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©2016 MFMER | slide-1
Heavy or Irregular Menstrual Bleeding: When to Intervene?
Shannon K. Laughlin-Tommaso, MD MPH Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology November 2 & 16, 2016
©2016 MFMER | slide-2
Disclosures • Supported by RC1HD063312 and R01HD060503 from
the NICHD/NIH and HS23418 from AHRQ/PCORI
• Funding to Mayo Clinic from Insightec, Ltd (Israel) for Focused Ultrasound Ablation trials
• Royalties from UpToDate for uterine fibroids
• Will discuss off-label uses of hormonal medications
©2016 MFMER | slide-3
Objectives • Review new nomenclature • Discuss evaluation: what is abnormal? • Offer treatment options individualized to patient
concerns
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What does “dysmenorrhea” mean? 1. Irregular menses 2. Heavy menses 3. Painful menses 4. Frequent menses
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What does “dysmenorrhea” mean? 1. Irregular menses 2. Heavy menses 3. Painful menses 4. Frequent menses
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What does “polymenorrhea” mean? 1. Irregular menses 2. Heavy menses 3. Painful menses 4. Frequent menses
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What does “polymenorrhea” mean? 1. Irregular menses (oligomenorrhea) 2. Heavy menses (menorrhagia) 3. Painful menses (dysmenorrhea) 4. Frequent menses (polymenorrhea)
©2016 MFMER | slide-8
Nomenclature
Out
• Dysfunctional bleeding • Menorrhagia
• Metrorrhagia
• Polymenorrhea
• -orrhea/orrhagia
In
• Abnormal uterine bleeding
• Heavy menstrual bleeding
• Intermenstrual bleeding
• Frequent menses
Munro, 2011.
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Describe bleeding… • Regularity
• Duration
• Frequency
• Volume
• Regular (less than 20 days variation) • Irregular • Absent
• Normal (5 days) • Prolonged • Shortened
• Normal (every 21-35 days) • Frequent • Infrequent
• Normal (5-80 mL*) • Heavy • Light
*changing protection more frequently than every 2 hours or any bleeding that interferes with activity/interrupts sleeping
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Is her bleeding abnormal?
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Case 1 • 52 year old parous woman with menses every
21 days, except she skipped March and June. Bleeds for 4 days. On day 2, she changes her pad every 3 hours.
• Started having hot flashes in February
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Is this normal? 1. Yes 2. No
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Is this normal? 1. Yes 2. No
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Case 2 • 46 year old parous woman with menses every
30-35 days. Bleeds for 4-9 days. On her heaviest days, she changes her pad and tampon every hour. At night she bleeds onto her sheets.
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Is this normal? 1. Yes 2. No
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Is this normal? 1. Yes 2. No
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Diagnosis for Case #2: • Heavy, regular, prolonged menstrual bleeding
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Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
Day 8
Day 9
Day 10
Day 11
Day 12
Total Tallies
Multiplying Factor ROW TOTAL
x1
x5
x20
x1
x5
x10
x1
x5
x5
Number of menstrual accidents
Amount of menstrual bleedingDo not use a check mark - indicate how many used (i.e. 1, 2, 3…) on
each day
PBLAC Score (sum of Row Totals)
Small blood clots (small coin)
Large blood clots (> quarter)
PICTORIAL BLOOD LOSS ASSESSMENT CHART FOR THE PREVIOUS MONTH
Instructions: 1. Indicate THE NUMBER (i.e., 1, 2, 3...) of sanitary pads and/or tampons that you used on each day of your last menstrual period. 2. Choose the picture that most closely represents the degree of staining of each pad or tampon used. 3. Indicate the presence and size of blood clots passed during your last menstrual period. 4. Indicate the occurrence of any menstrual accident during your last menstrual period (underwear, chair, or bed sheet soilage) in spite of protection.
Pictorial Blood Loss (2)
Mayo Clinic #: ______- _________ - ______ Patient's name: ___________________________________ Date: _______________________
Instructions: 1. Indicate THE NUMBER (i.e., 1, 2, 3...) of sanitary pads and/or tampons that you used on each day of your last menstrual period. 2. Choose the picture that most closely represents the degree of staining of each pad or tampon used. 3.
