8-janis-f-abnormal-uterine-bleeding.pdf

Abnormal Uterine Bleeding What the Medical Provider Needs to Know about Causes, Work Up, and Treatment Janis D. Fee, M.D. Updated, 2018

Overview New Terminology Causes: Hormonal, Medical, Physical abnormalities, and Premalignant and Malignant Lesions. Remember:PALMCOEIN Work Up: Physical Exam, Labs, Ultrasound, other diagnostics. D and C vs. EMB. Who needs it? Treatment: Medical, surgical and other options Questions

Terminology • A Revised Terminology System introduced in 2011 by International Federation of Gynecology and Obstetrics (FIGO) • Replaces poorly defined or confusing term, such as “menorrhagia”,oligomenorrhea,etc. • Abnormal Uterine Bleeding (AUB) refers to premenopause (reproductive age as well as menopause transition) plus Postmenopausal Bleeding • Acronym PALM-COEIN as reminder for causes

What is abnormal uterine bleeding (AUB)? Bleeding in any of the following situations is abnormal: •Bleeding between periods is Intermenstrual Bleeding (IMB) •Bleeding after sex (IMB) •Spotting anytime in the menstrual cycle for longer than 5 days (IMB) •Bleeding heavier or for more days than normal is Heavy Menstrual Bleeding (HMB) >80ml blood loss/cycle •Bleeding after menopause: Postmenopausal Bleeding Menstrual cycles that are longer than 35 days or shorter than 21 days are abnormal. The lack of periods for 3–6 months (amenorrhea) also is abnormal.

Irregular Bleeding: most commonly associated with Ovulatory dysfunction, or iatrogenic cause

Abnormal Uterine Bleeding • Very common: 18-50 years old prevalence is 53/1000 women annually • AUB has a major impact on women’s quality of life, productivity, utilization of healthcare resources • Somewhat subjective. ¼ of patients w normal periods considered them excessive, 40% of severe bleeders considered periods normal or even light.

Description by Heavy Bleeding Women Heavy Moderate Light-Mod Light

What is a normal menstrual cycle? The menstrual cycle begins with the first day of bleeding of one period and ends with the first day of the next. In most women, this cycle lasts about 28 days. Cycles that are shorter or longer by up to 7 days are normal.

At what ages is abnormal uterine bleeding more common? Abnormal uterine bleeding can occur at any age. However, at certain times in a woman’s life it is common for periods to be somewhat irregular. They may not occur on schedule in the first few years after a girl has her first period (around age 9–16 years). Cycle length may change as a woman nears menopause (around age 50 years). It also is normal to skip periods or for bleeding to get lighter or heavier at this time. <21 day cycles are considered abnormal

Usual Causes of Abnormal Bleeding  Neonates: estrogen withdrawl  Premenarche: Trauma, Infection, urethral Prolapse, Sarcoma, precocious puberty, ovarian tumor

 Early postmenarche: Ovulatory dysfunction, Bleeding diathesis, stress (psychogenic, exercise), Pregnancy, Infection

 Reproductive age: Ovulatory dysfunction, Pregnancy, Cancer, Polyps, Leiomyoma, Adenomyosis, etc

 Menopause transition: Anovulation, Polyps, Fibroids, Adenomyosis, Cancer

 Menopause: Endometrial atrophy, Cancer, HRT

Remember: PALM-COEIN (nonpregnant, ages 20-60)  Polyps  Adenomyosis  Leiomyomas / Fibroids  Malignancy and Premalignancy/ Hyperplasia  Coagulopathy  Ovulatory Dysfunction  Iatrogenic: IUDs, OCPs, HRT, other medications, etc  Endometrial: Endometritis, AV abnormalities, etc  Not classified…. Rarer causes, Csection Niche, etc.

Endometrial Polyps • Common, may be transient • May be associated with obesity, high estrogenic states, hyperplasia

• Most are benign • May represent a “focal” endometrial lesion on sonography

Adenomyosis • Characterized by a tender, enlarged uterus, with heterogenous echotexture on sonography

• Often associated with cramping, chronic pelvic pain

Leiomyomata: Fibroids • The most common structural abnormality causing increased bleeding

• Submucous myomas more likely to produce abnormal bleeding or cramps

Medical disorders • Coagulation Defects: need to rule out, particularly in the younger patient

• Ovulatory dysfuntion (AUB-O), often called “dysfunctional bleeding”

• May be due to PCO or other causes of anovulation

• Thyroid disease: need to workup but uncommon cause. AUB in 7% of hypothyroid pts, vs 1% in normal controls

Iatrogenic • Remember! possible medication effects • “breakthrough” on OCPs • Progestin or steroid effects • Anticoagulation effects • Common usually temporary effect of progestin IUDs

Endometrial Ca • The MOST common gynecologic malignancy in the US and most developed countries

