Abnormal Uterine Bleeding

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Abnormal Uterine Bleeding

• Cullen Archer, MD
• Assistant Professor
• Obstetrics and Gynecology
• UT Health Science Center at San Antonio

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Definitions

• Menses cyclic regular uterine bleeding occurring
  every 28 days with 4 days duration
• Menometrorrhagia prolonged uterine bleeding
  occurring at irregular intervals
• Menorrhagia (hypermenorrhea) prolonged (more
  than 7 days) or excessive (greater than 80 cc)
  uterine bleeding occurring at regular intervals.
• Polymenorrhea uterine bleeding occurring at
  regular intervals of less than 21 days
• Oligomenorrhea infrequent uterine bleeding
  occurring at irregular intervals from every 35
  days to 6 months
• Amenorrhea no menses for at least 6 months
• Dysfunctional Uterine Bleeding excessive uterine
  bleeding with no demonstrable organic cause. It
  is most frequently due to abnormalities of
  endocrine origin, particularly anovulation.

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How much is too much?

• 40 of women with blood loss gt 80 cc considered
  their menstrual flow to be small or moderate in
  amount (Halberg, et. al.)
• 14 of women with blood loss lt 20 cc thought
  menses was too heavy.
• Blood loss gt 80 cc per cycle is associated with
  significantly lower hemoglobin, hematocrit, and
  serum iron levels than women with less menstrual
  blood loss (Halberg).

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Classification

• Organic
• Inorganic (Dysfunctional)
• Diagnosis of exclusion
• Anovulatory
• Ovulatory

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Organic AUB

• Systemic Disease
• Coagulopathy
• Hypothyroidism
• Cirrhosis
• Genital tract disease

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Coagulopathies

• Von Willebrands disease
• Prothrombin deficiency
• Leukemia
• Sepsis
• ITP
• Hypersplenism

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Hypothyroidism

• Frequently associated with menorrhagia as well as
  intermenstrual spotting
• Incidence 0.3 to 2.5 among women with
  menorrhagia

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Organic AUB

• Systemic Disease
• Coagulopathy
• Hypothyroidism
• Cirrhosis
• Genital tract disease

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Genital Tract Disease

• Pregnancy
• Malignancy
• Infection
• Anatomic uterine abnormalities
• Foreign bodies (IUD)
• Oral and injectable steroids (OCPs and HRT)

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Pregnancy

• Intrauterine pregnancy
• Threatened abortion
• Incomplete abortion
• Complete abortion
• Missed abortion
• Ectopic

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Malignancy

• Cervical cancer
• Endometrial cancer
• Estrogen producing ovarian tumors

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Infection

• Endometritis
• Cervicitis
• Postcoital bleeding

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Anatomic Abnormalities

• Leiomyomata
• Submucosal
• Intramural
• Endometrial polyps
• Adenomyosis

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Dysfunctional (inorganic)

• Anovulatory DUB
• Ovulatory DUB

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Anovulatory DUB

• Predominant in the postmenarchal and
  premenopausal years
• Continuous estradiol production without corpus
  luteum formation and progesterone production
• steady state of estrogen stimulation leads to a
  continuously proliferating endometrium, which may
  outgrow its blood supply or lose nutrients with
  varying degree of necrosis
• In contrast to normal menses, uniform slough to
  the basalis layer does not occur, which produces
  excessive uterine blood flow

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Ovulatory DUB

• occurs most commonly after adolescent years and
  before perimenopausal years
• incidence 10 of ovulatory women

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Management

• Hypothyroidism
• 50-200 mcg LT4 daily resulted in disappearance of
  menorrhagia within 3-6 months

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Management

• Leiomyomata
• OCPs
• Myomectomy
• Leuprolide acetate 3.75 mg IM qmonth x3
• Hysterectomy
• Uterine artery embolization
• Endometrial polyps
• Hysteroscopy, DC
• Adenomyosis
• OCPs
• GnRH analog
• Hysterectomy

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Acute DUB

• Estrogens
• In pharmacologic doses causes rapid groth of the
  endometrium over denuded tissue
• CEE 10 mg/d po in 4 divided doses should control
  within 24 hours (if not, 20 mg)
• IV route for acute menorrhagia (25mg IV q 3hr x2
  3-6 hours for effect)
• Progestins
• Because most women with acute menorrhagia bleed
  because of anovulation, progestin therapy is also
  indicated
• MPA 10 mg daily with estrogen x 7-10 days
• OCP taper (or high dose) x 7 days

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Progestins

• Stop endometrial growth
• Support and organize the endometrium
• Organized slough to the basalis layer occurs
  after withdrawal allowing a rapid cessation of
  bleeding
• Long-term treatment of choice for anovulatory DUB
• Not as effective for acute bleeding

