Normal

1
Normal Abnormal Uterine Bleeding

• Suzanne Bush, MD, FACOG
• Clinical Associate Professor
• FSU College of Medicine

2
Objectives

• Recognize the characteristics of Normal Menstrual
  Bleeding (The LMP as the fourth vital sign!)
• Describe the etiologies of Abnormal Uterine
  Bleeding (AUB.)
• Understand etiologies of AUB with respect to the
  life stages of women.
• Understand the diagnostic tools to identify the
  etiology of the AUB.
• State the medical surgical options available in
  primary care and gynecology settings.

3
Case One

• 16 year old G0P0 presents because she is
  concerned about her periods being irregular. She
  describes her cycles as coming the 18th of one
  month the 16th the next month. She never knows
  when it is coming.
• How would you counsel this patient?

4
How would you counsel this patient?

1. Oral combined contraception pills will regulate
   her cycles
2. She needs to do 3 months of a menstrual diary
   using an App on her smartphone
3. She probably has a luteal phase defect and needs
   progesterone days 15-25.
4. She has normal cycles and needs reassurance.

5
Normal Menstruation

• The Menstrual Cycle
• In the normal menstrual cycle, orderly cyclic
  hormone production and parallel proliferation of
  the uterine lining prepare for implantation of
  the embryo.
• Berek Novaks
  Gynecology, 2012, p.145

6
Normal Menstruation

• The menstrual cycle starts with the first day of
  bleeding of one period and ends with the first
  day of the next. In most women, the cycle lasts
  about 28 days. Cycles that are shorter or longer
  by 7 days are normal.
• 
  ACOG Website FAQ095
• 
  

7
The Normal Menstrual Period

• Blood loss lt 80 ml (average 30-35
  ml)
• Duration of flow 2-7 days (average 4 days)
• Cycle length 21 - 35 days (average 29 days)
• 28 days /- 7 days

8
Phases of the Menstrual CycleReproductive Cycle

• Follicular (variable)
• Begins with Menses ends with luteinizing (LH)
  hormone surge
• Ovulation (30-36 hours)
• Begins with LH surge and ends with ovulation
• Luteal (14 days)
• Begins with the end of the LH surge and ends
  with onset of menses

9
Phases of the Menstrual CycleEndometrium

• Proliferative
• Begins with menses and ends at ovulation
• Secretory
• Begins at ovulation and ends with menses

10
Case Two

• A 25 year old G0P0 just moved to the area and
  desires a pregnancy. She has irregular menses.
  She was told by her previous doctor that she has
  polycystic ovarian syndrome (PCOS) and does not
  ovulate. She has results of a day 21 endometrial
  biopsy that shows Secretory Endometrium. What
  can you tell this patient?

11
What can you tell this patient?

• The biopsy confirms anovulation
• The biopsy was done on the wrong day
• The biopsy confirms ovulation.
• This patient does not have PCOS

12
Compare

• Phases of the Reproductive Cycle

• Phases of the Endometrium

• Follicular
• Ovulatory
• Luteal

• Proliferative
• Secretory

13
The Normal Menstrual CycleAnother Way of Looking
at It
M. Manting DUB LECTURE 2008
14
RegulationHypothalamic Pituitary Axis

• Hypothalamus is the pulse generator mediated
  through GnRH
• GnRH cannot be directly measured
• Negative Feedback Loop

15
Regulation of The Ovary2 Cell Theory

• Theca Cell
• Granulosa Cell

16
Abnormal Uterine Bleeding (AUB)

• Definition
• Any change in menstrual period
• Flow
• Duration
• Frequency
• Bleeding between cycles

• Prevalence
• 20 million office visits/year
• 25 of visits to gynecologists

17
Old Terminology

• Menorrhagia
• Metrorrhagia
• Menometrorrhagia
• Polymenorrhea

• Dysmenorrhea
• Amenorrhea
• Oligomenorrhea
• Hypomenorrhea

18
New Terminology

• Heavy Menstrual Bleeding
• Acute
• Chronic
• Intermenstrual Bleeding
• Munro MG, FIGO Classification
  of AUB 2011

