7/4/19 Period Problems: From Puberty to the Post-Menopause Jody Steinauer, MD, MAS ! No Disclosures, July 4th, 2019 • I have nothing to disclose ! 1 7/4/19 Objectives • What is new with the period • Workup and treatment of uterine bleeding • Treatment of abnormal bleeding due to contraceptives 1: Periods 2: Perimenopausal AUB 3: Fibroids 4: Contraceptive Side Effects ! Case 1 A 23 year-old woman tells you about an app she is using to track her cycle and wonders if it is effective as natural contraception. She also wonders what you think of the menstrual cup or the new disc she read about – do they work as well as tampons? ! 2 7/4/19 What’s new with the period? • Mail-order products – Many with donations to low-resource settings • Products – Menstrual cups and discs – Combo tampon + liner – Organic cotton tampons – Underwear – Washable pads ! Menstrual Cups • High acceptability • Higher acceptability than tampons • Lower cost and decreased waste Howard, FLOW, CFP, 2011. Liswood, Ob Gynm 1959. ! 3 7/4/19 Menstrual Cycle Apps! • Systematic review of free apps • Of 108 only 20 were accurate (19%) • 80% conception / 50% contraception • Only 1/8 women have a 28 day cycle • Accuracy: averaged 4 of prior cycles, including outside of usual range Moglia, Ob Gyn, 2016 ! • Collect data, few privacy policies • Advertising • Most fertility oriented • Incorrectly marketed as effective bc • Assumptions about gender/sexuality, odd emojis/ images Vox.com ! 4 7/4/19 Free App by Planned Parenthood • Includes birth control information and reminders • No assumptions about gender or sexuality • “No pink flowers or butterflies” • Allows limited import from other apps This one from Planned Parenthood is “Spot On”! Plannedparenthood.org ! Case 2 A 46 year-old woman reports her periods have become increasingly irregular and heavy over the last 6-8 months. Sometimes they come 2 times per month and sometimes there are 2 months between. She bleeds 10 days with clots and frequently bleeds through pads to her clothes. She also has diabetes and is obese. Her LMP was 2 months ago. ! 5 7/4/19 Q1: Which is the first test should you order in this patient? 1. FSH 2. Testosterone & DHEAS 3. Urine hcg 4. TSH 5. Transvaginal Ultrasound (TVUS) 6. Endometrial Biopsy (EMB) ! Step 1: Pregnant? Pregnant Not Pregnant • Ectopic • Anovulation *** • Spontaneous Abortion • Anatomic/structural ** • Threatened Abortion • Neoplastic * • (Molar Pregnancy) • Infectious • (Trauma) • Iatrogenic • (Other causes) • Non-gynecologic * = Most likely for this patient ! 6 7/4/19 Terminology: What is abnormal? • Normal: Cycle= 28 days +- 7 d (21-35); Length=2-7 days; Heaviness=self-defined • Too little bleeding: amenorrhea or oligomenorrhea • Too much bleeding: Menorrhagia (regular timing but heavy (according to patient or >80cc) OR long flow (>7 days) • Irregular bleeding: Metrorrhagia, intermenstrual or post- coital bleeding • Irregular and Excessive: Menometrorrhagia Preferred term for non-pregnant heavy and/or irregular bleeding = Abnormal Uterine Bleeding (AUB) ! Pathophysiology: Anovulatory Bleeding Bricks & Mortar Estrogen=Bricks, build endometrium Progesterone (P) =Mortar, stabilizes, only have P if ovulate Normal menses: Withdrawal of P causes wall to fall down, all at once (heavy when hemostatic & vaso- constriction not working, high PG) Anovulation: No P so when wall grows too tall, it falls –irregularly, irregular (FibroiDs: Un-steaDy vasculature, abnl contraction) ! 7 7/4/19 Abnormal Uterine Bleeding Bradley, AJOG, 2016 ! History and Physical Examination • Hx: bleeding pattern, symptoms of anemia, sexual & reproductive history, chronic medical illness, meds • Acute v. chronic • PE: signs of anemia, thyroid examination, abd and gyn exam, (cervical dysplasia/STI screening?) ! 8 7/4/19 Initial Work-up: Menometrorrhagia • Always: Urine pregnancy • Usually: TSH • Maybe: Hct, r/o coagulopathy • Maybe: EMB (Endometrial Biopsy) • Maybe but later: Transvaginal Ultrasound • Usually not necessary: FSH, LH, Testost, Estradiol ! ACOG, July 2012 ACOG Practice Bulletin 128, Diagnosis of AUB in Reproductive-Aged Women ! 9 7/4/19 Perimenopause • Averages 4 years • 12% suddenly stop menstruating • 18% have longer, heavier menses • 70% have short, irregular menses Should we therefore perform EMB on all but 12% of women? ! A Rational Approach to EMB • Natural history: Endometrial ca takes years to develop - no atypia→atypia → invasion. • Bleeding pattern cues: Cancer & hyperplasia commonly present with menometrorrhagia, sometimes with intermenstrual bleeding, rarely with regularly-timed menses. ! 