Abnormal Uterine Bleeding.docx

**Abnormal Uterine Bleeding:** - Menstrual bleeding of abnormal quantity, duration, or schedule - Prevalence: 10-30% of reproductive-aged AFAB (most common at menarche and perimenopause) - Major impact on individual's quality of life, productivity, and utilization of health care ser...

**Abnormal Uterine Bleeding:** - Menstrual bleeding of abnormal quantity, duration, or schedule - Prevalence: 10-30% of reproductive-aged AFAB (most common at menarche and perimenopause) - Major impact on individual's quality of life, productivity, and utilization of health care services **History:** - Current or recent pregnancy - LMP and several previous menstrual periods - Duration of bleeding: days of full bleeding and days of light bleeding/brown spotting - Bleeding between menstrual periods - How heavy is bleeding? What size tampons/pads are they using? - If bleeding is irregular: how many bleeding episodes have there been in the past 6-12 months? What is the average time from the first day of one bleeding episode to the next? - Is patient certain bleeding is from the vagina? Blood visible only after urination or defecation, blood only when wiping, location of blood on pad/presence of blood on tampon - Any precipitating factors, like trauma? Suggests vaginal or cervical origin - Any recent illness, stress, excessive exercise or possible eating disorder (suggests hypothalamic dysfunction) - Sexual history: risk for pregnancy or STIs - Hx of OBGYN surgeries: prior C- section can lead to increased risk for cesarean scar defect; prior myomectomy can lead to increased possibility of leiomyoma - Contraceptive history: combined contraceptives can cause unscheduled bleeding; progestin-only contraceptives can cause irregular bleeding or amenorrhea; copper IUD increases menstrual flow; levonorgestrel IUDs initially cause irregular spotting or bleeding but followed by decrease in flow and possible amenorrhea. - Risk factors for endometrial cancer increasing age, nulliparity, PCOS, obesity, tamoxifen therapy, unopposed exogenous estrogen, diabetes, family hx, hereditary non-polyposis colorectal cancer (lynch syndrome) or cowden syndrome - Risk factors for scarring of endometrial lining: OB catastrophe, severe bleeding, D and C, endometritis or other infection - Chronic medical disorders thyroid disease celiac disease, T1DM, CKD, OUD: may develop secondary amenorrhea connective tissue disorders: may develop heavy menstrual bleeding Bleeding disorders: symptoms include fatigue, SOB, bruising or petechiae, fever. Risk factors are anticoagulant therapy, thrombocytopenia, liver or renal disease. Family history of bleeding disorder. Hematologic malignant may be present with abnormal uterine bleeding - Medications: anticoagulants may cause heavy or prolonged bleeding. Some meds can cause hyperprolactinemia, which results in oligomenorrhea or amenorrhea. **How heavy is bleeding?** - Normal: change pads/tampons at 3-hr intervals; empty menstrual cup every 10-12 hrs, change underwear every 8-12 hrs - Frequency of changing pad/tampon during the night, emptying menstrual cup, or changing menstrual underwear during peak flow days - Size of clots passed; normal size is less than 1 inch in diameter (like a quarter) - Pictorial Blood Loss Assessment Chart (PBAC) a score of \>100 is indicative of heavy menstrual bleeding **Associated Symptoms:** - Galactorrhea, heat or cold intolerance, hirsutism, or hot flashes endocrine issues - Lower abdominal pain, fever, and/or vaginal discharge PID, endometritis - Changes in bladder or bowel function; pelvic pressure enlarged fibroid uterus or neoplasm - Headaches, visual field defects, fatigue, or polyuria and polydipsia hypothalamic-pituitary disease - Hot flashes, vaginal dryness, poor sleep, decreased libido primary ovarian insufficiency, perimenopause Risk factors for endometrial cancer Rick factors for scarring of endometrial lining **Physical Exam-** - **Vital signs including BMI** - Hair and body fat distribution - Systemic illness (fever, ecchymoses, pallor, LAD) - Optic fundi and visual fields (if suspect pituitary tumor) - Bruising or bleeding gums (concern for bleeding disorder) - Endocrine: hirsutism, acne, clitoromegaly, male pattern balding, striae, vitiligo, acanthosis nigricans, enlarged thyroid gland - Breasts: galactorrhea (suggestive of hyperprolactinemia), SMR (sexual maturity) in adolescents (breast development provides evidence of estrogenization) - Abdomen: pregnancy, uterine mass, ovarian mass - Genital exam: SMR bleeding from vulva, vagina, cervix, urethra, anus, or perineum mass, laceration, friable area, vaginal or cervical d/c, foreign body, signs of estrogen deficiency current uterine bleeding: