Endocrine causes Infections -Cushing’s disease -Chlamidia -Immature hypothalamic- -Gonorrhea pituitary axis -PID -Hyperprolactinemia -Hypothyroidism Medications -Menopause -Obesity -Hormonal agents -PCOD -Low dose OCs CAUSES OF AUB -Premature ovarian failure -IUD (differential -NSAIDs analysis Structural lesions -POP (“mini pill”} and diagnosis) -Tamoxifen -Adenomyosis -Warfarin -Coagulopathies -Condyloma accuminata Pregnancy -Dysplastic or malignant lesions of cervix or vagina -Ectopic pregnancy -Endometriosis -Incomplete abortion -Endometrial cancer -Pregnancy -Uterine or cervical polyps complications -Uterine leiomyomata -Trauma Risk factors for endometrial cancer (RR = relave risk) Age - 75% of cases occur aer menopause RR (age > 60 years) = 5.2 with peak incidence in the late 60s. Obesity - especially upper body fat. This may RR= 3 to 10 be secondary to increased estrogen producon and bioavailability. Polycysc ovary disease. RR = 5.2 Unopposed exogenous estrogen. RR = 2 to 14 When progesns are added (oral contracepves RR= 0.5 to 1 or with replacement therapy), relave risk is less than for the general populaon. Diabetes (all types grouped). Personal or family history of ovarian or breast RR = 2 to 2.8 cancer. Women who are overweight and have had breast cancer are at even greater risk. Nulliparity. RR = 1.3 Late menopause. RR entering menopause aer age 52 = 2.5 Tamoxifen therapy - Use for greater than one year is an independent risk factor. RR = 7.5 Basic FIGO classificaon system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproducve age Polyp Coagulopathy Adenomyosis Ovulatory dysfunction Leiomyoma (submucosal or other) Endometrial Malignancy & hyperplasia Iatrogenic Not yet classified Progesterone Dydrogesterone Tanaproget 17-OH-progesterone 19-norprogesterone derivated derivated PREGNANES NOR-PREGNANES - Hydroxyprogesterone - Nomegestrol acetate ESTRANES GONANES caproate - Demegestone -Lynestrenol -Norgestrel - Hydroxyprogesterone - Promegestone -Levonorgestrel -Desogestrel heptanoate - Nestorone -Norethisterone -Gestodene - Gestonorone caproate - Trimegestone -Norethisterone -Norgestimate - Chlormadinone acetate acetate - Medrogestone -Ethinodiol diacetate - Medroxyprogesterone -Norgestrienone acetate -Dienogest - Cyproterone acetate Drospirenone Hysterectomy remains the most absolutely curative treatment for DUB. Elective hysterectomy has a mortality rate of six per 10,000 operations. One randomized study found that hysterectomy was associated with more morbidity and much longer healing times than endometrial ablation. 12 hysterectomy was associated with more Fortunately,morbidity a and recent much study longer found thathealing sexual times functioning improved overall after hysterectomy than endometrial ablation with an increase in sexual activity and a decrease in problems with sexual functioning. 34 It still remains a popular method of treating DUB, especially in industrialized countries. 1. Neese RE. Abnormal vaginal bleeding in perimenopausal women. Am Fam Physician 1989; 40:185-92. 2. Bayer SR, DeCherney AH. Clinical manifestaons and treatment of dysfunconal uterine bleeding. JAMA 1993; 269:1823-8. 3. Baughan DM. Changes in the management of paents with dysfunconal uterine bleeding. Fam Pract Recerficaon 1993; 15:68-78. 4. Prior JC, Ho Yuen B, Clement P, Bowie L, Thomas J. Reversible luteal phase changes and inferlity associated with marathon training. Lancet 1982; 2:269-70. Endometrial biopsy (EMB) is the most commonly used diagnosc test for DUB. It provides an adequate sample for diagnosis of endometrial problems in 90% to 100% of cases,1,2 but may fail to detect polyps and leiomyomas. It is indicated in all women with DUB who are 35 years of age or older, since their risk of developing malignancy is much higher. Any woman with amenorrhea for one year or longer who experiences uterine bleeding also should have an EMB. The slim endometrial Endometrial biopsy may fail to detect polyps suc3on currees (Pipelleand ) produce samples comparable to older, leiomyomas. more traumac methods but with less pain.3 1. Goldschmit R, Katz Z, Blickstein I, Caspi B, Dgani R. The accuracy of endometrial Pipelle sampling with and without sonographic measurement of endometrial thickness. Obstet Gynecol 1993; 82:727-30. 2. Stovall TG, Ling FW, Morgan PL. A prospecve randomized comparison of the Pipelle endometrial sampling device with the Novak curee. Am J Obstet Gynecol 1991; 165:1287-9. 