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Home , Anovulation, Oligomenorrhea

Abnormal Uterine Bleeding

Benjie B. Mills, MD

Division Director, Pediatric & Adolescent Gynecology Medical Director of Gynecology, GHS OB/GYN Center

Associate Professor of Clinical Obstetrics & Gynecology University of South Carolina School of Medicine Greenville Disclosures

• I have nothing to disclose • This presentation will discuss off-label use of medications Objectives

• Describe etiologies, work up, and clinical course of abnormal uterine bleeding • Formulate a patient-centered and evidence-based treatment plan • Focus on issues of particular importance to the PCP such as prevention, therapeutic lifestyle changes, health maintenance, and when to refer to a specialist

Etiologies

Abnormal Uterine Bleeding (AUB-HMB) Intermenstrual Menstrual Bleeding (AUB-IMB)

PALM: Structural COEIN: Non-Structural Polyp (AUB-P) Coagulopathy (AUB-C) (AUB-A) Ovulatory Dysfunction (AUB-O) Leiomyoma (AUB-L) Endometrial (AUB-E) Malignancy & Hyperplasia (AUB-M) Iatrogenic (AUB-I) Not Yet Classified (AUB-N) Structural

• Polyps Structural

• Adenomyosis Structural

• Leiomyomata Structural

• Malignancy and Hyperplasia Coagulopathy

• Inherited and acquired • Occurs in up to 20% of patients with HMB • Indications for evaluation – Heavy menstrual bleeding since , or – Postpartum hemorrhage, excessive surgical bleeding or bleeding with dental work, or – Any two of the following • Bruising 1-2 times per month • Epistaxis 1-2 times per month • Frequent gum bleeding • Family history of bleeding symptoms

Ovulatory Dysfunction

• Encompasses to frequent irregular menses and in between – Hypothalamic hypogonadotropic hypogonadism – dysfunction – Hyperprolactinemia – Hyperandrogenemia/PCOS – Premature ovarian insufficiency – Idiopathic – Chronic illness Endometrial Abnormalities

• Abnormal endometrial angiogenesis • Prostaglandin production • Vasoconstriction • Increased fibrinolysis Iatrogenic

• Contraceptives – OCPs, contraceptive patch or ring – DepoProvera (DMPA) – Contraceptive implant (Nexplanon) – Intrauterine device • Hormonal ( IUD, Mirena, Skyla) • Non-hormonal (Paragard, copper T) • Other medications – Antipsychotics – Anticoagulants – Other Evaluation Evaluation: History

• Age of menarche • Menstrual bleeding pattern • Severity of bleeding (clots or flooding) • Pain • Medical history • Surgical history • Family history of bleeding disorders, PCOS, diabetes …

Medications

• Anticoagulants • Hormonal medications • NSAIDs • Antipsychotics • Ginkgo • Ginseng • Motherwort Physical Exam

• Abnormalities of weight • Skin – Acanthosis nigricans – Hirsutism – Pallor – Petechiae or ecchymoses • Thyroid • Abdomen • Pelvic

Laboratory Testing

• Pregnancy test • STD testing if indicated • CBC with diff • TSH Laboratory Testing

• Bleeding disorder – PT/PTT/INR – Platelet function screen – Fibrinogen • /PCOS – , free and total – DHEAS – 17 hydroxyprogesterone – HgbA1C, lipids, CMP Laboratory Testing

• Amenorrhea/ – – FSH/LH –

Imaging and Tissue Sampling

• Ultrasound • Saline infusion – Transvaginal sonogram – Transabdominal – Cavity assessment • MRI – – Müllerian • Hysteroscopy anomalies • Endometrial biopsy – Fibroid mapping – Adenomyosis Differential Diagnosis by Age Category Ages 13-18 Years

• Pregnancy – UCG – TV Ultrasound for positive UCG and bleeding and/or pain • Pelvic infection – GC and chlamydia NAATs – Trichomonas or – PID Ages 13-18 Years

