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High Yield OBGYN: How to Get the Correct Diagnosis with the Fewest Steps High Yield OBGYN: How to get the correct diagnosis with the fewest steps Courtney B Martin DO, FACOG Assistant Professor, Department of Gynecology and Obstetrics, Loma Linda University School of Medicine Division Chief, General Obgyn Medical Director Maternity Services, LLUCH Director of Quality, LLUCH 1 High Yield OBGYN Topics: Abnormal Uterine Bleeding Vaginal Discharge COVID-19 and Pregnancy 2 Faculty Disclosure It is the policy of the ACOFP Program Committee OMED organizers that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. All faculty in a position to control content for this session have indicated they have no relevant financial relationships to disclose. The content of this material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices. 3 Abnormal Uterine Bleeding (AUB) . Discuss the differential diagnosis of abnormal uterine bleeding by new FIGO criteria . Discuss the proper and evidence based evaluation of abnormal uterine bleeding . Discuss the different pathology of abnormal uterine bleeding . Understand the methodology of treatment for abnormal uterine bleeding 4 Everyone’s Favorite Cycle Endometrial Response to Ovarian Steroids 14 350 Menses Proliferative Secretory 12 Progesterone 300 Estradiol 10 250 8 200 6 150 Endometrial Thickness Estradiol (pg/ml) 4 100 Implantation 2 50 Endometrium (mm) Progesterone (ng/ml) Progesterone (mm) Endometrium 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Cycle Day 5 FIGO PALM-COEIN Classification of Abnormal Uterine Bleeding Abnormal uterine bleeding: • Heavy menstrual bleeding (AUB/HMB) • Intermenstrual bleeding (AUB/IMB) PALM—structural causes: COEIN—nonstructural causes: Polyp (AUB-P) Coagulopathy (AUB-C) Adenomyosis (AUB-A) Ovulatory dysfunction (AUB-O) Leiomyoma (AUB/L) Endometrial (AUB/E) Submucosal leiomyoma (AUB-LSM) Iatrogenic (AUB-I) Other leiomyoma (AUB-LO) Not yet classified (AUB-N) Malignancy and hyperplasia (AUB-M) Estrogen Terminology Estrogen withdrawal bleeding • Estrogen above a threshold level (50-100 pg/ml) and time (1-2 weeks) stimulates the endometrium to proliferate-- bleeding occurs when the estrogen is withdrawn Estrogen breakthrough bleeding • Estrogen above a threshold level 50-100 pg/ml) and time (3 weeks) stimulates the endometrium to proliferate--bleeding occurs when the endometrium cannot continue proliferating and begins to break down irregularly 7 AUB Diagnosis The most efficient management of abnormal bleeding is to arrive at the correct diagnosis with the fewest number of false moves, and to institute the most cost-effective therapy 8 Normal Endometrial Response • Estrogen Proliferation (growth) • Progesterone No effect • P after or with continuing E Arrests growth Causes maturation Secretory changes (glands) Decidual changes (stroma) • General concept Estrogen = “gas”, Progesterone = “brake” 9 How do you know if bleeding is abnormal?? We take the menstrual history and compare our patient’s menstrual story with the definition of normal menses. 10 What is normal menses???? • Interval 21-35 days • Duration 2-8 days • No intermenstrual bleeding • No excessive bleeding Pad or tampon “accidents” Clots Anemia Patient’s perception 11 12 Anovulation=No Progesterone • Sources of progesterone • Corpus luteum • Placenta • Both require ovulation • So anovulation = unopposed estrogen 13 The Question AUB/O AUB/PALM-CEIN . Cycle lost . Cycle preserved . Abnormal hormone . Normal hormone stimulus stimulus (no progesterone) (ovulation occurring, luteal P present normally) . (“Normal” uterine response) . Coagulopathy (AUB/C) . “Normal” uterus . Abnormal uterine response – Co-existing uterine pathology may not be responsible for – Pathology responsible bleeding (AUB/PALM) – Cause unclear (AUB/EN) . Iatrogenic (AUB/I) 14 14 The most common mistake…. The most common, and easily preventable error in evaluation/management of AUB-O is to give inadequate progestin to initially control the hyperproliferative endometrium when ovulatory dysfunction (= unopposed E) is the underlying fundamental cause of the bleeding 15 AUB Treatment-Patient is Bleeding Pt bleeding at onset of rx MPA 30 mg daily x 12 days If bleeding is emergently heavy, give large dose of estrogen as well (25 mg conjugated equine estrogens IV) Dose of IV CEE can be repeated in 4 hours x 2-3 times If bleeding has been prolonged and/or heavy, consider adding 5 mg CEE daily x 5 days Normal response Bleeding stops in 24-36 