3. Johnson CA. Making sense of dysfunconal uterine bleeding. Am Fam Physician 1991; 44:149-57 Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproducve-Aged Women Inial evaluaon of the paent with acute abnormal uterine bleeding should include a prompt assessment for signs of hypovolemia and potenal hemodynamic instability. The eologies of acute abnormal uterine bleeding should be classified using the PALM–COEIN system. Medical management : Opons include intravenous conjugated equine estrogen, mul-dose regimens of combined oral contracepves or oral progesns, and tranexamic acid. Decisions should be based on the paent’s medical history and contraindicaons to therapies. Surgical management should be considered for paents who are not clinically stable, are not suitable for medical management, or have failed to respond appropriately to medical management. The choice of surgical management should be based on the paent’s underlying medical condions, underlying pathology, and desire for future fer3lity. Once the acute bleeding episode has been controlled, transioning the paent to long-term maintenance therapy is recommended. Management of acute abnormal uterine bleeding in nonpregnant reproducve-aged women. Commiee Opinion No. 557. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:891–6. Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproducve-Aged Women Acute AUB refers to an episode of heavy bleeding that, in the opinion of the clinician, is of sufficient quanty to require immediate intervenon to prevent further blood loss. Acute AUB may occur spontaneously or within the context of chronic AUB (abnormal uterine bleeding present for most of the previous 6 months). The general process for evaluang paents who present with acute AUB can be approached in three stages: 1) assessing rapidly the clinical picture to determine paent acuity, 2) determining most likely eology of the bleeding, and 3) choosing the most appropriate treatment for the paent. Management of acute abnormal uterine bleeding in nonpregnant reproducve-aged women. Commiee Opinion No. 557. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:891–6. Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproducve-Aged Women Once the acute episode of bleeding has been controlled, mulple treatment opons are available for long-term treatment of chronic AUB. Effecve medical therapies include the levonorgestrel intrauterine system, OCs (monthly or extended cycles), progesn therapy (oral or intramuscular), tranexamic acid, and nonsteroidal an-inflammatory drugs (6). If a paent is receiving IV conjugated equine estrogen, the health care provider should add progesn or transion to OCs. Unopposed estrogen should not be used as long-term treatment for chronic AUB. Paents with known or suspected bleeding disorders may respond to the hormonal and nonhormonal management opons listed earlier in this secon. Consultaon with a hematologist is recommended Effec3ve medical therapies include: for these paents, especially if bleeding is difficult to control or the gynecologist is unfamiliar with the other opons for medical management. the levonorgestrel intrauterine system, Desmopressin may help treat acute AUB in paents with von Willebrand disease if the paent is known to respond to that agent. It may be administered by OCs (monthly or extended cycles), intranasal inhalaon, intravenously, or subcutaneously. This agent must be used with cauon because of the risks of fluid retenon and hyponatremia and should not be administered to paents with progesn therapy (oral or intramuscular), tranexamic massive hemorrhage who are receiving IV fluid resuscitaon because of issues with fluid overload (15). acid, Recombinant factor VIII and von Willebrand factor also are available and may be required to control severe hemorrhage (5). Other factor deficiencies may need factor-specific replacement. and nonsteroidal an-inflammatory drugs Paents with bleeding disorders or platelet funcon abnormalies should avoid nonsteroidal aninflammatory drugs because of their effect on platelet aggregaon and their interacon with drugs that might affect liver funcon and the producon of clong factors (17). Management of acute abnormal uterine bleeding in nonpregnant reproducve-aged women. Commiee Opinion No. 557. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:891–6. ABNORMAL UTERINE BLEEDINGS - CONCENSUS BRIJUNI 2015 2015 USA Conclusions and Recommendaons Based on the available evidence and expert opinion, the American College of Obstetricians and Gynecologists’ Commiee on Gynecologic Pracce makes the following conclusions and recommendaons: The eologies of acute AUB should be classified based on the PALM–COEIN system: Polyp, Adenomyosis, Leiomyoma, Malignancy and hyperplasia, Coagulopathy, Ovulatory dysfuncon, Endometrial, Iatrogenic, and Not otherwise classified. Medical management should be the inial treatment for most paents, if clinically appropriate. Opons include IV conjugated equine estrogen, mul-dose regimens