Abnormal Uterine Abnormal Uterine BleedingBleeding

Douglas Brown M.D.Douglas Brown M.D.

GYNOSPEAKGYNOSPEAK

Dysfunctional Uterine Bleeding – non-Dysfunctional Uterine Bleeding – non-menstrual bleeding due to failure of menstrual bleeding due to failure of ovulationovulation

May be frequent e.g. every 2 weeksMay be frequent e.g. every 2 weeks May be infrequent e.g. every 6 May be infrequent e.g. every 6

monthsmonths Generally heavier than mensesGenerally heavier than menses

More GynospeakMore Gynospeak

Menorrhagia – heavy menstrual bleedingMenorrhagia – heavy menstrual bleeding Menometrorrhagia – heavy irregular Menometrorrhagia – heavy irregular

bleeding – may be DUB or organicbleeding – may be DUB or organic Midcycle bleeding – periovulatory Midcycle bleeding – periovulatory

bleeding, usually light, lasting 1-5 daysbleeding, usually light, lasting 1-5 days Premenstrual bleeding – spotting or light Premenstrual bleeding – spotting or light

bleeding 2-7 days prior to menses, bleeding 2-7 days prior to menses, leading into mensesleading into menses

Even More GynospeakEven More Gynospeak

Breakthrough bleeding (BTB) – irregular Breakthrough bleeding (BTB) – irregular bleeding associated with exogenous bleeding associated with exogenous hormone use such as OCPs ot HRThormone use such as OCPs ot HRT

Oligomenorrhea – infrequent menses, Oligomenorrhea – infrequent menses, generally less often than every 6 weeksgenerally less often than every 6 weeks

Postmenopausal bleeding – occurs afer Postmenopausal bleeding – occurs afer 1 year following cessation of menses1 year following cessation of menses

AdolescentAdolescent

Expect DUB with the first several Expect DUB with the first several “periods” as the hypothalamus matures“periods” as the hypothalamus matures

Regular menses may take a year to Regular menses may take a year to developdevelop

DUB more likely to be chronic in obese DUB more likely to be chronic in obese teens (?genetic?) Watch for PCOteens (?genetic?) Watch for PCO

Watch for amenorrhea in athletic teensWatch for amenorrhea in athletic teens Consider OCPs, calcium supplementConsider OCPs, calcium supplement

Adolescent MenorrhagiaAdolescent Menorrhagia

Distinguish menorrhagia from DUBDistinguish menorrhagia from DUB 15-20% of teens requiring 15-20% of teens requiring

transfusion will have a coagulation transfusion will have a coagulation disorderdisorder

Von Willebrand’s is most commonVon Willebrand’s is most common If VW test other women in familyIf VW test other women in family

Isolated Early or Late Isolated Early or Late MensesMenses

Most common etiology is stressMost common etiology is stress Change in environmentChange in environment Short term corticosteroid useShort term corticosteroid use Exclude pregnancy with home test or Exclude pregnancy with home test or

serum HCGserum HCG The Holiday RuleThe Holiday Rule

Meds and Medical Meds and Medical conditionsconditions

Hyper and hypo thyroidismHyper and hypo thyroidism Chronic renal or endocrine diseaseChronic renal or endocrine disease EndometriosisEndometriosis Hyperprolactinemia due to CNS or Hyperprolactinemia due to CNS or

pituitary diseasepituitary disease PhenothiazenesPhenothiazenes MetoclopromideMetoclopromide TricyclicsTricyclics

Postcoital BleedingPostcoital Bleeding

Cervical lesion – polyp, cancer, Cervical lesion – polyp, cancer, ectropionectropion

Vaginal atrophyVaginal atrophy EndometritisEndometritis Unstable or atrophic endometrium due Unstable or atrophic endometrium due

to OCs, HRT or Depoproverato OCs, HRT or Depoprovera Endometrial polyp or myomaEndometrial polyp or myoma Have a low threshold for endometrial Have a low threshold for endometrial

biopsybiopsy

Bleeding with ContraceptionBleeding with Contraception

BTB with OCs – change pills – increase BTB with OCs – change pills – increase estrogen, change progestinestrogen, change progestin

Depoprovera or minipill – add estrogen Depoprovera or minipill – add estrogen until bleeding stopsuntil bleeding stops

Paraguard copper IUD –irregular Paraguard copper IUD –irregular bleeding, menorrhagia – may be bleeding, menorrhagia – may be endometritisendometritis