presence and volume from cervical os; blood or blood clots in vaginal vault size, contour, tenderness, and mobility of uterus 1. Enlarged: pregnancy, leiomyomas, adenomyosis, malignancy 2. Limited mobility: pelvic adhesions or mass 3. **Boggy, diffusely enlarged, tender: adenomyosis** 4. Tenderness: PID **FIGO Classification: PALM-COEIN** - Abnormal uterine bleeding can have two causes: structural (PALM) or nonstructural (COEIN) - PALM: structural; P for polyp, A for adenomyosis, L for leiomyoma, and M for malignancy and hyperplasia - COEIN: nonstructural causes; C for coagulopathy, O for ovulatory dysfunction, E for endometrial, I for iatrogenic, N for not yet classified **P for Polyps:** - Could be cervical, uterine, or endometrial - Prevalence increases with age - Typically present with intermenstrual bleeding - Bleeding after straining or lifting can also occur **A for Adenomyosis:** - Endometrium invading uterus wall - Risk factors: parity, early menarche ( \2 months and other phases with either spotting or episodes of heavy bleeding - Molimina symptoms: thin cervical mucus secretions mid cycle breast tenderness, bloating, cramps, appetite/mood changes prior to menses are more likely ovulatory - Causes: PCOS Thyroid disease hyperprolactinemia disruption of hypothalamic-pituitary-ovarian-axis because of stress, weight loss, strenuous exercise, poor nutrition cushing chronic renal or liver disease ovarian or adrenal turmors **Pathophysiology of AUB-O:** - Sex steroids are produced but not cyclically - Estrogen production unopposed by adequate progesterone production lead to continued proliferation of endometrium (risk for hyperplasia) - Eventually, thickened endometrium outgrows its blood supply and undergoes focal necrosis with partial shedding - Progesterone and prostaglandin-related changes have not occurred causes irregular bleeding, prolonged and/or heavy - Oligo-ovulation: some episodes of partial shedding and some episodes of normal menses **Initial eval of abnormal uterine bleeding:** - Urine hcg as initial test in all reproductive-aged individuals with AUB - If negative and suspect early pregnancy, need to do a serum hCG: urine hCG 2 weeks after conception serum hCG 1 week after conception **Secondary Evaluation of Heavy Menstrual Bleeding:** - **CBC and ferritin:** Hgb and/or Hct: anemia Serum ferritin: depleted iron stores in absence of anemia Platelets: bleeding disorder WBC: infection or leukemia - **Laboratory tests based on h and p** coagulation tests if suspecting bleeding disorder TSH is suspected thyroid disease Prolactin: anovulatory bleeding, amenorrhea or galactorrhea, or medication that can cause hyperprolactinemia serum androgens: hirsutism or virilization FSH and estradiol: if suspect premature ovarian insufficiency FSH, LH, and estradiol: if suspect hypothalamic dysfunction due to poor nutrition or intense exercise - **Imaging** suspect fibroids, adenomyosis, endometrial polyps, or uterine AV malformation - **Endometrial sampling** risk factors, or suspicion for uterine malignancy For age 45 years to menopause: any bleeding that is frequent (\8 days), or occurs between cycles younger than 45 years: AUB is persistent (6 months or more) AND occurs in setting of unopposed estrogen exposure, failed medical management of bleeding, or in individuals at high risk of endometrial cancer (tamoxifen therapy, lynch, or cowden syndrome) endometrial biopsy is typically performed: D&C or hysteroscopy if bleeding persists despite normal biopsy or other indication **Postmenopausal Bleeding:** - ANY bleeding warrants evaluation: either endometrial biopsy or transvaginal ultrasound - Endometrial biopsy: usually initial diagnostic test because of high sensitivity, low complication rate and low cost. If benign biopsy and continued concern for cancer then do TVUS or D&C with hysteroscopy - Transvaginal ultrasound: alternative to endometrial biopsy in POSTMENOPAUSAL women only. Indicationsa biopsy cannot be performed, suspected structural pathology, or evaluation of adnexa is needed. Endometrial thickness \ 2. MRI: used for follow up to rule out ultrasound ONLY if it will provide additional information; suspected ovarian or endometrial cancer 3. Saline infusion sonography: saline put in endometrium and transvaginal ultrasound performed; allows for architectural evaluation of uterine cavity including cesarean scar defects 4. Hysteroscopy: direct visualization of endometrial cavity; allows targeted biopsy or excision of lesions **AUB Management:** **Treatment of reproductive-aged individuals is based on:** - Etiology - Severity: anemia - Associated symptoms and issues: pelvic pain, infertility - Contraceptive needs and future pregnancy intentions - Medical