19
Clinical dimensions of menstruation and the menstrual cycle Descriptive terms Normal limits (5th to 95th percentiles)
Frequency of menses (days) Frequent lt24
  Normal 2438
  Infrequent gt38
Regularity of menses (cycle to cycle variation over 12 months) Absent No
  Regular 220 days
  Irregular gt20 days
Duration of flow (days) Prolonged gt8.0 days
  Normal 4.58.0 days
  Shortened lt4.5 days
Volume of monthly blood loss (mL) Heavy gt80
  Normal 580
  Light lt5
20
History for AUB
Ask lots of questions!

• HPI
• Onset
• Quantity
• Spotting or heavy
• daily or intermittent
• Duration

21
History for AUB

• Gender Specific
• Menstrual
• Contraception
• Gynecologic
• Obstetric
• Sexual
• Genital Infections

• Associated Symptoms
• Pain
• Nausea
• Fatigue
• Headache
• Mastalgia

22
Other Important Details

• Family History
• Anyone else?
• Von Willebrand's
• PCOS
• PSH
• Nutrition and exercise
• Weight changes
• Exercise habits
• Diet

• PMH
• Chronic conditions
• Liver disease
• Kidney disease
• Anemia
• Drugs /medications
• Psychiatric medications
• Thyroid Disorders
• Blood thinners

23
Case Three

• 48 year old G2P2, S/P Bilateral Tubal Ligation 14
  years ago, referred from her primary care office
  with RLQ pain of 3 months duration. LMP 5 weeks
  ago has had many years of irregular menses
  thought to be menopause transition.
• Ultrasound shows an 8 cm adnexal cyst
  with CA 125 normal.

24
The next step is

• Get her on the schedule for surgery
• MRI
• Order Follicle Stimulating hormone(FSH)
• Urine Pregnancy Test
• Estradiol

25
Pregnancy
Never forget pregnancy
Age is not an issue!
Prove it!
Assumption can lead to death
26
Differential Diagnosis Of AUB

• Structural PALM-COEIN
• (Non Gravid
  Women)
• Life Cycles Pre-menarche
  Menarche
  
• Reproductive
• Post-Menopause
• Anatomic Bottoms Up

27
PALM-COEIN

• FIGO Classification System (PALM-COEIN) for
  causes of AUB in non gravid women of reproductive
  age
• Structural vs. Non-Structural
• Developed to create a universally accepted
  nomenclature

28
PALMStructural Causes

• P- Polyp (AUB-P)
• A- Adenomyosis(AUB-A)
• L- Leiomyoma (AUB-L) Submucosal myoma
  (AUB-LSM)M- Malignancy hyperplasia (AUB-M)

29
COEINNon-Structural Causes

• C- Coagulopathy (AUB-C)
• O-Ovulatory dysfunction (AUB-O)
• E- Endometrial (AUB-E)
• I- Iatrogenic (AUB-I)
• N- Not yet classified (AUB-N)

30
Case Four

• 42 year old G3P3 who is in your civic group
  presents with heavy, cyclic uterine bleeding.
  You note spider angioma across her chest down
  her arms. She has a slightly protuberant
  abdomen. Her husband had a vasectomy 7 years ago,
  and her pregnancy test is negative.

31
The best next step in evaluating her heavy
uterine bleeding

• Fasting Blood Glucose
• Thyroid Stimulating Hormone
• Liver Function Test
• Follicle Stimulating Hormone
• Estradiol

32
What FIGO nomenclature would you use to label her
AUB?

• AUB-C
• AUB-O
• AUB-E
• AUB-I
• AUB-N

33
Liver Disease

• Patients known to have liver disease manifest
  additional symptomatology because of abnormal
  hepatic function.
• Evaluate patients for spider angioma, palmar
  erythema, splenomegaly, ascites, jaundice, and
  asterixis.