10 7/4/19 A Rational Approach to EMB Post-Menopause: ALL women WITH ANY BLEEDING (except 4-6 months after starting HT) Recent onset irregular bleeding: Consider treating first and if bleeding normalizes, no need for EMB >50: All women with recurrent, irregular bleeding (consider not doing if periods light and spacing out) 45-50: Recurrent irregular bleeding plus >1 risk factor OR > 6 mos menometrorrhagia (consider not doing if periods light and spacing out) <45: Long history (>2 yr?) of untreated anovulatory bleeding or failed medical management ! A Rational Approach to EMB Other reasons: Pap with atypical glandular cells or endometrial cells (if not done at time of menses). EMB is not perfectly sensitive so further evaluation mandatory if: 1. Persistent AUB after negative EMB 2. Persistent AUB after 3-6 months of medical therapy ! 11 7/4/19 Do all women with AUB need an ultrasound? Although TVUS is the best imaging choice for pelvic pathology (better than MR, CT)…. • 80% with heavy menstrual bleeding have no anatomic pathology • Incidental findings such as functional ovarian cysts and small fibroids (~50%) are often found leading to anxiety and unnecessary treatments • SO….treat first, TVUS if treatment fails ! What about U/S instead of EMB for post-menopausal bleeding? Transvaginal Ultrasound • Measure endometrial stripe • Abnormal= >4 mm (or 5) • Non-specific: myomas, polyps also cause thick EM • Operator skill mandatory • NOT USEFUL PRE-MENOPAUSE ! 12 7/4/19 TVUS vs EMB to detect cancer (in post-menopausal women) !!!!!!TVUS! ! !!!!!!!!!!EMB! 96%! Sensitivity! 94%! 61%! Specificity! 99%! 99%! NPV! 99%! 40;50%! Further!w/u! ?!<5%! necessary! ! ! Can offer patient choice as long as either is quickly available and patient understands she may need EMB after U/S ! Q2: You decide to do a urine pregnancy test and check her TSH – which is the most appropriate next test? 1. FSH 2. Testosterone & DHEAS 3. Serum beta-HCG 4. Transvaginal Ultrasound 5. Endometrial Biopsy ! 13 7/4/19 Q2: You decide to do a urine pregnancy test and check her TSH – which is the most appropriate next test? 1. FSH A 46 year-old woman reports her periods have become 2. Testosterone & DHEAS increasingly irregular and heavy over the last 6-8 months. 3. Serum beta-HCG Sometimes they come 2 times 4. Transvaginal per month and sometimes there are 2 months between. LMP 2 Ultrasound months ago. She bleeds 10 days 5. Endometrial Biopsy with clots and frequently bleeds through pads to her clothes. She also has diabetes and is obese. ! EMB=“Disordered Proliferative”. How do I stop the bleeding? Medical Surgical NSAID’s Endometrial ablation E+P pill, patch, ring D&C/Hysteroscopy Oral Progestin Hysterectomy Progestin IUD IM Progestin GnRH agonist Tranexamic Acid Disordered proliferative= Anovulation ! 14 7/4/19 Treatment of AUB: NSAIDs • Suppress prostaglandin synthesis, increases platelet aggregation, and reduces menstrual blood loss • Reduces blood loss by 40% • Use alone or with other treatments • Prescribe 5 days ATC – Ibuprofen, mefenamic acid, naproxen ! Treatment of AUB: Estrogen • CHC – pill, patch, ring – improve cycle control, decrease menstrual blood loss, decrease irregular bleeding, when used traditionally or continuously – One approved by FDA for heavy menstrual bleeding – Often used to treat acute and chronic AUB – despite limited (but some) evidence to support it ! 15 7/4/19 Treatment of AUB: Progestins • Oral progestin – If ovulatory AUB: daily progestin decreases blood loss (MPA 2.5-10mg qd, norethindrone 2.5-5mg qd) – If anovulatory: cyclic progestin -12-14 d/month improves menses in half of women • Injectable progestin – 50% amenorrhea after 1 year, irreg. bleeding in first few months and 50% at one year • Intrauterine progestin – Significant decrease in blood loss, superior to other progestins and CHCs ! First Line Hormonal Treatments • First choice: Levonorgestrel IUD – >80% reduction in blood loss, decreased cramping, prevents/treats hyperplasia, highly effective birth control – Very few contraindications to using – Blood loss comparable to ablation, satisfaction comparable to hyst. • 2nd choice: combined contraceptives (pill, patch, ring) or oral progestin (cyclic v. daily) or progestin injection – Proven to decrease irregular peri-menopausal bleeding – Any type ok, 20 mcg preferred for women >40 – Estrogen contraindications: smokers>35, HTN, complicated DM, multiple RF for CAD, h/o DVT, migraines ! 16 7/4/19 Treatment of AUB: Tranexamic Acid • Prevents plasma formation, fibrin degradation, and clot degradation • More effective than placebo, NSAID, cyclic progestin • Dose: 1 g to 1.3 g every 6-8 hours during menses • Risks: Theoretic risk of VTE, no increase in large studies. Contraindicated with history of / risk factors for VTE. Probably safe in conjunction with CHC. • Side effects: Minimal ! Surgical Treatments • D&C, Hysteroscopy: – Temporary reduction in bleeding. Curative if fibroid or polyp removed. • Endometrial