14. Abnormal Uterine Bleeding.pptx

Abnormal Uterine Bleeding And Leiomyoma Presented by: R. Kraig Smith, MD objectives • Lecture: Abnormal Uterine Bleeding, Leiomyomas • Reading Reference: Beckmann, pp. 384-386 457-462 • Learning Objectives: • Define and characterize normal menstruation. • Define: • Menorrhagia (Heavy Menstrual Bl...

Abnormal Uterine Bleeding And Leiomyoma Presented by: R. Kraig Smith, MD objectives • Lecture: Abnormal Uterine Bleeding, Leiomyomas • Reading Reference: Beckmann, pp. 384-386 457-462 • Learning Objectives: • Define and characterize normal menstruation. • Define: • Menorrhagia (Heavy Menstrual Bleeding) • Metrorrhagia (Irregular Uterine Bleeding) • Menometrorrhagia (irregular and heavy menstrual bleeding) • Intermenstrual Bleeding (cyclical, and Acyclical) • Dysmenorrhea Objectives • Recall the PALM-COEIN system to classify causes of AUB. • Apply the patient’s clinical history and diagnostic testing to diagnose the etiologies of abnormal uterine bleeding described in PALM-COEIN. • List treatment modalities for each cause of abnormal uterine bleeding. Objectives a.Define postmenopausal bleeding. b.Define acute vaginal bleeding. c.Define abnormal uterine bleeding. d.List and characterize structural causes of abnormal uterine bleeding. e.List and characterize nonstructural causes of abnormal uterine bleeding. f. Recall the PALM-COEIN system to classify causes of AUB. g.Apply the patient’s clinical history and diagnostic testing to diagnose the etiologies of abnormal uterine bleeding described in PALM-COEIN. h.List treatment modalities for each cause of abnormal uterine bleeding. Some definitions…. • Normal menstrual cycle • Duration: 3-7 days (average 5 days) • Cycle length: 21-35 days • Amount: Less than 80 cc blood loss Difficult to accurately measure! • Postmenopausal vaginal bleeding • Bleeding that occurs after 12 months of amenorrhea • Acute vaginal bleeding • Episode of heavy bleeding that is of sufficient quantity to require immediate intervention to Abnormal Uterine Bleeding • Definition: Bleeding from the uterine corpus that is abnormal In regularity, volume, frequency or duration TERMS you may see again!  Heavy Menstrual Bleeding: >7 days, >80 mL  Irregular Menstrual Bleeding: irregular  Menometrorrhagia: heavy, irregular  Frequent Menstrual Bleeding<21 days apart  Infrequent Menstrual Bleeding>35 days apart Abnormal Uterine Bleeding   Dysmenorrhea: painful menses “Break through bleeding” 7 PALM-COEIN Classifies abnormal uterine bleeding as related or not related to structural abnormalities Abnormal Uterine Bleeding Heavy menstrual bleeding Intermenstrual bleeding PALM: Structural Causes Polyp Adenomyosis Leiomyoma Malignancy COEIN: Non-structural causes Coagulopathy Ovulatory dysfunction Endometrial Iatrogenic Abnormal Uterine Bleeding: PALM (structural causes) 1. Polyp • Focal, benign hyperplastic process (<5% malignant) • Premenopausal or immediately postmenopausal • Most common symptom is abnormal uterine bleeding (usually intermenstrual spotting) Abnormal Uterine Bleeding: PALM 2. Adenomyosis • Presence of endometrial tissue within the myometrium • Symptoms: extremely painful menses; heavy, prolonged bleeding, chronic pelvic pain (THINK OUCH!!!!) Adenomyosis Abnormal Uterine Bleeding: PALM 3. Leiomyoma (also called fibroids, myomas) • Localized proliferation of smooth muscle cells surrounded by a pseudocapsule of compressed muscle fibers (leiomyosarcoma rare!!) • Premenopausal women (prevalence may be as high as 80%!) • Most common indication for a hysterectomy • Symptoms: painful, heavy menstrual bleeding Leiomyoma Abnormal Uterine Bleeding: PALM 4. Malignancy • Leiomyosarcoma Presentation: postmenopausal woman with rapidly enlarging mass with postmenopausal bleeding • Endometrial cancer EVALUATE THE ENDOMETRIUM OF WOMEN WITH: 1. Metrorrhagia > 35 years or prolonged AUB 2. Postmenopausal bleeding YOU MUST RULE OUT ENDOMETRIAL CANCER!!! Leiomyosarcoma Endometrial Cancer SDL Abnormal Uterine Bleeding: COEIN (non-structural causes) 1. Coagulopathy • ~10% of women with heavy menstrual bleeding have a biochemically detectable systemic disorders of hemostasis • Most common coagulopathy: Von Willebrand’s disease • missing or defective von Willebrand factor (VWF), a clotting protein which binds factor VIII and platelets • Most common presentation, newly menstruating girl with very heavy periods and anemia •M. Shankar, C.A. Lee, C.A. Sabin, D.L. Economides, R.A. Kadir von Willebrand disease in women with menorrhagia: