PANEL DISCUSSION

on

ABNORMAL UTERINE BLEEDING

THROUGH CASE DISCUSSIONS

Moderator :- Dr. Jyoti AgarwalDr. Sharda Jain

AUB PANEL—15 nov 2017Moderator :- Dr. Jyoti Agarwal

Dr Shard Jain

Panelists

Dr.Meenakshi Sharma , Dr.Ila Gupta

Dr.Deepti Nabh , Dr.Surjit Kapoor

Dr. Jyoti Bhaskar Dr. Vandana Gupta

PEERS

OBSERVATIONMY

EXPERIENCE

EVIDENCE

AND

GUIDELINES

Case 1• 13 yr old girl comes to OPD

• c/o continous ,moderate , painless bleeding for last 22 days

• Menarche 22 days back

• No h/o easy bruisibility, epistaxsis , or gum bleeding

• No significant personal and family history or any drug intake

• Not sexually active ,

• Salient features O/E vitals stable

• Pallor mild , No petechiae , Wt 50 kg ,

• P/A soft, no organomegaly ,P/S , P/V not done

First Menarchal Bleed

What will be your approach towards this little girl ??

Investigations Required

• CBC

• Thyroid profile

• Coagulation profile - Platelet count ,PT , APTT , INR , VWfactor , Factor 8

• S. Prolactin – galactorrhoeaor h/o headaches

USG pelvis

To rule out any structural problems

Testing Should Be Done Before Starting Therapy

AUB – O in Adolescents

• CBC Hb 10.5 gm %

• Thyroid profile normal

• Coagulaton profile normal

• USG pelvis (TAS) shows

• Uterus normal in size and echotexture

• ET 6 mm

• Both ovaries are normal

• No free fluid

What’s your impression and how will you manage ?

Most common cause of AUB in adolescents is

Immaturity of HPO axis

40 - 50% of adolescents with first heavy menarchal bleed have coagulopathy

AGE AT MENARCHE DURATION TOOVULATORY CYCLES

< 12 years 1 year

12-13 3 years

> 13 4.5 years

Wilkinson, Kadir: Management of Abnormal Uterine Bleeding inAdolescents. J Pediatr Adolesc Gynecol (2010) 23:S22-S30

In adolescents with AUB-OBoth Hormonal And Non-Hormonal therapies can be

given (Grade A; Level 4)

• Non hormonal treatment is the primary option

• Tranexamic acid 1g qidfor 5 days

(Grade A; Level 2)

• Hormonal treatment-COC , secondary option

• Role of progesterone only pills ??

Reassurance and Counseling

Hormone TherapyMonophasic Combined Oral Contraceptives

with a minimum of 30 -35 mcg Ethinyl Estradiol

Moderate bleeding

• One tab tds till the bleeding stops

(usually within 48 hrs )

• One pill bd for 5 days, then

• One pill once a day for a total of at least 21 days

• If bleeding recurs when the dose is decreased to once per day, twice per day dosing is necessary for the full 21 days

Severe Bleeding

• Inj conjugated Estrogen 25 mg 4-6 hrly

(not more than 6 inj /day )

• One pill qid till the bleeding stops

• One pill tds for 3 days, then

• One pill bd for up to 2 weeks

Rationale of Hormone Therapy

I

•Administration of exogenous estrogen causes endometrial proliferation, which heals the sites of endometrial bleeding, and provides haemostasis

• Administration of progestin stabilizes the endometrial lining

Progestin only pills are indicated only when COC are contraindicated or not tolerated

OUR CONCERN

• High-dose estrogen therapy can cause nausea, which may result in decreased adherence …. Consider antiemetic

• High doses of estrogen may cause premature closure of the growth plates, reducing ultimate adult height

• However, by the time of menarche, most female adolescents have already undergone their growth spurt and achieved approximately ≥ 95 percent of adult height

Close Follow-up is essential

• In person or by phone while the pills are being taken

• Should maintain a menstrual calendar to monitor response to therapy and subsequent episodes of bleeding

• Several smart phone "apps," available at no cost, may facilitate recording

MONITORING RESPONSE

• First follow up at subsequent period

• Thereafter 3 monthly

• Assess response after one yr to decide to

continue or discontinue the treatment

Same girl with deranged coagulation profile Treatment Guidelines: AUB-C

In consultation with haematologistTreatment remains the same

NSAIDs are contraindicated as they can alter platelet function and interact with drugs that might affect liver function and production of clotting factors

I/M Injection are to be avoided,if given, prolonged pressure should be applied at injection site

Case 2• 15 yr old girl comes with her mother c/o

Heavy periods for 8 months

• Menarche at 12 yrs

• Cycles are 7-10 days /40 -42 days

• Not sexually active

• No significant personal and family history

• Salient features O/E

• Wt 78 kg , BMI 30.4

No clinical features of hyperandrogenism

What will be your approach ??