PICTORIAL BLOOD LOSS ASSESSMENT CHART FOR THE PREVIOUS MONTH
Amount of menstrual bleedingDo not use a check mark - indicate how many used (i.e. 1, 2, 3…) on each dayDay 1Day 2Day 3Day 4Day 5Day 6Day 7Day 8Day 9Day 10Day 11Day 12Total TalliesMultiplying FactorROW TOTAL
x1
x5
x20
x1
x5
x10
Small blood clots (small coin)x1
Large blood clots (> quarter)x5
Number of menstrual accidentsx5
PBLAC Score (sum of Row Totals)
©2016 MFMER | slide-19
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
Day 8
Day 9
Day 10
Day 11
Day 12
Total Tallies
Multiplying Factor ROW TOTAL
x1
x5
x20
x1
x5
x10
x1
x5
x5
Number of menstrual accidents
Amount of menstrual bleedingDo not use a check mark - indicate how many used (i.e. 1, 2, 3…) on
each day
PBLAC Score (sum of Row Totals)
Small blood clots (small coin)
Large blood clots (> quarter)
PICTORIAL BLOOD LOSS ASSESSMENT CHART FOR THE PREVIOUS MONTH
Instructions: 1. Indicate THE NUMBER (i.e., 1, 2, 3...) of sanitary pads and/or tampons that you used on each day of your last menstrual period. 2. Choose the picture that most closely represents the degree of staining of each pad or tampon used. 3. Indicate the presence and size of blood clots passed during your last menstrual period. 4. Indicate the occurrence of any menstrual accident during your last menstrual period (underwear, chair, or bed sheet soilage) in spite of protection.
2 2 3 3
3 3
35 7 6 120
30 6
207
3 2 2 2
3 1 1
3 15 5
Pictorial Blood Loss (2)
Mayo Clinic #: ______- _________ - ______ Patient's name: ___________________________________ Date: _______________________
Instructions: 1. Indicate THE NUMBER (i.e., 1, 2, 3...) of sanitary pads and/or tampons that you used on each day of your last menstrual period. 2. Choose the picture that most closely represents the degree of staining of each pad or tampon used. 3.
PICTORIAL BLOOD LOSS ASSESSMENT CHART FOR THE PREVIOUS MONTH
Amount of menstrual bleedingDo not use a check mark - indicate how many used (i.e. 1, 2, 3…) on each dayDay 1Day 2Day 3Day 4Day 5Day 6Day 7Day 8Day 9Day 10Day 11Day 12Total TalliesMultiplying FactorROW TOTAL
x1
x5
x20
x1
x5
x10
Small blood clots (small coin)x1
Large blood clots (> quarter)x5
Number of menstrual accidentsx5
PBLAC Score (sum of Row Totals)
©2016 MFMER | slide-20
Case 3 • 41 year old nulliparous woman with menses
every 3 to 6 months that vary from very light to heavy with clots. Duration: 3-5 days
©2016 MFMER | slide-21
Is this normal? 1. Yes 2. No
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Is this normal? 1. Yes 2. No
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Diagnosis for Case #3: • Irregular, occasionally heavy, infrequent
menstrual bleeding
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FIGO staging: the PALM-COEIN method
• Polyp
• Adenomyosis
• Leiomyoma (Fibroid)
• Malignancy (hyperplasia)
• Coagulopathy
• Ovulatory dysfunction
• Endometrial disorders (local endometrial hemostasis)
• Iatrogenic (exogenous steroids, IUDs)
• Not yet classified
Structural
Medical
Munro, 2011; Munro, 2011; Munro, 2011
©2016 MFMER | slide-25
Evaluation Simplified
• Endometrial biopsy
• Coagulopathy • Infection
•Ultrasound
• Pregnancy test • TSH • PCOS • Iatrogenic
Hormonal Structural
Endometrial Other
©2016 MFMER | slide-26
Other clues for hormone-associated bleeding • Pregnancy
• Fatigue, weight gain
• Hirsutism/virilization
• Headaches/vision changes
• Hot flashes
• Until age 56!