a systematic reviewBJOG, 111 (7) (200 Abnormal Uterine Bleeding: COEIN 2. Ovulatory • Causes irregular menstrual periods • Differential • Endocrinopathies: • Hypothyroidism • Hyperprolactinemia • Polycystic ovarian syndrome • Mental stress • Obesity • Anorexia • Weight loss • Extreme exercise in an elite athlete Abnormal Uterine Bleeding: COEIN 3. Endometrial (LESS COMMON!) • Examples causing intermenstrual spotting • Deficiency in the molecular mechanisms of endometrial repair • Endometrial infection • Examples causing heavy, prolonged menstrual bleeding: • Deficiency in local production of endothelim1 and prostaglandin F2 • Excessive production of accelerated lysis of endometrial Monro M. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. clots • International Journal of Gynecology and Obstetrics 113 (2011) 3–13 Abnormal Uterine Bleeding: COEIN 4. Iatrogenic • Hormonal therapies (oral contraceptives, Depoprovera, etc) “Break through bleeding” • Intrauterine devices • Anticonvulsants • Antibiotics • Medications that impact dopamine metabolism: ↓serotonin uptake inhibits dopamine release, ↓ prolactin inhibition causes disruption in the HPO axis and ovulatory dysfunction Etiology of abnormal bleeding depends on patient age. YOUNGER WOMEN • Menarche (10-14) • Anovulation due to immature HPO axis • Von Willebrand disease • Anovulatory cycles: (PCOS) • Reproductive (15-39) • Pregnancy!! • Structural lesion (leiomyoma and polyp) • Anovulation cycles (PCOS) • Hormonal contraception • Endometrial hyperplasia Etiology of AUB older woman • Perimenopause (40-50’s) • Structural lesions • Anovulatory cycles • Endometrial hyperplasia or cancer • Post menopausal bleeding • Think hyperplasia/cancer until proven otherwise! • Endometrial atrophy (the endometrial lining becomes so thin that superficial vessels are exposed and bleed) Where is the bleeding from? Don’t forget Think: Broad Differential Where is the bleeding from? Don’t forget Think: Broad Differential Lower genital tract Vulva, vagina, cervix Urinary system Urethritis Bladder (cancer or urinary tract infection) Bowel Inflammatory bowel disease Hemorrhoids Case Presentation Chief complaint • “My periods have gotten heavier and heavier, and the pain is terrible.” Ms. LM A 44 yo G3P3 woman complains of heavy regular painful periods. History of present illness What questions do you have to help you discern the pattern of bleeding? Woman with normal volume menstrual loss:  Change pads/tampons every 3 hrs  Use fewer than 21 pads/cycle  Don’t need to change pad/tampon at night  Pass clots less than 1 inch in diameter  Not anemic Case Presentation Our patient tells us . . . • Changes pads 1-2x/hour, flow 7 days • Passes golf ball size clots • Feels lightheaded • Has no spotting between periods • Has terrible pain, no menopausal sx How would you describe her bleeding pattern? Case Presentation Physical exam: • BP: 125/82, T = 37.1 • General: well developed woman in no acute distress • Abdominal exam: irregular-sized mass extending halfway between the pubic symphysis and umbilicus and to the right of the mid-line. Pelvic Exam • Inspection of vulva: • No erythema or lymphadenopathy • Speculum exam: • Cervix, pink, smooth • Small amount of blood at the os • Bi-manual exam • Uterus is markedly enlarged, especially on the right side where it appears to reach the lateral pelvic sidewall. • Ovaries are not palpable due to the mass Case Presentation: Imaging US evaluation of our patient MRI evaluation Leiomyoma Diagnosis • Usually made clinically • Transvaginal ultrasound • Hysterosonogram (Saline infused sonogram) • MRI (helps discern relationship to other structures) Risk factors • Early menarche • Family history • Caucasian women develop in their 30-40’s • African American women RR 2-3, develop 4-6 years earlier Symptoms depend on size and location Mo st c of myoma s om ym Heavy bleeding m pto ms (not usually intermenstrual) Pain on Anemia Infertility Dyspareunia Pelvic pressure: bulk related  Anterior: bladder pressure  Posterior: constipation, back pain, hydronephrosis LEIOMYOMA Treatment • Options: • • • • Expectant management Medical therapy Surgery Interventional radiology Intervention should be based on: • • • • Size of myoma Location of myoma Severity of symptoms Patient age & reproductive plans Treatment of Uterine Fibroids Medical Therapy • Hormonal - Oral contraceptives • Progestin-only therapies (oral or Depo Provera) mixed results • Gonadotropin-releasing hormone (GnRH) agonist • Gonadotropin-releasing hormone