comorbidities - Underlying risk for venous and arterial thrombosis - Patient preference: medical vs surgical; short-term vs long-term - Time to menopause **Goals of initial therapy:** - Normalize the bleeding - Correct/prevent anemia - Prevent endometrial hyperplasia/cancer particularly important in AUB-O (ovulatory) - Restore quality of life **Managing Acute Episode of Heavy Menstrual Bleeding:** - **High dose combined oral contraceptive**: **preferred treatment** to do monophasic COC (35 ethinyl estradiol) can wait 48 hrs; for heavy bleeding start with 5 pills on day 1 and for moderate bleeding start with 3 pills. Bleeding should stop within 48 hrs. Short term use of E2 okay in patients with HTN, DM, SLE, Smoking - **High dose oral estrogen: alternative for those who can't wait 48 hrs or don't want to take COC:** Premarin 2.5 mg q6 hrs until bleeding subsides or is minimal; twice a day for moderate bleeding followed by medroxyprogesterone acetate 10 mg every day for 10 days. If prescribing E2 prescribe an antiemetic like promethazine 12.5 or 25 mg per rectum prn - **Tranexamic acid:** 2^nd^ line option; 1300 mg PO TID x 5 days; contraindicated in those at high risk of thrombosis - **Surgical interventions:** **when medical therapy is ineffective or contraindicated** endometrial ablation: precludes subsequent pregnancy and more effective at providing long-term improvement uterine curettage: good option is future childbearing is desired **Medical Management of Non-acute Abnormal Uterine Bleeding:** - LNg52IUD is the first line medication (Mirena or Kyleena): most effective replace every 5 years not indicated with submucosal leiomyoma - CHC (first line) also: 35-69% reduction in bleeding Natazia is the only FDA approved CHC for HMB rule out contraindications (smoker, HTN, over 35 years old) - Other hormonal contraceptives: Depo-provera a 49% reduction after 2 months; not effective with AUB-L POPs and etonogestrel implant not effective - Cyclic oral progestins: Medroxyprogesterone acetate (Provera) start on day 16 or 21 of cycle norethindrone acetate, give during 2^nd^ half of menstrual cycle 87% reduction withdrawal bleed in 7-10 days not contraception - Tranexamic acid with menses: commonly used in women with bleeding disorder not for AUB-O - NSAIDS use for 3-4 days or until menses stop, this is useful where there is dysmenorrhea ibuprofen 600 mg 2-4 times daily not for AUB-O **Surgical Management non-acute AUB:** - Would refer to oBGYN for this anyhow - Polypectomy: endometrial or cervical polyps - Myomectomy: uterine leiomyoma preserves fertility hysteroscopic: submucosal only laparoscopic: all other leiomyomas - Endometrial ablation: when medical management fails, or individual does not want to use chronic medical therapy; when women are finished childbearing - Uterine artery embolization: used for uterine leiomyomas finished childbearing - Hysterectomy: definitive treatment, typically used when medical management has failed **Amenorrhea:** - Primary no menses by age 13 and complete absence of secondary sex characteristic no menses by age 15 in the presence of normal growth and development of secondary sexual characteristic most common causes: gonadal dysgenesis; Mullerian agenesis; physiologic delay of puberty; PCOS Refer to Peds Endocrinology - Secondary: no menses for at least 3 previous cycles or 6 months most common causes: pregnancy, lactation, hypothalamic and PCOS would do pregnancy test first and if that is negative will do: FSH, PRL, TSH, E2 and add total T with s/s hyperandrogenism If E2 is low then thinking hypogonadotropic hypogonadism; if E2 is now low check to see if there is evidence of hyperandrogenism (if yes then PCOS) **Dysmenorrhea:** - Prostaglandin release from endometrial sloughing at the beginning of menses - Primary: presence of recurrent, crampy, lower abdominal pain that occurs during menses in the absence of demonstrable disease diagnosis of exclusion typically made in adolescents/young adults - Secondary: endometriosis, adenomyosis, leiomyomas - 50-90% of reproductive-aged AFAB worldwide - Risk factors: younger age, smoking, stress - Pain starts 1-2 hrs before or with the onset of menses and gradually diminished over 12-72 hrs **Dysmenorrhea Diagnosis:** - Rule-out secondary dysmenorrhea - Onset after age 25 - AUB - Non-midline pelvic pain - Absence of N/V/D, back pain, dizziness, or headache - Presence of dyspareunia or dyschezia (difficulty pooping) - Progression in symptom severity **Dysmenorrhea treatment:** - Self care: heart, exercise, low-fat vegetarian diet, vitamin E, B1, B6, D3, fish oil, ginger - Medications: NSAIDs, acetaminophen, hormonal contraception (estrogen-progestin, POPs, Dep, LNG IUDs, etonogestrel implant)