• Thyroid
• PCOS/androgen
• Hyperprolactinemia
• Premature Ovarian Failure or menopause
©2016 MFMER | slide-27
Diagnosis for Case #3: • Irregular, occasionally heavy, infrequent
menstrual bleeding
• Additional clues: Class 2 obesity, acne, hirsutism, and infertility PCOS & at risk for hyperplasia
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Hormonal causes: Iatrogenic
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Hormonal Causes: Iatrogenic • Progestin-only IUDs, implants, or pills can
cause irregular bleeding • Bleeding should be lighter • Heavy, irregular bleeding should be evaluated
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Evaluation Simplified
• Endometrial biopsy
• Coagulopathy • Infection
•Ultrasound
• Pregnancy test • TSH • PCOS • Iatrogenic
Hormonal Structural
Endometrial Other
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Diagnosis for Case #2: • Heavy, regular, prolonged menstrual bleeding
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Fibroids
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Adenomyosis
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Evaluation Simplified
• Endometrial biopsy
• Coagulopathy • Infection
•Ultrasound
• Pregnancy test • TSH • PCOS • Iatrogenic
Hormonal Structural
Endometrial Other
©2016 MFMER | slide-39
When to biopsy? • American College of Obstetrics & Gynecology:
• Women 45+ • Women 35 + risk factor
ACOG practice bulletin, 2012
©2016 MFMER | slide-40
Risks for hyperplasia/endometrial cancer • Age
• White race
• Obesity
• Nulliparity
• Infertility
• Late menopause
• Early menarche
• Unopposed estrogen
• Tamoxifen
• Diabetes mellitus
• Hypertension
• Lynch syndrome
• Irregular bleeding
• *Thickened endometrial stripe
• *Recurrent postmenopausal bleeding
©2016 MFMER | slide-41
Evaluation Simplified
• Endometrial biopsy
• Coagulopathy • Infection
•Ultrasound
• Pregnancy test • TSH • PCOS • Iatrogenic
Hormonal Structural
Endometrial Other
©2016 MFMER | slide-42
Coagulopathy • 13% of heavy menstrual bleeding • History:
• Postpartum hemorrhage • Bleeding with dental work • Family history of bleeding symptoms
• Symptoms: • Bruising or epistaxis 1-2 x per month • Frequent gum bleeding
ACOG practice bulletin, 2012
©2016 MFMER | slide-43
Coagulopathy • von Willebrand disease
• vWF-ristocetin cofactor activity • vWF antigen • Facto VIII
• PT, PTT, Platelets • Medication review: warfarin, low-molecular
weight heparin, rivaroxaban (and similar)
ACOG practice bulletin, 2012
©2016 MFMER | slide-44
Infection • Chronic endometritis
• Tender uterus • Cultures:
• Mycoplasma/Ureaplasma • Endometrial biopsy
• Cervicitis • PCR: Gonorrhea/Chlamydia
©2016 MFMER | slide-45
Treatment options
©2016 MFMER | slide-46
Not all abnormal bleeding needs treatment • **But it needs evaluation! • Reassurance • Discuss anemia and quality of life • Ovulatory dysfunction could put them at risk for
hyperplasia/cancer • Generally want a bleeding episode at least
every 3 months
©2016 MFMER | slide-47
Treat the abnormality • Structural:
• Polypectomy (in office) • Myomectomy
• Hyperplasia • Simple/Complex without atypia:
• Progestin therapy with repeat biopsy • Hyperplasia with atypia or Cancer:
• Hysterectomy
©2016 MFMER | slide-48
Treat the abnormality • Coagulopathy
• DDAVP at start of menses • Anti-fibrinolytics:
• Aminocaproic acid or tranexamic acid • Consider other heavy bleeding therapies
(pills, IUD, ablation, etc.)