• 2008: 287,000 worldwide, • U.S. 52,000 cases in 2013, 8600 deaths

• Adenocarcinoma of the Endometrium is the most common type

• 75-90% present with AUB • 68% of women present w/disease confined to the uterus, with a 96% 5 year survival rate

Endometrial Ca Staging

Endometrial Ca: Prognosis

 High Risk Endometrial Cancer includes Clear cell Ca, deep myometrial invasion, grade 3 disease, Serous Carcinomas

120 100 80

 SEER study (

Grade1 Grade 2 Grade 3

60 40 20 0 Stage I Stage II Stage III Stage IV

1998-2001) demonstrates effect of grade, stage on 5 year survival

Risk Factors for Endometrial Cancer Risk Factor

Relative Risk

Increased age

Women 50-70 1.4 % risk

Unopposed estrogen

2-10

Late menopause >55)

2

Nulliparity

2

PCO syndrome Obesity Diabetes

3 2-4 2

Lynch syndrome Cowden syndrome

22-50% lifetime risk 13-19% lifetime risk

Tamoxifen

2-4

Basic Workup for AUB  Initial Evaluation: Is the uterus the source? Evaluate for other sources

 Pre or postmenopause? Pregnant or non-pregnant?  History and Physical : bleeding pattern, symptoms, general medical, surgical history, meds, risk factors, family history. Physical exam, targeted as needed.

 Initial labs: HCG if needed, Hgb and Hct.  Next: Ultrasound, further labs as indicated ( pap, GCT/culture on cervix, coagulopathy workup if indicated, iron stores, other metabolic workup such as TSH, CMP.

Endometrium thickness on Sonography • A normal endometrium thickness may vary substantially

• “Normal” endometrial thickness is 814mm during midcycle

• Use of a <5mm “threshold” for risk of endometrial Ca good for Postmenopausal bleeding. Sensitivity 96%, Specificity61%

• Less predictive for asymptomatic postmenopause. Recommended cutoff of 11mm

• Premenopause: NO standard threshold. Base decision on regularity of lining, clinical situation.TVS on day 4-6

Next: Endometrial Assessment: Who needs it?  Postmenopause: any uterine bleeding, regardless of volume. Further evaluation of sonographic endometrium of >4mm.

 45 to menopause: any AUB, including intermenstrual bleeding in ovulatory women. AUB that is frequent, heavy, or prolonged.

 Menarche to 45: AUB that is persistent, failed medical

management or risk factor(s), including obesity, chronic anovulation.

 AGC on pap- all ages  Pap with endometrial cells ( nl) when not on period, >40 with AUB or risk factors

 Lynch syndrome, previous history of hyperplasia of endometrium

Pipelle office Biopsy

Pipelle biopsy  This has become the first line of assessment since minimal to no cervical dilation, local or no anesthesia needed, low cost

 Less than 50% of the endometrium is sampled  A large meta-analysis (39 studies) showed this to be superior in initial sampling to other techniques

 99.6% sensitivity postmenopause, 91% premenopause, 81% specificity for atypical hyperplasia

 Best for global pathology, not a localized lesion  If insufficient, the clinical situation should dictate further testing.

Dilation and Curettage/Hysteroscopy • Best for localized pathology. The “gold” standard, along with Hysteroscopy • When a patient not able to tolerate a EMB or stenotic cervix • Insufficient tissue on EMB with risk factors or persistent symptoms • Additional procedures (LSC) are needed • Benign EMB but persistent AUB noted.

Abnormal Uterine Bleeding: Treatment Options  After an appropriate workup, a trial of medical therapy is ok for low risk women<45, no risks, or <40 with some, not high risk

 Medical therapy: OCPs, Progestin ( Provera or Norethindrone most effective), short or longer term

 Progestin IUD an option for those not wanting daily medication.  Endometrial ablation appropriate for AUB, benign EMB, persistent symptoms, tried conservative therapy, <12 weeks size uterus, nl cavity

 Directed therapy for fibroids, including HSC morcellation  Further surgical therapy, including hysterectomy, UAE, myomectomy, especially for patients with rapid growth, persistent symptoms

Important Points:  Abnormal Uterine Bleeding in the Reproductive Age group is a common gynecologic complaint, the most common etiologies being pregnancy, structural uterine abnormalities, cancer or ovulatory abnormalities

 The initial approach is to confirm that the bleeding is from the uterus, confirm if possible pregnant and confirm menopause status.

 Direct further workup to suspected etiology, while assessing possible risk for malignancy and need for endometrial assessment

Important Points (cont)  Endometrial Cancers are common. Cure rate highly dependent on Stage at Diagnosis. Most are > 40 years, not all. Most present with AUB.

 EMB and/or D&C, hysteroscopy important for all PMB, peri or premenopause with clinical suspicion, postmenopause with endometrium 5 or above, or persistent AUB. EMB procedure of choice, but may require also D and C in focal lesions

 Evaluate for other sources!

Thank you

Questions: [email protected] or preferred office (714)282-1892