·:{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 tampon 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 adenomyosis 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 uterus 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 Menometrorrhagia Oligomenorrhea Prolonged bleeding Intermenstrual bleeding Any other irregular pattern Irregular Bleeding Not every patient needs evaluation! Adolescent in the first 2 yr after menarche 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 endometrial biopsy Reproductive age woman Some spotting just before, just after, or at ovulation can be normal However, ANY midcycle bleeding in an older patient should be worked up HCG, TSH, prolactin 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 endometrium 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 endometritis – 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 anemia 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 Hormonal Contraception 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 Heavy Menstrual Bleeding. American Family Physician. Volume 84, Number 8. October 15, 2011. Enjoy Puerto Rico!!!! Michele Tartaglia, DO, FACOOG, CS [email protected] 14.