• Anovulation – immaturity or dysregulation of the hypothalamic-pituitary-ovarian axis – Irregular cycle length – Within 3 years of menarche (80% in a regular pattern) – Plan: • R/O pregnancy • Cyclic medroxyprogesterone acetate 10 mg x 10 days per month or OCPs if desires treatment • TSH in patients with other symptoms of thyroid dysfunction • Coagulopathy workup if heavy since menarche • Assess for anemia if heavy or prolonged bleeding

Ages 13-18 Years

• Coagulopathies – Prolonged, heavy menses – May be irregular due to immature HPO axis – Plan: • TSH • Bleeding disorder labs • Treat underlying condition • Treatment choices – OCPs (increases factor secretion) – Anti-fibrinolytics – Menstrual suppression Ages 13-18 Years

• Hormonal contraceptive use – OCPs

Cycle 1 Cycle 4 Extended > 7 days 65% 42% Cycle OCP > 20 days 35% 15% Cycles 1-4 Cycles 10-13 28d Cyclic > 7 days 38% 39% OCP > 20 days 6% 4% Ages 13-18 Years

• Hormonal contraceptive use – Etonogestrel implant Bleeding Patterns Definitions %* Less than three bleeding Infrequent and/or spotting episodes in 90 33.6 days (excluding amenorrhea) No bleeding and/or spotting in 22.2 Amenorrhea 90 days Any bleeding and/or spotting Prolonged episode lasting more than 14 17.7 days in 90 days More than 5 bleeding and/or 6.7 Frequent spotting episodes in 90 days Ages 13-18 Years

• Hormonal contraceptive use – Depo Medroxyprogesterone Acetate (DMPA) • 54% with AUB at 1 year • 46% with amenorrhea • 25% discontinue because of AUB Ages 19-39 Years

• Pregnancy • Infection • • Structural abnormalities – Fibroids – Polyps – Adenomyosis Ages 19-39 Years

• Anovulation – Polycystic ovarian syndrome is the most common cause – Chronic disease – Idiopathic – Premature ovarian insufficiency • and malignancy (rare) – Endometrial sampling in high risk patients Ages 40 to

• Pregnancy • Anovulation – Physiologic when approaching menopause – PCOS • Structural abnormalities • Endometrial hyperplasia and malignancy Imaging & Tissue Sampling Who gets imaging?

• Abnormal pelvic examination • Unresponsive to initial treatment in a patient with a normal pelvic exam • Suspicion for structural abnormality Which imaging is best?

• Transvaginal ultrasound (2D and 3D) – Screening test – Intracavitary pathology • Sensitivity 56% • Specificity 73% – Endometrial thickness is not helpful • Saline infusion sonography – Superior at determining intracavitary pathology – Global changes vs. specific lesions • MRI is not recommended for evaluation of AUB

Who needs endometrial sampling? • Women > age 45 with AUB • Women < age 45 with AUB and chronic anovulation (unopposed ) – – PCOS – Endometrial cancers and hyperplasias can be diagnosed in young patients at very high risk Evidence-Based Evaluation and Treatment Plans Adolescent with AUB (IMB or HMB)

History & Physical Exam

Peripubertal Anovulatory Bleeding Disorder Bleeding

Treat with Expectant Labs Cyclic MPA or Management Refer to Peds Gyn OCPs Reproductive Age with HMB

History, Physical Exam & Labs

Abnormal Pelvic Normal Pelvic Exam Exam

Treat: Ultrasound Treatment Success OCPs Treat Abnormality No further workup LngIUD DMPA Tranexamic acid Treatment Failure Ultrasound Refer to OB/Gyn Reproductive Age with IMB

History, Physical Exam, Normal Pelvic Exam & Labs

Short-term IMB Long-standing IMB

Expectant Management or EMB and Cavity Treat: Evaluation OCPs Refer to OB/Gyn Cyclic MPA

Treatment Failure Treatment Success Needs Cavity Eval No further workup Refer to OB/Gyn Prevention Prevention

• Maintain healthy weight • Evaluate for PCOS if patient is 3 years post- menarche and having IMB – Prevent hirsutism – Prevent long-term morbidity of PCOS via education and health maintenance – Prevent psychologic sequelae • Avoid use of DMPA for AUB • Recognize patients at high-risk for hyperplasia or malignancy