ABNORMAL UTERINE BLEEDING: - PowerPoint Presentation

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ABNORMAL UTERINE BLEEDING:GUIDE TO DIAGNOSIS AND TREATMENT

Anita Showalter, DO, FACOOG (Dist.)

Assistant Dean of Clinical Education

Associate Professor and Chief, Division of Women's Health

College of Osteopathic Medicine

Pacific Northwest University of Health SciencesSlide2

LEARNING OBJECTIVES

Know normal uterine physiology

Know conditions causing abnormal uterine bleeding, their work up and treatment

Discuss unusual presentations that need special consideration

Know current treatments and the changes in philosophy of treating abnormal uterine bleeding Slide3

No disclosuresSlide4

REVIEW OF UTERINE PHYSIOLOGY

Pulsatile release of GNRH stimulates FSH and LH release

The follicular phase begins with menstruation and ends with the LH surge

Estrogen dominates the follicular phase of the cycle and develops the

functionalis

layer of the endometrium

Progesterone dominates the luteal phase and causes maturation of the spiral arteries and clean shedding of the endometrium

When pregnancy occurs, hCG supports the corpus luteum and continual production of progesterone Slide5

DIFFERENTIAL DIAGNOSIS OF ABNORMAL UTERINE BLEEDING

Iatrogenic

Exogenous hormones

Tamoxifen

IUD's

AnticoagulationSlide6

DIFFERENTIAL DIAGNOSIS OF ABNORMAL UTERINE BLEEDING

Dyscrasias

Thrombocytopenia

Leukemia

Increased fibrinolysis

Von

Willebrand's

Autoimmune disordersEhler Danlos SyndromeSlide7

DIFFERENTIAL DIAGNOSIS OF ABNORMAL UTERINE BLEEDING

Systemic

Thyroid

disorders

Hypothyroidism and Hyperthyroidism affect FSH/LH feedback

Hepatic

disorders

Impaired liver function – delayed metabolism of estrogen and precursorsPT may become abnormal in late stage diseaseClotting abnormalities also late stage

Renal diseaseDefective platelet aggregationHyperuremia leads to platelet dysfunctionAnticoagulation and aspirin in dialysis cause increased bleedingAbnormal FSH/LH cyclingSlide8

DIFFERENTIAL DIAGNOSIS OF ABNORMAL UTERINE BLEEDING

Organic Causes

Dysfunctional Uterine Bleeding (DUB)

Endometrial Hyperplasia

Endometritis

/Atrophic

endometritis

Uterine Leiomyomas (Fibroids)Endometrial PolypsAdenomyosis

MalignanciesSlide9

PRESENTATIONS REQUIRING SPECIAL CONSIDERATION

Any vaginal bleeding before age 9 or after 52 needs work-up

Normal menstruation may extend to age 57-58

Before age 9 consider:

Precocious puberty

Functional ovarian cyst (bleeding stops with cyst resolution)

Vulvovaginitis

Exogenous hormones (ingestion of oral contraceptives)Hormone producing ovarian tumorsVaginal tumors - Sarcoma botryoidesSlide10

LABORATORY WORK UP

CBC

Platelets

Serum Iron and Iron Binding Globulin

PT, PTT

Bleeding Time

hCG

TSHSerum ProgesteroneLiver FunctionsProlactinSerum FSHSlide11

DYSFUNCTIONAL UTERINE BLEEDING

Diagnosis of exclusion

Underlying problem is anovulation

Endometrium thickens under the influence of estrogen

Lack of LH surge and progesterone means estrogen is not sufficiently opposed and may bleed erratically

In conditions like PCOS, unopposed estrogen can lead to endometrial carcinoma at young ages.Slide12

DYSFUNCTIONAL UTERINE BLEEDINGFailure of the hypothalamic-pituitary system, may be stress related

Perform

labs, endometrial biopsy

and ultrasound for other causes

Treated with oral contraceptives or cyclic progesterone

Medroxyprogesterone

5-10 mg daily for 10-14 days monthly

Micronized progesterone 100 mg daily for 10-14 days monthlySlide13

TREATING DUB

Alternative

treatment:

tranexamic

acid

Inhibits plasminogen binding sites and decreases plasmin formation and fibrinolysis

Endometrial ablation may be utilized for persistent cases or where medical management is

contraindicatedSlide14

ENDOMETRIAL ABLATIONTubal ligation should be done in reproductive age women

unless there is a

commitment to contraception

Hydroablation

Electrocautery

Cryoablation

Microwave ablation

Causes Asherman’s syndrome70% amenorrhea, 90% hypomenorrheaSlide15

ASHERMAN’S SYNDROME

Normal endometrium

with submucous fibroid

Post-ablationSlide16

ENDOMETRIAL HYPERPLASIA

Growth

of the endometrium secondary to

over-stimulation

of estrogen

Categorized as simple, complex, or

atypical

Diagnosed by ultrasound measurementNormal endometrial stripe is 0.8-1.0 cm in reproductive agesLess than 0.5 cm in menopauseSlide17

ENDOMETRIAL HYPERPLASIANeed tissue sample to rule out endometrial carcinoma

Can perform endometrial biopsy with a pipelle in the office

Hysteroscopy and Dilation and Curettage if patient is a poor candidate for an office procedure

Adding hysteroscopy greatly improves efficacy of diagnosis

Treat with medroxyprogesterone, micronized progesterone or levonorgestrel IUDSlide18
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TREATING ENDOMETRIAL HYPERPLASIA

