins. 2006. • Lysteda (package insert). Parsippany, NJ: Ferring Pharmaceuticals Inc.; Rev 10/2013. • Kost A, Pitney C. Tranexamic Acid (Lysteda) for Cyclic . American Family Physician. Volume 84, Number 8. October 15, 2011.

Enjoy Puerto Rico!!!!

Michele Tartaglia, DO, FACOOG, CS [email protected]

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