antagonist • Antiprogesterone: RU 486, (Mifepristone) (decreases uterine volume 20-70%) • Mirena IUD • Antifibrinolytic: Tranexamic acid (Lysteda) • Stabilizes a protein that helps blood to clot • NSAIDS Treatment of uterine fibroids Surgical • Endometrial ablation • Radiofrequency ablation • Myomectomy • • • • Hysteroscopic, laparoscopic, abdominal, robotic assisted Effective therapy for heavy menstrual bleeding and pelvic pressure Women who desire to retain fertility Disadvantage risk of reoccurrence • Hysterectomy Treatment of uterine fibroids IR: Uterine Fibroid Embolization Indications: • • • • Poor surgical candidate Woman who wishes to preserve uterus but NOT interested in future fertility Advantage: Shorter recovery compared to myomectomy or hysterectomy Disadvantage: more complications and readmissions Case Presentation 2 Chief complaint • “My periods have gotten irregular, and I am spotting a lot..” Ms. LM A 45 yo G2P0020 woman complains of very heavy, irregular menstrual bleeding every 6 weeks to 3 months and spotting at irregular intervals for the last 2 years. How would you describe her bleeding pattern? Common Causes of Irregular Menstrual Bleeding PALM • Polyp • Leiomyoma • Malignancy COEIN • Iatrogenic (HRT, Contraceptives, anticoagulants, psychopharmacologic) • Ovulatory dysfunction (think disruption of HPO axis, anovulation!!) • • • • • • Perimenopause Thyroid disease Elevated prolactin Polycystic ovarian syndrome Stress (CRH inhibits pulsatile GnRH) Weight loss or gain Evaluation • History • HPI: fatigue, lethargy, no nipple discharge • No medical history • No medications • Exam • External: No erythema or lymphadenopathy • Speculum exam • Cervix, pink, smooth • Small amount of blood at the os • Bi-manual exam • Uterus 4–6-week size • No adnexal masses Case Presentation Laboratory evaluation Laboratory • • • • • Hematocrit/hemoglobin Thyroid stimulating hormone Prolactin levels Serum FSH levels (perimenopausal.. possible ovarian failure?) Quantitative bHCG Additional studies: • Coagulation studies, bleeding time, platelet count • IMAGING??? • Tissue sampling • Is she over 35?? Endometrial pipelle ENDOMETRIAL SAMPLING IS REQUIRED!!! • Women > 35 • Prolonged metrorrhagia(irregular menstrual bleeding) Results for our patient Endometrial Biopsy Proliferative endometrium Laboratory • bHCG < 5 mIU/L • HCT/Hemoglobin 40% • Thyroid stimulating hormone 10.0 mIU/L (normal = .4 to 4.0 mIU/L) • Prolactin levels 34 (normal =2-29 ng/mL) DIAGNOSIS: ?? Remember the mechanism of HPO axis disruption? • TRH stimulates prolactin from anterior pituitary • Elevated prolactin interferes with pulsatile GnRH #2 Case Presentation • Although Ms. Smith’s metrorrhagia(irregular menstrual bleeding) is resolved, she is still complaining of heavy menstrual periods and continued anemia. What would be reasonable therapeutic options for our patient? A.Mirena IUD (intrauterine device) B.Hysteroscopic ablation C.Combined oral contraceptive pills D.Luteal phase progesterone E.All of the above Mirena intrauterine device Hysteroscopic ablation Management options: Endometrial ablation Cryoablati on Novasure Balloon ablation Hydrothermablation Case # 3 • CC: Irregular periods • HPI: • A 23-year-old presents to the clinic with complaints of irregular menstrual bleeding. This started approximately one year ago and seems to be worsening. She has intermittent bleeding episodes at least 3 per month. She denies any cramping or pelvic pain. She is sexually active with one partner. Her last bleeding episode was one week ago and lasted 3 days. 47 Case # 3 48 Case # 3 • PMH • Allergies-NKDA • Meds- Oral Contraceptive Pill Norethindrone/Ethinyl estradiol 1/20 • PSH -appendectomy age 10 • Chronic Illness- none • ROS- denies N,V,D,F,C • -Denies visual changes, neuro symptoms • -denies any bleeding abnormalities 49 Case # 3 Physical Exam -HEENT- WNL,visual fields intact -Neck-supple negative thyromegaly -Lungs –CTA -CV-RRR without M,G,R -Abdomen- no lesions no palpable masses no rebound or percussion tenderness -Pelvic- external genitalia-no lesions or abnormalities -Speculum- cervix is nulliparous no lesions seen - Bimanual exam- Uterus is posterior NSSC nontender 50 Case # 3 • What is working differential diagnosis at this point? • What labs or tests are needed at this point to confirm the diagnosis? • PALM-COEIN 51 Case # 3 This Is Iatrogenic Why? Mechanism of the Irregular bleeding?? 52 Case # 3 • What would be the next management step for this patient? 53 Abnormal uterine bleeding 54 55