hrs (major slowing in 3-4 hours if IV CEE is given) Bleeding remains stopped for duration of P rx Withdrawal bleeding begins 1-3 days after P stops and is self-limited (amount variable, may be heavy) Re-treatment with CEE (usually 5 mg daily x 5 days is enough) and MPA 30 mg daily x 12 days may be required if the first withdrawal bleed is very heavy Second withdrawal bleed should be normal 16 AUB Treatment- Not Bleeding Pt not bleeding at onset of rx • MPA 10 mg daily x 12 days • Normal response No bleeding occurs during P rx Withdrawal bleeding begins 1-3 days after P stops and is reasonable in amount and self- limited 17 Patton’s Law A normal uterus should bleed normally if given (or already receiving) normal estrogen and progesterone hormone stimulation and no coagulopathy is present 18 US Measurement of Endometrial Thickness? . Premenopause . Postmenopause – Changes with cycle – Bleeding . Even when the endometrium is <5 mm, – Value not established for there is still a 5% chance of abnormal screening for endometrial pathology cancer – Not bleeding . If endometrium <12 mm, chance of endometrial cancer 0.002% . If endometrium >11 mm, chance of endometrial cancer 6.7%* 19 *based on a theoretical cohort—Smith-Bindman, R., et al, Ultrasound Obstet Gynecol 24:558 (2004) 19 Reference Hemostasis and menstruation: investigation for underlying disorders. www.ncbi.nlm.nih.gov/pubmed/16275228 and www.ncbi.nlm.nih.gov/pubmed/16275227 and www.ncbi.nlm.nih.gov/pubmed/16275229 Adolescent Gynecology, Clinical Expert Series. www.ncbi.nlm.nih.gov/pubmed/19305342 Managment of Anovulatory Bleeding. ACOG Practive Bulletin #14, ACOG. Int Journal Gynaecol Obset 2001; 72(3):263-271 Hysterectomy compared with endometrial ablation for DUB. Green Journal. www.ncbi.nlm.nih.gov/pubmed/18055721 Munro MG, Critchley HO, Broder MS, Fraser IS. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. FIGO Working Group on Menstrual Disorders. Int J Gynaecol Obstet 2011;113:3–13. (Level III) Diagnosis of abnormal uterine bleeding in reproductive-aged women. Practice Bulletin No. 128. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;120:197–206. (Level III) Von Willebrand disease in women. ACOG Committee Opinion No. 451. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;114:1439– 43. (Level III) Polycystic ovary syndrome. ACOG Practice Bulletin No. 108. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;114:936–49. (Level III) Pellerin GP, Finan MA. Endometrial cancer in women 45 years of age or younger: a clinicopathological analysis. Am J Obstet Gynecol 2005;193:1640–4. (Level III) Hickey M, Higham JM, Fraser I. Progestogens with or without oestrogen for irregular uterine bleeding associated with anovulation. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD001895. DOI: 10.1002/14651858.CD001895.pub3. (Level III) Gallos ID, Shehmar M, Thangaratinam S, Papapostolou TK, Coomarasamy A, Gupta JK. Oral progestogens vs levonorgestrel-releasing intrauterine system for endometrial hyperplasia: a systematic review and metaanalysis. Am J Obstet Gynecol 2010;203:547.e1–547.10. (Meta-analyis) Moschos E, Ashfaq R, McIntire DD, Liriano B, Twickler DM. Saline-infusion sonography endometrial sampling compared with endometrial biopsy in diagnosing endometrial pathology. Obstet Gynecol 2009;113:881–7. (Level II-3) 20 Vaginal Discharge: What is wrong down there? . Describe the vaginal environment . Discuss the epidemiology of Vaginitis . Discuss the most common causes of vaginitis and patient complaints . Discuss the Physical exam findings and diagnostic aids to identify cause . Discuss the treatments of different types of Vaginitis 22 Vaginal Discharge . Described as a spectrum of conditions that cause symptoms such as itching, burning, and abnormal discharge . The most common cause of Vaginitis is Bacterial Vaginosis (22-50%), Vulvovaginal Candidiasis (17-39%), and Trichomoniasis (4-35%). In undiagnosed women (7-72%), the symptoms can be from a wide array of conditions, including atrophic vaginitis, dermatologic conditions, and vulvodynia. Empiric Therapy can be effective, but many suffer from recurrence, making an accurate diagnosis important for successful therapy. 23 The Vaginal Environment A Utopian Society 24 The Vaginal Environment . Estrogen plays a crucial role in the normal vaginal state . In Pre-pubertal and post menopausal states, the vaginal epithelium is thinned, and the pH of the vagina is usually elevated (4.7 or higher). During the reproductive years,
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