34
Differential Diagnosis of AUB
Post-Menopausal
Menarche
Reproductive
Pre-menarche
35
Differential Diagnosis of AUB Anatomical

• Bottoms Up
• Vulva
• Vagina
• Cervix
• Ovary
• Brain

• Contiguous Anatomy
• GU
• GI
• Non-Pelvic Etiology
• Endogenous
• Iatrogenic

36
EVALUATION OF AUB
NO
YES
Acute Sub-Acute Chronic
37
AUB

• Initial Assessment

• Evaluation

• History Physical
• Vital Signs
• Shock Signs
• Laboratory
• Pregnancy Test
• Complete Blood Count

• Evaluation of the Uterus Endometrium
• Endometrial Biopsy
• Transvaginal /or abdominal Ultrasound (TVS/AUS)
• Saline Sono-hysteroscopy (SIS)
• Hysteroscopy

38
Endometrial Biopsy (EMB)

• Evaluation of the Endometrium
• Pipelle

39
TVS SIS
TVS
SIS
40
Evaluation

• Hysteroscopy

• MRI

• Precisely localizes sub-mucosal fibroids
• MRI is not superior to TVS SIS in overall
  diagnostic potential
• Dueholm M, et al. Fertil Steril.
  200176(2)350357

41
Treatment of AUB

• Observation
• Medical
• Minimally invasive surgery
• Major surgery

42
Medical Management

• Iron
• Anti-fibrinolytics
• Anti-prostiglandin
• Progestins
• Estrogen progestins (OCP)

• Parenteral estrogens
• Androgens
• GnRH agonists
• Anti-progestational agents

43
Surgical Approach

• Minimally Invasive Surgery

• Major Surgery

• Intrauterine Device (IUD) with progesterone
• Dilation Curettage
• Endometrial Ablation

• Myomectomy
• Total Abdominal Hysterectomy (TAH)
• Total Vaginal Hysterectomy (TVH)
• Laparoscopic Hysterectomy
• LSH (laparoscopic supra-cervical)
• TLH (total laparoscopic)
• LAVH (laparoscopically assisted vaginal
  hysterectomy)
• Robotic (TLH or LSH)

44
Final Case

• 32 year old G2P2002 presents to the ER with 10
  day history of heavy uterine bleeding. She is
  pale and appears frightened. Pulse is 120, BP is
  90/60. Hemoglobin is 6, Hematocrit is 18.
  Pregnancy test is negative.
• How do you manage this patient?

45
The Best Next Step?

• Oxygen IV Fluids
• Type and Cross 2 units of blood
• Order a pelvic ultrasound
• Order TSH, CBC, Coagulation panel
• IV Conjugated Equine Estrogen
• Consent for surgery

46
Management

• Chronic, Stable AUB

• Acute AUB

• Can be a life-threatening emergency
• Monitor vital signs, Start oxygen
• IV fluids (wide bore IV catheter)
• Type and Cross 2-4 units of blood
• IV Estrogen
• IM Progesterone
• NSAIDS (Anti-prostaglandins vs.
  Anti-fibrinolytics)
• Emergency DC

• Combined Oral Contraception
• AUB-O progestin therapy
• Levonorgestrel IUD
• Endometrial sampling is indicated prior to
  starting hormones in older women
• Medical failures have the surgical options

47
Clinical Pearls
Never Forget Pregnancy!
PROVE IT!
Age is Not an Issue!
Assumptions Can Lead to Death!
48
References

• ACOG Practice Bulletin No. 136, July 2013
• Beckmann, et al., Obstetrics Gynecology, 7th
  ed., Chapters 37, 39
• Clinical Management of Abnormal Uterine Bleeding
  APGO Educational Series, May 2002
• Dueholm M, et al. Fertil Steril.
  200176(2)350357
• Fritz, MA, Speroff et al, Clinical and
  Gynecologic Endocrinology and Infertility,
• 8th ed. 2011.
• Manting M., AUB Lecture 2008
• Munro, MG, et al, FIGO Classification System
  (PALM-COEIN) for causes of AUB in non gravid
  women of reproductive age. Int J Gynaecol Obstet
  2011 1133-13