Abnormal Uterine Abnormal Uterine BleedingBleeding
Douglas Brown M.D.Douglas Brown M.D.
GYNOSPEAKGYNOSPEAK
Dysfunctional Uterine Bleeding – non-Dysfunctional Uterine Bleeding – non-menstrual bleeding due to failure of menstrual bleeding due to failure of ovulationovulation
May be frequent e.g. every 2 weeksMay be frequent e.g. every 2 weeks May be infrequent e.g. every 6 May be infrequent e.g. every 6
monthsmonths Generally heavier than mensesGenerally heavier than menses
More GynospeakMore Gynospeak
Menorrhagia – heavy menstrual bleedingMenorrhagia – heavy menstrual bleeding Menometrorrhagia – heavy irregular Menometrorrhagia – heavy irregular
bleeding – may be DUB or organicbleeding – may be DUB or organic Midcycle bleeding – periovulatory Midcycle bleeding – periovulatory
bleeding, usually light, lasting 1-5 daysbleeding, usually light, lasting 1-5 days Premenstrual bleeding – spotting or light Premenstrual bleeding – spotting or light
bleeding 2-7 days prior to menses, bleeding 2-7 days prior to menses, leading into mensesleading into menses
Even More GynospeakEven More Gynospeak
Breakthrough bleeding (BTB) – irregular Breakthrough bleeding (BTB) – irregular bleeding associated with exogenous bleeding associated with exogenous hormone use such as OCPs ot HRThormone use such as OCPs ot HRT
Oligomenorrhea – infrequent menses, Oligomenorrhea – infrequent menses, generally less often than every 6 weeksgenerally less often than every 6 weeks
Postmenopausal bleeding – occurs afer Postmenopausal bleeding – occurs afer 1 year following cessation of menses1 year following cessation of menses
AdolescentAdolescent
Expect DUB with the first several Expect DUB with the first several “periods” as the hypothalamus matures“periods” as the hypothalamus matures
Regular menses may take a year to Regular menses may take a year to developdevelop
DUB more likely to be chronic in obese DUB more likely to be chronic in obese teens (?genetic?) Watch for PCOteens (?genetic?) Watch for PCO
Watch for amenorrhea in athletic teensWatch for amenorrhea in athletic teens Consider OCPs, calcium supplementConsider OCPs, calcium supplement
Adolescent MenorrhagiaAdolescent Menorrhagia
Distinguish menorrhagia from DUBDistinguish menorrhagia from DUB 15-20% of teens requiring 15-20% of teens requiring
transfusion will have a coagulation transfusion will have a coagulation disorderdisorder
Von Willebrand’s is most commonVon Willebrand’s is most common If VW test other women in familyIf VW test other women in family
Isolated Early or Late Isolated Early or Late MensesMenses
Most common etiology is stressMost common etiology is stress Change in environmentChange in environment Short term corticosteroid useShort term corticosteroid use Exclude pregnancy with home test or Exclude pregnancy with home test or
serum HCGserum HCG The Holiday RuleThe Holiday Rule
Meds and Medical Meds and Medical conditionsconditions
Hyper and hypo thyroidismHyper and hypo thyroidism Chronic renal or endocrine diseaseChronic renal or endocrine disease EndometriosisEndometriosis Hyperprolactinemia due to CNS or Hyperprolactinemia due to CNS or
pituitary diseasepituitary disease PhenothiazenesPhenothiazenes MetoclopromideMetoclopromide TricyclicsTricyclics
Postcoital BleedingPostcoital Bleeding
Cervical lesion – polyp, cancer, Cervical lesion – polyp, cancer, ectropionectropion
Vaginal atrophyVaginal atrophy EndometritisEndometritis Unstable or atrophic endometrium due Unstable or atrophic endometrium due
to OCs, HRT or Depoproverato OCs, HRT or Depoprovera Endometrial polyp or myomaEndometrial polyp or myoma Have a low threshold for endometrial Have a low threshold for endometrial
biopsybiopsy
Bleeding with ContraceptionBleeding with Contraception
BTB with OCs – change pills – increase BTB with OCs – change pills – increase estrogen, change progestinestrogen, change progestin
Depoprovera or minipill – add estrogen Depoprovera or minipill – add estrogen until bleeding stopsuntil bleeding stops
