Transcript Abnormal Uterine Bleeding

Abnormal Uterine Bleeding
Cullen Archer, MD
Assistant Professor
Obstetrics and Gynecology
UT Health Science Center at San Antonio
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.
How much is too much?
• 40% of women with blood loss > 80 cc
considered their menstrual flow to be small or
moderate in amount (Halberg, et. al.)
• 14% of women with blood loss < 20 cc thought
menses was too heavy.
• Blood loss > 80 cc per cycle is associated with
significantly lower hemoglobin, hematocrit, and
serum iron levels than women with less
menstrual blood loss (Halberg).
Classification
• Organic
• Inorganic (Dysfunctional)
– Diagnosis of exclusion
– Anovulatory
– Ovulatory
Organic AUB
• Systemic Disease
– Coagulopathy
– Hypothyroidism
– Cirrhosis
• Genital tract disease
Coagulopathies
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Von Willebrand’s disease
Prothrombin deficiency
Leukemia
Sepsis
ITP
Hypersplenism
Hypothyroidism
• Frequently associated with menorrhagia
as well as intermenstrual spotting
• Incidence 0.3% to 2.5% among women
with menorrhagia
Organic AUB
• Systemic Disease
– Coagulopathy
– Hypothyroidism
– Cirrhosis
• Genital tract disease
Genital Tract Disease
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Pregnancy
Malignancy
Infection
Anatomic uterine abnormalities
Foreign bodies (IUD)
Oral and injectable steroids (OCPs and
HRT)
Pregnancy
• Intrauterine pregnancy
– Threatened abortion
– Incomplete abortion
– Complete abortion
– Missed abortion
• Ectopic
Malignancy
• Cervical cancer
• Endometrial cancer
• Estrogen producing ovarian tumors
Infection
• Endometritis
• Cervicitis
– Postcoital bleeding
Anatomic Abnormalities
• Leiomyomata
– Submucosal
– Intramural
• Endometrial polyps
• Adenomyosis
Dysfunctional (inorganic)
• Anovulatory DUB
• Ovulatory DUB
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
Ovulatory DUB
• occurs most commonly after adolescent
years and before perimenopausal years
• incidence ~ 10% of ovulatory women
Management
• Hypothyroidism
– 50-200 mcg LT4 daily resulted in
disappearance of menorrhagia within 3-6
months
Management
• Leiomyomata
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OCPs
Myomectomy
Leuprolide acetate 3.75 mg IM qmonth x3
Hysterectomy
Uterine artery embolization
• Endometrial polyps
– Hysteroscopy, D+C
• Adenomyosis
– OCPs
– GnRH analog
– Hysterectomy
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
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
Levonorgestrol IUD
• 80% reduction in menstrual blood loss at 3
months and 100% at one year
• Particularly effective in women with
ovulatory DUB
Levonorgestrol IUD
is contraindicated when one or more of the following conditions exist:
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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
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
Endometrial Ablation
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Rollerball
Thermachoice Balloon
Novasure
Contraindications
– Desires future fertility
• Complications
– Fluid overload
– Uterine perforation
– Thermal damage to adjacent organs
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.
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.
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