Management of Abnormal Uterine Bleeding - PowerPoint Presentation

Slide1

Management of Abnormal Uterine Bleeding

Sonnie

Kim-

Ashchi

, MD. FACOGSlide2

Patient No 1

Emily is 14 years old, started her first menses last year, irregular at the beginning , now regular monthly. But she reports heavy bleeding that soaks through her uniform. And very “ inconvenient” to have heavy bleeding during her soccer/ lacrosse/crew practices

.Slide3

Patient No2.

Laura is 26 years old

trying to get pregnant for last 2 years. She has 4 to 5 periods a year. She is getting more hair in her face and darker in back of her neck.

She is getting nervous about her future fertility. Slide4

Patient No. 3

Mrs. Robinson is 50 years old. Her last period was 6 months ago. Now bleeding heavily for 10 days passing clots. Slide5

Patient No. 4

Mrs. Hopkins is 70 years old. She has been postmenopausal since her early 50’s. She noticed pink spotting about three months ago. At that time, she was too embarrassed to her PCP during her routine checkup. But now, spotting changed to heavy bright red bleeding. Slide6

Abnormal Uterine Bleeding Associated with Ovulatory Dysfunction ( AUB-O)

The most common cause for

gyn

visits and referrals.Ovulatory dysfunction presents with heavy irregular uterine bleeding due to the effects of chronic unopposed estrogen on the endometrium.

Acute AUBChronic AUB- topic todaySlide7

Causes of Anovulation

Physiologic

Pathologic

Adolescence

PregnancyLactationPerimenopause

Hypothalamic dysfunction (secondary to anorexia nervosa)Hyperprolactinemia

Primary pituitary diseasePremature ovarian failureThyroid diseaseHyper androgenic anovulation(PCOS, CAH, or Androgen-producing tumor)Iatrogenic(secondary to radiation or chemotherapy)

MedicationSlide8

Causes of AUB by FIGO and ACOG

PALM

-Structural Causes

COEIN-Nonstructural causes

P

olyp and PregnancyA

denomyosisLeiomyomaMalignancy and

hyperplasia

C

oagulopathy

O

vulatory dysfunction

E

ndometrial

I

atrogenic

N

ot yet classified

International Federation of Gynecology and Obstetrics ( FIGO)

American College of Ob/

Gyn

( ACOG)Slide9

Age-Based Consideration in Differential Diagnosis

13-18

Years

Differential diagnosis is similar to other age groups except endometrial hyperplasia and malignancy.

1. Anovulation; Hypothalamic immaturity ( 90%) 2.Stree-exercise-induced 3. Obesity 4. Coagulation disorder like Von Willebrand disease

5. Pregnancy, sexual trauma, STD regardless of her “reported “ sexual history

6. Look for PCOS such as acne, hirsutism, Slide10

Age-Based Consideration in Differential Diagnosis;

19-39

YearsPCOS is one of the most common causes in this group.

AnovulationObesity is comorbid condition.Endocrine disorder eg. hypothyroidism

PregnancyPolyp, fibroids, adenomyosisMedication related esp. OCPInfection

Premalignant or malignant endometrial pathology must be considered for high risk patients especially medical management is not successful.Slide11

Age-Based Considerations in differential diagnosis ;

40 Years to Menopause

Most likely normal perimenopausal changes with irregular sometimes heavy menses

Anovulation-

unppopsed estrogen and hyperplasiaMean age of menopause is 52 years.The average duration of the menopausal transition is 4 years.

Polyp, fibroid, adenomyosisHyperplasia or cancerPregnancy must be excluded.Definition of

Menopause-cessation of menses for 12 consecutive months, NOT blood hormone testsSlide12

Age-Based Considerations in

differential diagnosis;

Menopause and on

1.Vaginal atrophy

2.Cancer/polyp3. Estrogen therapySlide13

Basic information about your patients via,,,,

History

Physical Exam

Pertinent medical and surgical history-- Surgery-related bleeding? Bleeding after dental work? Bruising easily? Frequent nose bleeding or gum bleeding? Family history of bleeding?

Medication– anticoagulant? Chemo agents?

Detailed gyn history-menarche? Current bleeding frequency, interval, duration, related symptoms such as vaginal discharge, pain, LMP

General—signs of systemic illness, ecchymosis, thyromegaly, signs of

hyperandrogenism

such as hirsutism, acne, male pattern balding. Acanthosis

nigricans

Pelvic exam including speculum exam and bimanual exam to look for genital trauma, cervical tumor, uterine enlargement. Slide14

Based on patient’s history and physical examination,,,,

Laboratory Testing

Imaging

Urine pregnancy test

Complete Blood Counts and platelets

TSHIf indicated, von Willebrand-ristocetin cofactor activity, vW factor antigen and Factor VIII, Liver Function Test.Pap smearEndometrial biopsy if older than 45 years or “ high risk” patients

Transvaginal or transabdominal ultrasoundSonohysterogram

HysteroscopySlide15

Treatment approach to guide therapy for AUB-O

The choice of treatment is according to the goals of therapy

√ Age group, 13 ? 25? 50? 75?

√ To stop acute bleeding? √ To avoid future irregular heavy bleeding? √ Need for contraception?

√ Need for comorbidity such as anemia √ Need for surgical treatment? Only when medical therapy fails, is contraindicated, is not tolerated by the patient, or the patient has intracavitary lesions.Slide16

FIGO and ACOG recommends

Abnormal Uterine Bleeding, NOT Dysfunctional Uterine bleeding, DUB which was used in the past for the bleeding with no systemic or structural cause.