Mirena levonorgestrel IUD – may Mirena levonorgestrel IUD – may cause 2-4 months irregular bleeding, cause 2-4 months irregular bleeding, then hypomenorrhea or amenorrheathen hypomenorrhea or amenorrhea

DUBDUB

Due to anovulationDue to anovulation Distinguish from oligomenorrheaDistinguish from oligomenorrhea Risk is endometrial hyperplasia or CaRisk is endometrial hyperplasia or Ca Consider endometrial biopsy (later)Consider endometrial biopsy (later) If chronic evaluate for PCOIf chronic evaluate for PCO Draw fasting glucose and insulinDraw fasting glucose and insulin

DUB Acute therapyDUB Acute therapy

IV premarin 25mg q 4-6 hrs – IV premarin 25mg q 4-6 hrs – vasospasmvasospasm

Monophasic OCs “OCP Taper” – qid Monophasic OCs “OCP Taper” – qid for 4 days, tid for 3 days, bid for 2 for 4 days, tid for 3 days, bid for 2 days, daily for remainder of two days, daily for remainder of two packspacks

MPA (provera,cycrin) – 10 mg MPA (provera,cycrin) – 10 mg 2-3x/day for 2 weeks 2-3x/day for 2 weeks

DUB long term therapyDUB long term therapy

OCPsOCPs Withdrawal with progestin for 10-14 Withdrawal with progestin for 10-14

days every 6-8 weeksdays every 6-8 weeks Use provera 10 mg, prometrium 100 Use provera 10 mg, prometrium 100

mg, aygestin 2.5 – 5 mgmg, aygestin 2.5 – 5 mg

MenorrhagiaMenorrhagia

MyomaMyoma PolypPolyp Coagulation DisorderCoagulation Disorder ““Humoral”Humoral” IdiopathicIdiopathic

Uterine MyomaUterine Myoma

Menorrhagia is most common Menorrhagia is most common symptomsymptom

Look for intramural or submucous Look for intramural or submucous myomasmyomas

Interruption of contractile hemostasisInterruption of contractile hemostasis Dx with ultrasoundDx with ultrasound Smell any fish?Smell any fish?

Therapy for MyomasTherapy for Myomas

Continuous OCPsContinuous OCPs GnRH agonists e.g LupronGnRH agonists e.g Lupron Myomectomy/HysterectomyMyomectomy/Hysterectomy Operative hysteroscopyOperative hysteroscopy Uterine artery embolizationUterine artery embolization Post-DUBYA – Mifepristone 50 Post-DUBYA – Mifepristone 50

mg/daymg/day

Humoral MenorrhagiaHumoral Menorrhagia

Diagnosis of exclusionDiagnosis of exclusion Consider coagulopathy workup – 10%Consider coagulopathy workup – 10% Diff Dx: VWDz, Diff Dx: VWDz,

thrombocytopenia,TTP, ITP,vasculitis, thrombocytopenia,TTP, ITP,vasculitis, liver diseaseliver disease

Desmopressin nasal spray for VW DzDesmopressin nasal spray for VW Dz

Medical TherapyMedical Therapy

NSAIDs – Ibuprofen, Naproxen, NSAIDs – Ibuprofen, Naproxen, Mefenamic acid (meclomen, ponstel)Mefenamic acid (meclomen, ponstel)

OCPs – consider continuous regimenOCPs – consider continuous regimen DepoproveraDepoprovera Iron replacementIron replacement Endometrial ablation – Rollerball, Endometrial ablation – Rollerball,

Novasure (mesh), Thermachoice Novasure (mesh), Thermachoice (balloon), MEA (microwave)(balloon), MEA (microwave)

PerimenopausePerimenopause

Oligomenorrhea if you’re luckyOligomenorrhea if you’re lucky Anovulatory biweekly “menorrhagia” Anovulatory biweekly “menorrhagia”

if you’re notif you’re not Therapy – low dose OCPs or higher Therapy – low dose OCPs or higher

dose HRT such as Activella or dose HRT such as Activella or FemHRTFemHRT

Don’t forget space-occupying diseaseDon’t forget space-occupying disease

PostmenopausePostmenopause

All postmenopausal bleeding is cancer All postmenopausal bleeding is cancer until proven otherwiseuntil proven otherwise

90% of BTB due to atrophy90% of BTB due to atrophy Prove it with endometrial Bx or TV U/SProve it with endometrial Bx or TV U/S On U/S endometrial “stripe” should be On U/S endometrial “stripe” should be

less than 5 mmless than 5 mm BTB common in new start HRTBTB common in new start HRT Obese patients may require withdrawalObese patients may require withdrawal