To be done in all cases of AUB

• CBC

• Thyroid profile

• Coagulation profile

• USG pelvis

• CBC Hb 10.5 gm %

• Thyroid profile normal

• Coagulaton profile normal

• USG pelvis (TAS) shows

• Uterus normal in size and echotexture

• ET 5 mm

• Both ovaries shows multiple small follicles

• No free fluid

In adolescents with AUB-O

• Both Hormonal And Non-Hormonal therapies can be given (Grade A;Level 4 )

• Reassurance and Counseling

• Weight reduction and Lifestyle modification

• Correction of anaemia

Case 3

• 28 yr old female had lSCS 3 month back

• Antenatal , postnatal period uneventful

• She is breastfeeding

• Now complains that her bleeding has not yet stopped since delivery ,not very heavy ,has to use one pad every day

• O/E pallor mild , afebrile , vitals stable , wt 70 kg

• P/A ut not palpable, bld p/v +,os closed , ut bulky, fxclear

• CBC

• Hb 10.5 gm %

• TLC is 7000

• Thyroid profile normal

• Coagulaton profile normal

• TVS shows

• Uterus bulky with normal echotexture

• ET 7 mm , cavity is empty , No POC

• Both ovaries normal

• Small free fluid + in POD

Treatment Guidelines: AUB-O

Options available• LNG Insertion

• DMPA / Pg only pills

• Ormeloxifene (centchroman )

• COC

LNG-IUS is recommended if she wishes to use it for at least 1 year (Grade A; Level 1)

Ormeloxifene

• 60 mg tablet twice a week for 3 months followed by one tablet of 60 mg once a week for another 3 mnths

• Effective upto 1 year after stopping it

• In lactating women, it is excreted in milk in quantities considered unlikely to cause any deleterious effect on suckling babies

• Not recommended for women suffering from recent history of hepatitis or liver disorders

Increases endometrial thickness and forms ovarian cysts on USG

Case 4

• 34 yr old c/o painless heavy periods for 1 yr

• Associated with premenstrual spotting for 3-5 days

• Cycles are 10 – 12days /18 – 30 days

• P2 ,both LSCS , not ligated

• No h/o any drug intake

• P/S superficial erosion all around

• Hb 9 gm% TSH normal

• Pap’s smear is normal

• TVS shows bulky uterus, ET 8 mm ,small clear cyst of 2x2 cm in right ovary ,rest all normal

Ultrasound Imaging – Mandatory

USG should be done in all patients of AUB to evaluate uterus, adnexa and endometrial thickness (Grade A; Level 1)

Role of D & C / Endometrial biopsy /aspirate ??

GCPR- Endometrial Assessment and Biopsy

recommended in women with AUB

Older than 40 years of age (Grade A; Level 2)

Less than 40 years who are at risk of endometrial cancer (Grade A; Level 2)

Risk factors of endometrial cancer• Irregular bleeding• Obesity associated with hypertension• Endometrial thickness > 12 mm• Polycystic Ovarian syndrome (PCOS)• Diabetes Mellitus• H/O malignancy of ovary/breast/

endometrium/colon• Use of Tamoxifen for HRT or breast cancer• AUB-unresponsive to medical management• HNPCC syndrome (hereditary nonpolyposis

colorectal cancer or Lynch Syndrome)

Endometrial assessment (EA)

Endometrial histopathology Dilatation and curettage Hysteroscopy

Performed if endometrium is thick on imaging but HPE is inadequate, to rule out polyps(Grade A; Level 2)

Not be a procedure of choicefor EA (Grade A; Level 3)

Endometrial aspiration is the preferred procedure for obtaining endometrial sample for HPE

Treatment Guidelines: AUB-O

Options available

• LNG Insertion

• DMPA / Pg only pills

• Ormeloxifene (centchroman )

• COC

• Rx erosion

LNG-IUS is recommended if she wishes to use it for at least 1 year (Grade A; Level 1)

Case 5

• 40 yr old female c/o heavy and painful periods for last 2 yrs

• Cycles are 5-6 days / 18 – 23 days

• Hb 9 gm% , vitals stable , wt 70 kg

• TVS shows uterus uniformly enlarged to 8 wks

• Myometrium shows salt and pepper appearance

• ET 9 mm

• Rt ovary shows a small hemorrhagic cyst of 1.8 x 2.0 cm, rest normal

• Endo aspirate shows

Secretory endometrium

What’s your impression and how will you manage this case ??