• Infection • Chronic endometritis: doxycycline 100mg
twice daily x 10 days
©2016 MFMER | slide-49
Heavy bleeding is easier to treat • Non-hormonal options
• Treat during cycle • Benefit of Contraception:
• Combined estrogen-progestin • Progestin-only
• Surgical • Endometrial ablation • Hysterectomy
©2016 MFMER | slide-50
Treating only during the cycle • Tranexamic Acid:
• Reduces bleeding 26-54%1 • 650mg x 2 pills (1300 mg) three times a day • During the heavy days, up to 5 days • Not always helpful for painful periods • VTE risk
• NSAIDs: • Naproxen: 500mg first dose, 250mg every 8 hours • Mefanamic acid: 500 mg three times per day • Ibuprofen: 600 mg daily
Lukes et al, 2010
©2016 MFMER | slide-51
Providing contraception • Combined estrogen/progestins:
• Not an option for women with hypertension, risk of thrombosis, or smokers over 35
• Great if planning a pregnancy in the near future
• Regular Cycles, reduces bleeding 30-40% • Levonorgestrel IUD:
• 52mcg/day, lasts 5 years • Decreases bleeding 71-90%2
2Kaunitz et al, 2009
©2016 MFMER | slide-52
Not confirmed, but probably work: • Continuous progestin-only pills
• Irregular at first, but eventually lighter • Less reliable as contraceptive
• Etonorgestrel implant* & lower dose levonorgestrel IUDs:
• Irregular at first, but eventually lighter • Highly reliable as contraceptive • *Great in women with uterine anomaly or
structural abnormality
©2016 MFMER | slide-53
Surgical options • *Must be done child-bearing • Endometrial ablation1
• 5 second generation techniques • In office or with anesthesia • 80-90% reduction in bleeding • Requires reliable contraception
• Hysterectomy
1ACOG Practice Bulletin, 2007
©2016 MFMER | slide-54
Irregular bleeding: the ovaries fault • Suppress ovaries:
• Combined estrogen-progestin provide most regular cycles
• Problematic for women at risk • Implants/injection work too
• Force a period • Cyclic progestin to mimic the cycle
• Medroxyprogesterone 10mg x 10 days (days 16-25)
©2016 MFMER | slide-55
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Treating irregular bleeding • Suppress the endometrium:
• Levonorgestrel IUD
• Note: Endometrial ablation is not indicated for irregular bleeding
• Puts women at risk for undiagnosed uterine cancer
• Hysterectomy
©2016 MFMER | slide-57
Thank you!
Abnormal Uterine Bleeding Clinic: MDs: NPs: Ola Famuyide Lois McGuire Dan Breitkopf Jenna Miller Matthew Hopkins Lisa Ahlberg Isabel Green Tatnai Burnett Shannon Laughlin-Tommaso
©2016 MFMER | slide-58
References • ACOG Practice Bulletin. Clinical management guidelines for obstetricians-gynecologists Number
81, May 2007.
• ACOG Practice Bulletin. Diagnosis of abnormal uterine bleeding in reproductive-aged women. Number 128, July 2012.
• Kaunitz AM et al. Levonorgestrel-releasing intrauterine system and endometrial ablation in heavy menstrual bleeding: a systematic review and meta-analysis. Obstet Gynecol, 2009.
• Lukes et al. Tranexamic Acid Treatment for Heavy Menstrual Bleeding; A Randomized Controlled Trial. Obstet Gynecol, 2010.
• Munro MG, Critchley HO, Broder MS, Fraser IS. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet, 2011.
• Munro MG, Critchley HO, Fraser IS. The flexible FIGO classification concept for underlying causes of abnormal uterine bleeding. Semin Reprod Med, 2011.
• Munro MG, Critchley HO, Fraser IS. The FIGO classification of causes of abnormal uterine bleeding in the reproductive years. Fertility and Sterility, 2011.
Heavy or Irregular Menstrual Bleeding: When to Intervene?�DisclosuresObjectivesWhat does “dysmenorrhea” mean?What does “dysmenorrhea” mean?What does “polymenorrhea” mean?What does “polymenorrhea” mean?NomenclatureDescribe bleeding…Is her bleeding abnormal?Case 1Is this normal? Is this normal? Case 2Is this normal? Is this normal? Diagnosis for Case #2:Slide Number 18Slide Number 19Case 3Is this normal? Is this normal? Diagnosis for Case #3: FIGO staging: the PALM-COEIN methodEvaluation SimplifiedOther clues for hormone-associated bleedingDiagnosis for Case #3: Hormonal causes: IatrogenicHormonal Causes: IatrogenicEvaluation SimplifiedDiagnosis for Case #2:Slide Number 32Slide Number 33Slide Number 34Slide Number 35Slide Number 36AdenomyosisEvaluation SimplifiedWhen to biopsy?Risks for hyperplasia/endometrial cancerEvaluation SimplifiedCoagulopathyCoagulopathyInfectionTreatment optionsNot all abnormal bleeding needs treatmentTreat the abnormalityTreat the abnormalityHeavy bleeding is easier to treatTreating only during the cycleProviding contraceptionNot confirmed, but probably work:Surgical optionsIrregular bleeding: the ovaries faultSlide Number 55Treating irregular bleeding�Thank you!��[email protected]