Brent E Seibel MD Chief Benign Gynecology Medical Director UF Health North Jacksonville Associate Professor of Obstetrics and Gynecology University of F lorida College of MedicineJacksonville ID: 919862
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Slide1
Approach to Abnormal Uterine Bleeding
Brent E. Seibel, MD
Chief, Benign Gynecology
Medical Director, UF Health North Jacksonville
Associate Professor of Obstetrics and Gynecology
University of
F
lorida College of Medicine-Jacksonville
Slide2Disclosures
I have no conflicts to disclose
Slide3Objectives
Describe nomenclature, work up and management of abnormal uterine bleeding
Illustrate treatment plan options for the PCP
Slide4Resources
Committee on Practice Bulletins-Gynecology.
Practice Bulletin no. 128
: diagnosis of abnormal uterine bleeding in reproductive-aged women.
Obstet
G
ynecol
2012; 120:197
Munro MG,
Critchley
HO, et al. FIGO classification system (
PALM-COEIN
) for causes of abnormal uterine bleeding in
nongravid
women of reproductive age.
Int
J
Gynaecol
Obstet
2011; 113:3
UpToDate
R
: Approach to abnormal uterine bleeding in
nonpregnant
reproductive-age women.
www.uptodate.com
Slide5Introduction
Abnormal uterine bleeding (AUB
)
Menstrual bleeding of abnormal quantity, duration, or schedule
AUB terminology more descriptive than
menorrhagia
,
metrorrhagia
, etc.
Accounts for 1/3 outpatient visits to gynecologists
Wide variety of local and systemic diseases or medications
Annual prevalence of 53 per 1000 women
Common etiologies
Structural,
anovulation
, disorders of
hemostasis
or
neoplasia
Slide6Abnormal Uterine Bleeding
Heavy Menstrual Bleeding (AUB-HMB)
Intermenstrual
Menstrual Bleeding (AUB-IMB)
PALM
: Structural
Polyp (
AUB-P
)
Adenomyosis
(
AUB-A)Leiomyoma (AUB-L)Malignancy and Hyperplasia (AUB-M)
COEIN: Non-StructuralCoagulopathy (AUB-C)Ovulatory Dysfunction (AUB-O)Endometrial (AUB-E)Iatrogenic (AUB-I)Not Yet Classfied (AUB-N)
Slide7P
ALM: Structural
Polyps
Slide8P
A
LM: Structural
Adenomyosis
Slide9PA
L
M: Structural
L
eiomomas
Slide10PAL
M
: Structural
Malignancy and
Hyperplasia
Slide11C
OEIN: Non-structural
Coagulopathy
Inherited and acquired
May occur in up to 20% of patients with HMB
Indications for evaluation
HMB since menarche
Postpartum hemorrhage, excessive surgical bleeding or bleeding with dental work, or any two of the following
Bruising 1-2 times per month
Epitaxis
1-2 times per month
Frequent gum bleedingFamily history of bleeding symptoms
Slide12C
O
EIN: Non-structural
Ovulatory
Dysfunction
(
From amenorrhea and
oligomenorrhea
to frequent irregular menses)
Hypothalimic
hypogonadotropic hypogonadismThyroid dysfunctionHyperprolactinemia
Hyperandrogenemia/PCOSPremature ovarian insufficiencyIdiopathic anovulationChronic illness
Slide13CO
E
IN: Non-structural
Endometrial Abnormalities
Abnormal endometrial angiogenesis
Prostaglandin production
Vasoconstriction
Increased
fibrinolysis
Slide14COEI
N: Non-structural
Iatrogenic
Contraceptives
OCPs
, patch or ring
Depo
Provera
(DMPA)
Contraceptive implant (
Nexplanon)Intrauterine device (IUD)Other medicationsAntipsychoticsAnticoagulants
other
Slide15Evaluation: History
Age of menarche
Menstrual bleeding pattern
Severity of bleeding
Pain
Medical history
Surgical history
Family history
Bleeding disorders, PCOS, diabetes, cancer
Slide16Evaluation: Medications
Anticoagulants
Hormonal medications
NSAIDS
Antipsychotics
Supplements
Slide17Evaluation: Physical Exam
Weight extremes
Skin
Acanthosis
nigrans
Hirsuitism
Acne
Pallor
Petechiae
or
echymosisThyroidAbdomenPelvic
Slide18Evaluation: Labs
Pregnancy test
STD testing if indicated
Pap smear
CBC
TSH
Slide19Evaluation: Labs
Bleeding disorder
PT/PTT/INR
Platelet function
Fibrinogen
Hyperandrogenism
/PCOS
Testosterone
DHEAS
17-OHP
HgbA1C, lipids, CMP
Slide20Evaluation: Labs
Amenorrhea/
Oligomenorrhea
Prolactin
FSH/LH
E
stradiol
Slide21Evaluation: Imaging
Transvaginal
ultrasound
Saline Infusion
Sonohysterogram
(SIS)
Excellent for cavity assessment
MRI
Fibroid mapping
Mullerian
anomalies
Adenomyosis
Slide22Evaluation: Tissue Sampling
Endometrial biopsy
Women
>
age 45 with AUB
Women < age 45 with chronic
anovulation
Obese
PCOS
Unopposed estrogens
Hysteroscopy
D&C
Slide23Treatment: Medical
Combined oral contraceptives
Progesterone therapy
Oral
Intramuscular
Levonorgestrel
intrauterine system (IUD)
Tranexamic
acid
NSAIDs
Slide24Treatment: Surgical
Dilation and Curettage (D&C)
Hysteroscopy
Diagnostic
Operative (
polypectomy
,
myomectomy
)
Endometrial ablation
Uterine artery
embolization (UAE)MyomectomyHysterectomy
Slide25Adolescent with AUB
(HMB or IMB)
History and physical exam
*
Pelvic ultrasound
Peripubertal
anovulatory
bleeding
Expectant management
Treatment with
OCPs or cyclic MPA
Bleeding disorder
Refer
Ped
/Ad
Gyn
or
Hematology
Slide26Reproductive Age with AUB-HMB
History, Physical exam and labs
*
Pelvic ultrasound
Abnormal pelvic exam
Normal pelvic exam
Pelvic ultrasound
Treat abnormality
Treat:
OCPs
Progesterone
LngIUD
Tranexamic
acidNSAIDs
Success!
No further workup
Pelvic ultrasound
Refer to GYN
Slide27Reproductive Age with AUB-IMB
History, Physical exam and labs
*
Pelvic ultrasound
Short-term IMB
Long-standing IMB
Expectant management
or
Treatment:
OCPs
Progesterone
Pelvic ultrasound (TVS)
Cavity evaluation
*GYN referralEmBx
*
Treatment failure
TVS/Cavity evaluation
GYN referral
Success!
No further workup
Slide28Summary
AUB a common condition among reproductive age women
Evaluation and initial management by PCP
Differentiate between structural and non-structural causes
PALM – COEIN terminology
Slide29Thank you!
Questions?