Treatment Algorithm: AUB-A

LNG IUS is recommended as 1st line therapy (Grade A; Level 1)

In women with AUB due to Adenomyosis

Women desirous of fertility

Unwilling for immediate conception

Resistant or unwilling to use LNG IUS

Gonadotropin releasing hormone (GnRH) agonists with add back therapy is recommended as 2ndline therapy (Grade A; Level 1)

GnRH agonists cannot be indicated for symptomatic relief

Combined oral contraceptives, Danazol, NSAIDS and progestogens are recommended (Grade B; Level 4)

Women not desirous of fertility

Vaginal or laparoscopic hysterectomy / Trans-cervical resection of endometrium is recommended (Grade A; Level 3)

LNG IUS 1st LINElong-term GnRH agonists and add-back therapy can be initiated

Medical management

Failure or refusal for medical management

L.IN.MA.WH.02.2016.0746

Adenomyomectomy conservative surgery offered in selected cases with infertility or with strong desire to retain uterus. (Grade B; Level 2)

What is Add Back therapy ?

++++++++

Add Back Therapy

• Estrogen and progesterone are given either sequentially or combined so as to prevent osteoporosis

• Low dose estrogen– CEE (premarin ) 0.625 /0.3 mgm OD or– Estradiol valerate 1 mgm OD for 30 days

• Low dose Progesterone– Medroxy progesterone acetate 2.5 mgm OD for 30 days or 10 mgm OD

for 10 days– Norethisterone 1mg– Micronised Progesterone 100 mg

• Tibolone (SERM) 2.5mgm OD

Case 6

• 42 yr old obese female c/o heavy periods for 3 yrs

• Diabetic , controlled with drugs

• No HT, TB or hypothyroidism

• Wt 86 kg

• TVS shows uterus enlarged to 6 wks size

• ET 11 mm

• Both ovaries have small,simple clear cyst of 2x2 cm

• No free fluid

• EB shows

• Endometrial hyperplasia without atypia

Role of Hysteroscopy ??

Recommendations:

Indications:

Intermenstrual spotting

Evaluation of intracavitary lesion

Dys-synchronicity between symptoms, USG & HPE (Grade A; Level 2)

Increased Endometrial thickening on TVS, but HPE inadequate/atrophic

No response to medical management

HYSTEROSCOPY – NOT TO BE DONE ROUTINELY

Women with endometrial hyperplasia without atypiashould be informed that the risk of progression to

endometrial cancer is less than 5% over 20 years

Majority of cases of endometrial hyperplasia without atypia will regress spontaneously during follow-up

REASSURANCE IS ESSENTIAL

New Term Coexistent Invasive

Endometrial Cancer

Progression To

Invasive

Cancer

Hyperplasia without

Atypia

<1% RR:1.01-1.03

Atypical

Hyperplasia

25-33% RR:14-45

Revised classification of Endometrial hyperplasia WHO 2014

AUB – Endometrial HyperplasiaWithout Atypia

• LNG IUS is recommended as 1st line therapy

(Grade A; Level 1)

• If LNG IUS is contraindicated or patient unwilling to use LNG IUS

• Oral continuous Progesterones can be used(Grade A; Level 1)

• Medroxyprogesterone10–20 mg/day or

• Norethisterone 10–15 mg/day

• Cyclical progestogensshould not be used because they are less effective in inducing REGRESSION ofendometrial hyperplasia without atypia

Follow up• Oral progestogens or the LNG-IUS should be used

for a minimum of 6 months in order to induce histological regression

• At least two consecutive 6-monthly negative biopsies should be obtained

• Once two consecutive negative endometrial biopsies have been obtained then long-term follow-up should be considered with annual endometrial biopsies , life long or till hysterectomy is indicated

Hysterectomy is indicated when

• Progression to atypical hyperplasia occurs during follow-up, or

• There is no histological regression of hyperplasiadespite 12 months of treatment, or

• There is relapse of endometrial hyperplasia after completingprogestogen treatment, or

• There is persistence of bleeding symptoms, or

• The woman declines to undergo endometrial surveillance or comply with medical treatment

Case 7

• 58 yr old female c/o first episode of spotting 3 days back

• Menopause at age of 50 yr

• Earlier cycles were regular

• P2 last delivery 26 yrs back

• No HT, DM ,TB UTI or hypothroidism

• No family h/o malignancy

• O/E Pallor mild ,BP 146/86, Wt 65 kg

• P/S ,P/V NAD , Breast normal

• NO evidence of vaginitis

• TVS shows uterus is normal

• ET is 5 mm

• Both ovaries normal

• No cyst

• No free fluid

• No tenderness

• EB

Atrophic endometrium

• Hyteroscopy

Normal

No focal lesion seen

Reassurance : Reassurance : Reassurance

• Estrogen creams or pessaries can be used , although treatment may not be necessary if symptoms are mild

(NHS.UK 2014)

• Regular Follow up is mandatory (TVS)

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