DUBSlide17

Treatment

for AUB-O

Progestin Therapy

Medroxyprogesterone

acetate( Provera)

Megestrol acetate (Megace) Norethindrone

acetate(Aygestin)Depo Medroxyprogesterone

acetate (

Depo

Provera)

Implanon

/

Nexaplanon

Levonorgestrel

-releasing intrauterine device (

Mirena

or Skyla or

Liletta

)Slide18

Treatment for

AUB-O

Progesterone and Estrogen combination therapy

Oral contraceptives (Monophasic vs.

Triphasic vs. combination extended cycle)Transdermal patchesVaginal ringsSlide19

Surgical Management of AUB-O,

ONLY IF

medical managements fail

Hysteroscopy Dilatation and Curettage

Endometrial ablationHysterectomySlide20

Patient No 1

Emily is 14 years old, started her first menses last year, irregular at the beginning , now regular monthly. But she reports heavy bleeding that soaks through her uniform. And very “ inconvenient” to have heavy bleeding during her soccer/ lacrosse/swimming practices.

Lab tests- urine

hCG

, CBC, TSH,

vWd factorTreatment – Iron supplements and/or Low dose OCP or Progesterone IUD ( Skyla)Consider CONTINOUS combined hormonal contraceptives e.g., Seasonale

, Seasonique. 4 periods a yearSlide21

Patient No2.

Laura is 34 years old Gravida 0, having noncyclic menses, 4 to 5 periods a year. She is not sure about her fertility.

Any hyper androgenic signs?

Obesity?

Labs-CBC, TSH, Fasting ProlactinPelvic ultrasound

Endometrial biopsy for high risk patients for hyperplasia or even cancerFertility desired? If yes, induce ovulation. If not, OCP or Levonorgestrel IUD (Mirena or Liletta

) whose benefit includes reduction of endometrial cancer.Weight Loss and Exercise Slide22

Patient No. 3

Need to rule out endometrial hyperplasia and cancer with EMB!

Labs- B HCG, CBC, TSH, Prolactin

Pelvic ultrasound

Treatment- low dose OCP, cyclic progestin therapy, Mirena IUD or endometrial ablation.Remember perimenopausal women can get pregnant!!

Mrs. Robinson is 50 years old, last period was 6 months ago. Now bleeding heavily for 10 days passing clots. Very frustrated.Slide23

Patient No. 4

Mrs. Hopkins is 70 years old. She has been postmenopausal since her early 50’s. She noticed pink spotting about three months ago. At that time, she was embarrassed to see her gynecologist. But now spotting changed to heavy bright red bleeding.

EMDOMETRIAL BIOPSY!!

Transvaginal

ultrasound especially endometrial stripeSlide24

When is EMB indicated?

§ Purpose of EMB is to rule out hyperplasia and cancer.

§ Incidences of endometrial cancer in different age groups

Younger than 20; 0.2 in 100, 000 Age 20-34; 1.6%

Age 35-44; 6.2%, the incidence increases with aging, Age 70-74; 88 cases per 100,ooo§ EMB is indicated for patients older than 45 years with AUB-O

§ Also indicated younger than 45, 1.if medical management failed and systemic diseases such as leukemia or liver disease were ruled out in young patients.

2.patients with h/o unopposed estrogen exposure such as obesity (BMI greater than 30) and PCOS, chronic anovulation, h/o breast cancer,

Tamoxifen

use, family h/o endometrial cancer. Slide25

Surgical management for AUB-O

ONLY IF

medical managements fail

Saline infused

sonohysterogramHysteroscopyDilation and CurettageEndometrial ablation

HysterectomySlide26

Surgical management for AUB-O

Hysteroscopy and Dilation and Curettage

Saline infusion

sonohysteroscopySlide27

Surgical management for AUB

Endometrial ablation

“

Hysterectomy Alternative

”Can be done in the office,= Just copay for the office visit

Resectoscopic endometrial ablation since 1937Global nonresectoscopic ablation

Freeze-Cryotherapy Radiofrequency electricity-Novasure

Heated fluid-

Thermachoice

,

HydroThermAblator

Microwave-

Microsulis

Treatment Goal is to “ normalize “ menses ( 70 to 90 % patient satisfaction rate) ,

NOT

amenorrhea.

Prerequisites -uterus less than 10 cm, no

cavitary

lesion, adequate contraception after the procedure

Patient must be counseled about the risks

of masking

endometrial

cancer in the future.

Post ablation

Asherman

syndrome,

synechiae

, endometrial distortion/strictureSlide28

Surgical management for AUB

Endometrial Ablation

Therma

Choice

Hydro

ThermAblator

)

Novasure

MicroSulis

Resectoscopic

ablationSlide29

Surgical management for AUB; Hysterectomy

ONLY

indicated for medical management failure or patient’s desire for definitive treatment.Slide30

daVinci robot assisted total hysterectomy

Advantages for the patients

*Minimally invasive.

*Less painful.

*less blood loss, about 50 cc.

*Less infection.

*Less hospitalization days.*More cosmetically appealing.

*Quicker recovery.

*Faster return to normal life/work.

Advantages for the surgeons

*Much improved 3 D visualization

*Less complication

*Less ergonomically challenging,, Less tiring

Single Site EntrySlide31

Last Note,,Health

apps for Patients

Objective data collection instead of “ I bleed a lot”Slide32

Thank you

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