Paraguard copper IUD –irregular Paraguard copper IUD –irregular bleeding, menorrhagia – may be bleeding, menorrhagia – may be endometritisendometritis
Mirena levonorgestrel IUD – may Mirena levonorgestrel IUD – may cause 2-4 months irregular bleeding, cause 2-4 months irregular bleeding, then hypomenorrhea or amenorrheathen hypomenorrhea or amenorrhea
DUBDUB
Due to anovulationDue to anovulation Distinguish from oligomenorrheaDistinguish from oligomenorrhea Risk is endometrial hyperplasia or CaRisk is endometrial hyperplasia or Ca Consider endometrial biopsy (later)Consider endometrial biopsy (later) If chronic evaluate for PCOIf chronic evaluate for PCO Draw fasting glucose and insulinDraw fasting glucose and insulin
DUB Acute therapyDUB Acute therapy
IV premarin 25mg q 4-6 hrs – IV premarin 25mg q 4-6 hrs – vasospasmvasospasm
Monophasic OCs “OCP Taper” – qid Monophasic OCs “OCP Taper” – qid for 4 days, tid for 3 days, bid for 2 for 4 days, tid for 3 days, bid for 2 days, daily for remainder of two days, daily for remainder of two packspacks
MPA (provera,cycrin) – 10 mg MPA (provera,cycrin) – 10 mg 2-3x/day for 2 weeks 2-3x/day for 2 weeks
DUB long term therapyDUB long term therapy
OCPsOCPs Withdrawal with progestin for 10-14 Withdrawal with progestin for 10-14
days every 6-8 weeksdays every 6-8 weeks Use provera 10 mg, prometrium 100 Use provera 10 mg, prometrium 100
mg, aygestin 2.5 – 5 mgmg, aygestin 2.5 – 5 mg
MenorrhagiaMenorrhagia
MyomaMyoma PolypPolyp Coagulation DisorderCoagulation Disorder ““Humoral”Humoral” IdiopathicIdiopathic
Uterine MyomaUterine Myoma
Menorrhagia is most common Menorrhagia is most common symptomsymptom
Look for intramural or submucous Look for intramural or submucous myomasmyomas
Interruption of contractile hemostasisInterruption of contractile hemostasis Dx with ultrasoundDx with ultrasound Smell any fish?Smell any fish?
Therapy for MyomasTherapy for Myomas
Continuous OCPsContinuous OCPs GnRH agonists e.g LupronGnRH agonists e.g Lupron Myomectomy/HysterectomyMyomectomy/Hysterectomy Operative hysteroscopyOperative hysteroscopy Uterine artery embolizationUterine artery embolization Post-DUBYA – Mifepristone 50 Post-DUBYA – Mifepristone 50
mg/daymg/day
Humoral MenorrhagiaHumoral Menorrhagia
Diagnosis of exclusionDiagnosis of exclusion Consider coagulopathy workup – 10%Consider coagulopathy workup – 10% Diff Dx: VWDz, Diff Dx: VWDz,
thrombocytopenia,TTP, ITP,vasculitis, thrombocytopenia,TTP, ITP,vasculitis, liver diseaseliver disease
Desmopressin nasal spray for VW DzDesmopressin nasal spray for VW Dz
Medical TherapyMedical Therapy
NSAIDs – Ibuprofen, Naproxen, NSAIDs – Ibuprofen, Naproxen, Mefenamic acid (meclomen, ponstel)Mefenamic acid (meclomen, ponstel)
OCPs – consider continuous regimenOCPs – consider continuous regimen DepoproveraDepoprovera Iron replacementIron replacement Endometrial ablation – Rollerball, Endometrial ablation – Rollerball,
Novasure (mesh), Thermachoice Novasure (mesh), Thermachoice (balloon), MEA (microwave)(balloon), MEA (microwave)
PerimenopausePerimenopause
Oligomenorrhea if you’re luckyOligomenorrhea if you’re lucky Anovulatory biweekly “menorrhagia” Anovulatory biweekly “menorrhagia”
if you’re notif you’re not Therapy – low dose OCPs or higher Therapy – low dose OCPs or higher
dose HRT such as Activella or dose HRT such as Activella or FemHRTFemHRT
Don’t forget space-occupying diseaseDon’t forget space-occupying disease
PostmenopausePostmenopause
All postmenopausal bleeding is cancer All postmenopausal bleeding is cancer until proven otherwiseuntil proven otherwise
90% of BTB due to atrophy90% of BTB due to atrophy Prove it with endometrial Bx or TV U/SProve it with endometrial Bx or TV U/S On U/S endometrial “stripe” should be On U/S endometrial “stripe” should be
less than 5 mmless than 5 mm BTB common in new start HRTBTB common in new start HRT Obese patients may require withdrawalObese patients may require withdrawal
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