ABNORMAL UTERINE BLEEDINGT O N Y H OA N G , M D

ABNORMAL UTERINE BLEEDING

• AUB accounts for approx. 70% of all gyn visits in the peri-menopause & post-menopausal years

• Menstrual disorders accounts for 20% of all gyn visits• 2 millions visits per year

• Growing popularity of Bio-Identical hormones use

WHAT IS NORMAL BLEEDING

• AGE OF THE PATIENT (NON-PREGNANT)• ADOLESCENCE• REPRODUCTIVE• MENOPAUSAL

• FLOW• FREQUENCY• DURATION

NORMAL BLEEDING

• FLOW (5 days)• 30 ml – 80 ml of bleeding

• FREQUENCY• Every 21-35 days

• DURATION• Bleeding for 2 – 8 days

TERMINOLOGY

• MENORRHAGIA – heavy menstrual bleeding

• METRORRHAGIA – bleeding btwn periods

• MENOMETRORRHAGIA - combo

• OLIGOMENORRHEA – bleeding less frequent than 35 days

• POLYMENORRHEA – bleeding more often than 21 day

• AMENORRHEA – cessation of periods for 6 months

INITIAL EVALUATION

• HISTORY

• MENSTRUAL • BLEEDING PATTERNS• ASSOCIATED PAIN SYMPTOMS• SEVERITY• FAMILY HSTORY (20%)

• PAST OR PRESENT ILLNESSES

• USE OF MEDICATIONS / Herbal Products (Ginkgo Biloba/Ginseng/ motherwort)

• USE OF BIRTH CONTROL METHODS (IUDs / IMPLANTS / INJECTIONS)

• WEIGHT, EATING HABITS, EXERCISE, STRESS LEVEL

• PAP HISTORY

UNDERLYING BLEEDING DISORDER

• SCREEN• QUESTION ABOUT BLEEDING AT MENARCHE• HEMORRHAGE (ONE OF THE FOLLOWING)• POSTPARTUM• POST SURGICAL• BLEEDING ASSOC. WITH DENTAL WORK

• HEMORRHAGE (TWO OF THE FOLLOWING)• BRUISING ONE OR TWO TIMES PER MONTH• EPISTAXIS ONE OR TWO TIMES PER MONTH• FREQUENT GUM BLEEDING• FAMILY HISTORY

MENSTRUAL CYCLE DIARY

INITIAL EVALUATION

INITIAL EVALUATION

DIFFERENTIAL DIAGNOSIS

• PREGNANCY / MISCARRIAGE / ECTOPIC• ENDOMETRIAL POLYPS• ENDOMETRIAL ATROPHY• FIBROIDS• ADENOMYOSIS• OVULATORY• ANOVULATORY• BIRTH CONTROL SIDE EFFECT (IMPLANTS/IUD)• INFECTION (ENDOMETRITIS)• BLOOD CLOTTING DISORDERS• ENDOMETRIAL HYPERPLASIA • UTERINE CANCERS• PCOS• IATROGENIC• NOT YET CLASSIFIED

DIFFERENTIAL DIAGNOSIS

• PREGNANCY / MISCARRIAGE / ECTOPIC• ENDOMETRIAL POLYPS• ENDOMETRIAL ATROPHY• FIBROIDS• ADENOMYOSIS• OVULATORY• ANOVULATORY• BIRTH CONTROL SIDE EFFECT (IMPLANTS/IUD)• INFECTION (ENDOMETRITIS)• BLOOD CLOTTING DISORDERS• ENDOMETRIAL HYPERPLASIA • UTERINE CANCERS• PCOS• IATROGENIC• NOT YET CLASSIFIED

PALM-COEIN

WHAT TO ORDER

• HCG test• CBC• vWF (IF INDICATED)• Ristocetin cofactor (IF INDICATED)• PT/INR/PTT (IF INDICATED)• TSH• CHLAMYDIA

WORK UP TOOLS

• TRANSVAGINAL ULTRASOUND• SALINE INFUSION SONOHYSTEROGRAPHY• MRI• HYSTEROSCOPY• PAP SMEAR• ENDOMETRIAL BIOPSY• 45 YRS OR OLDER• OR RISK FACTORS: PCOS; OBESITY; FAILED RX;

PERSISTENT

TREATMENT

• MEDICATIONS• HORMONAL• NON-HORMONAL

• SURGICAL OPTIONS• DILATATION & CURETTAGE• HYSTEROSCOPIC RESECTION• UTERINE ARTERIAL EMBOLIZATION• MYOMECTOMY• ENDOMETRIAL ABLATION• HYSTERECTOMY

MEDICATION

• HORMONAL• OCP’S (Monophasic 35 mcg pills)• 4 X 4 - 3 X 3 – 2 X 2 – 1X1 THEN STOP FOR ONE WEEK – RESUME• 3 pills for Seven days• OCP Q 6 HRS (48 HRS)• ESTROGENS (CEE) 25-40 mg IV Q 4-6hrs• PROGESTINS • PROVERA 10 mg PO Q 4 hrs or 20 mg PO TID x 7 days• PROVERA 60 -120 mg PO x 1 then 20 mg Daily x 9 days• NORETHRINDRONE 5-10 mg PO Q 4hrs

• DMPA• MIRENA IUD

• NON-HORMAL• MOTRIN 800 mg PO TID x 5 days• TRANEXAMIC ACID 500 mg – 1.3 gm PO TID x 5 days (FDA warning)• DOXYCYCLINE 100 mg PO X 10 DAYS• MEFEPREX 100 mg

SURGICAL

• UTERINE ARTERY EMBOLIZATOIN / UFE• DILATATION & CURETTAGE• HYSTEROSCOPIC RESECTION / SYMPHION• ABLATION• HTA / NOVASURE / MEA / HER OPTION / THERMACHOICE

• HYSTERECTOMY• SUPRACERVICAL• MYOMECTOMY• LAVH• LTH• TVH• TAH

UTERINE ARTERY EMBOLIZATION

• COMPLETE CHILD BEARING• CATHERIZATION VIA FEMORAL ARTERY• IV CONTRAST • PVA (POLYVINYL ALCOHOL) • 1- 3 HRS PROCEDURE TIME• 6 HRS POST PROCEDURE BEDREST• POST OP PAIN 6-12 HRS (POSSIBLE SEVERAL MONTHS)• MAY REDUCE FIBROID BY 50%• 20% RETREATMENT OR REQUIRED SURGERY• S/E: INFECTION; PREMATURE MENOPAUSE;

PERSISTENT PAIN; SCAR TISSUE; AMENORRHEA

ABLATIONS

• HTA• MIA• NOVASURE• HER OPTION• THERMACHOICE

MEA

HER OPTION

THERMACHOICE

NOVASURE

HYDROTHERMAL

DEMOSTRATION OF HTA

• http://www.genesyshta.com

OBAMACARE??

thoang@premierwomensmedical.com

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