Patients with endometrial hyperplasia can be given a “chemical D&C” ie. Cyclic progesterone

Warn patients that first menses will be very heavy and subsequently normalize

Patients with markedly thickened endometrium may have bleeding heavy enough to require surgical intervention with a D&C

Rule of thumb: Call for evaluation if bleeding more than 1 pad per hour, lightheadedness or faintingSlide20

Atrophic Endometritis and Vaginitis

The most common organic cause of postmenopausal uterine bleeding (30 %)

All postmenopausal bleeding needs investigation

An endometrial stripe under 5mm is reassuring

Tamoxifen

treatment causes changes in the endometrium that can be confusing and lead to false positive results.Slide21

ENDOMETRITISInflammation within the endometrium

Rarely causes fever

Symptoms include foul smelling discharge and low pelvic achiness

Generally is preceded by instrumentation or delivery

A tender uterus with negative cultures can be somatic dysfunction – treat with osteopathic manipulation

Infections treated with

Cefoxitin

or Ampicillin/sulbactamSlide22

UTERINE LEIOMYOMAS (FIBROIDS)

Fibroids are benign growths emanating from the myometrium

Classified as

subserosal

,

submucousal

, intramural, cervical or

pedunculatedDiagnosed by palpation and by ultrasoundCan cause bleeding, pressure and painSlide23

UTERINE LEIOMYOMAS (FIBROIDS)

Definitive treatment is surgical

Lupron

Depo

may be used as a

temporizing treatment

to shrink tumors prior to surgery – effect lasts about three months

May be approached laparoscopically, hysteroscopically, open laparotomy or by robotic surgeryInterventional radiologists may use embolization techniquesConsider microwave ablationSlide24

TREATING UTERINE FIBROIDSTreatment not required if not symptomatic

Hysteroscopic

myomectomy for

submucous

fibroids

Laparoscopic/robotic myomectomy

Open myomectomy

Hysterectomy – Vaginal, Laparoscopic/robotic, open laparotomySlide25

LAPAROSCOPIC MYOMECTOMY

Myomenukleation.jpg

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UTERINE ARTERY EMBOLIZATION

Can be a viable alternative to hysterectomy in patients with one or several dominant fibroids

Hospitalization is often needed overnight for pain relief after the procedure

28.4% of 88 patients had hysterectomy after 5 year follow up in one

studySlide27

ENDOMETRIAL POLYPS

Endometrial polyps are fleshy outgrowths of the endometrium

Can cause profuse life-threatening bleeding

Can be removed by sharp curettage or by

hysteroscopic

resection

Polyps sometimes outgrow their blood supply and break down with significant

bleedingSlide28

ADENOMYOSIS

Characterized by increasingly severe menorrhagia and pelvic pain

Symmetrically enlarged uterus is tender and boggy to palpation

Pockets of endometrial glands and

stroma

within the myometrium cause an inflammatory reaction

Hysterectomy is the only definitive diagnostic

optionSlide29

ENDOMETRIAL ADENOCARCINOMA

Rule out with any post-menopausal bleeding or heavy bleeding in younger patients

Usually can be diagnosed by endometrial biopsy

Early stage low grade treated with surgery alone

Appropriate to treat low grade disease with progesterone in patients who are poor surgical candidatesSlide30

UTERINE SARCOMAS

Sarcomas make up about 3% of uterine cancers

Come from the stromal components of the uterus

Malignant cells may not be found on curettage

Leiomyosarcomas

cause a rapidly enlarging uterus

2-5 year survival is

poor

HomologusHeterogenousLeiomyosarcomaRhabdomyosarcomaEndometrial stromal sarcomaChondrosarcoma, OsteosarcomaEndometrial sarcomaLiposarcoma

CarcinocarcomaMalignant Mixed Mesodermal tumorSlide31

WHAT ABOUT ROBOTICS?

A Comparison of Quality Outcome Measures in Patients Having a Hysterectomy for Benign Disease: Robotic vs. Non-robotic Approaches

Conclusions

Lower chance

of readmission <30 days after surgery compared

with

laparoscopic, abdominal (open) hysterectomy, and vaginal approaches.

Shorter length of stayLess estimated blood lossCost savings associated with readmissions when compared to non-robotic approaches. Prospective registries recommended to track

quality outcomes, total sum of costs including 30 days follow-up, as well as patient-related quality of life benefitsSlide32

Questions?Slide33

ReferencesHacker & Moore's Essentials of Obstetrics and Gynecology, 5th Edition. Saunders/Elsevier 2010.

A Comparison of Quality Outcome Measures in Patients Having a Hysterectomy for Benign Disease: Robotic vs. Non-robotic

ApproachesMartin

A. Martino, Elizabeth A. Berger, Jeffrey T.

McFetridge

, Jocelyn

Shubella

, Gabrielle Gosciniak, Taylor Wejkszner, Gregory F. Kainz, Jeremy Patriarco, M. Bijoy Thomas, Richard Boulay The Journal of Minimally Invasive Gynecology - 28 October 2013 (10.1016/j.jmig.2013.10.008)Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 5-year outcome from the randomized EMMY trial Sanne M. van der

Kooij, MDa, b, Corresponding author contact information, E-mail the corresponding author, Wouter J.K. Hehenkamp, MD, PhDa, Nicole A. Volkers, MD, PhDa, Erwin Birnie, PhDc, Willem M. Ankum, MD, PhDb, Jim A. Reekers, MD, PhD