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Levonorgestrol IUD

• 80 reduction in menstrual blood loss at 3 months
  and 100 at one year
• Particularly effective in women with ovulatory DUB

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Levonorgestrol IUD

• is contraindicated when one or more of the
  following conditions exist
• Pregnancy or suspicion of pregnancy
• Congenital or acquired uterine anomaly, including
  fibroids if they distort the uterine cavity
• Acute pelvic inflammatory disease or a history of
  pelvic inflammatory disease, unless there has
  been a subsequent intrauterine pregnancy
• Postpartum endometritis or infected abortion in
  the past 3 months
• Known or suspected uterine or cervical neoplasia,
  or unresolved abnormal Pap smear
• Genital bleeding of unknown etiology
• Untreated acute cervicitis or vaginitis,
  including bacterial vaginosis or other lower
  genital tract infections, until infection is
  controlled
• Acute liver disease or liver tumor (benign or
  malignant)
• Woman or partner has multiple sexual partners
• Conditions associated with increased
  susceptibility to infections with microorganisms.
  Such conditions include, but are not limited to,
  leukemia, acquired immune deficiency syndrome
  (AIDS), and I.V. drug abuse
• Genital actinomycosis
• A previously inserted IUD that has not been
  removed
• Hypersensitivity to any component of this product
  
• Known or suspected carcinoma of the breast
• History of ectopic pregnancy or condition that
  would predispose to ectopic pregnancy

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NSAIDs

• Reduce MBL particularly in women who ovulate by
  20-50
• A complete understanding of MOA not known
• Mefenamic acid 500mg TID
• Ibuprofen 400mg TID
• Meclofenamate 100mg TID
• Naproxen-Na 275mg q6hr after 550mg load

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Endometrial Ablation

• Rollerball
• Thermachoice Balloon
• Novasure
• Contraindications
• Desires future fertility
• Complications
• Fluid overload
• Uterine perforation
• Thermal damage to adjacent organs

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• INDICATIONS
• The GYNECARE THERMACHOICE UBT System is a thermal
  balloon ablation device intended to ablate the
  endometrial lining of the uterus in premenopausal
  women with menorrhagia (excessive uterine
  bleeding) due to benign causes for whom
  childbearing is complete.
• CONTRAINDICATIONS
• The device is contraindicated for use in
• A patient with known or suspected endometrial
  carcinoma (uterine cancer) or premalignant change
  of the endometrium, such as unresolved
  adenomatous hyperplasia.
• A patient with any anatomic or pathologic
  condition in which weakness of the myometrium
  could exist, such as history of previous
  classical cesarean sections or transmural
  myomectomy.
• A patient with active genital or urinary tract
  infection at the time of procedure (e.g.,
  cervicitis, vaginitis, endometritis, salpingitis,
  or cystitis).
• A patient with an intrauterine device (IUD)
  currently in place.
• A patient who is pregnant or who wants to
  become pregnant in the future.

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• Indications
• NovaSure Endometrial Ablation is intended to
  ablate the endometrial lining of the uterus in
  premenopausal women with menorrhagia (heavy
  menstrual bleeding) due to benign causes for whom
  childbearing is complete.
• Contraindications
• NovaSure Endometrial Ablation is contraindicated
  for use in patients who
• Are pregnant or want to become pregnant in the
  future pregnancies following ablation can be
  dangerous for both mother and fetus.
• Have known or suspected endometrial carcinoma
  (uterine cancer) or pre-malignant conditions of
  the endometrium, such as unresolved hyperplasia.
• Have any anatomic or pathologic condition in
  which weakness of the myometrium could exist,
  such as history of previous classical cesarean
  section or transmural myomectomy.
• Have active genital or urinary tract infections
  at the time of the procedure (e.g., cervicitis,
  vaginitis, endometritis, salpingitis, or
  cystitis).
• Have an intrauterine device (IUD) in place.
• Have a uterine cavity length less than 4 cm. (The
  minimum length of the electrode array is 4 cm
  treatment of a shorter uterine cavity will result
  in thermal injury to the endocervical canal).
• Have active pelvic inflammatory disease.

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Hysterectomy

• History of
• Excessive bleeding evidenced by
• Menorrhagia or polymenorrhea
• Anemia due to chronic blood loss
• Failure of hormonal treatment or contraindication
  to its use
• No current medication that can cause bleeding, or
  contraindication to stopping
• Endometrial sampling performed
• No evidence of remediable pathology by one of the
  following
• SHG
• Hysteroscopy
• HSG
• Consideration of alternate therapies
• Assessment of surgical risk from anemia and need
  for treatment