1. ABNORMAL UTERINE BLEEDING
TONY HOANG, MD

2. 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

3. WHAT IS NORMAL BLEEDING
AGE OF THE PATIENT (NON-PREGNANT)
ADOLESCENCE
REPRODUCTIVE
MENOPAUSAL
FLOW
FREQUENCY
DURATION

4. NORMAL BLEEDING FLOW (5 days) FREQUENCY DURATION
30 ml – 80 ml of bleeding
FREQUENCY
Every days
DURATION
Bleeding for 2 – 8 days

6. 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

7. INITIAL EVALUATION HISTORY MENSTRUAL PAST OR PRESENT ILLNESSES
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

8. 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

9. MENSTRUAL CYCLE DIARY

10. Initial evaluation

11. Initial evaluation

12. 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

13. 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

14. PALM-COEIN

15. WHAT TO ORDER HCG test CBC vWF (IF INDICATED)
Ristocetin cofactor (IF INDICATED)
PT/INR/PTT (IF INDICATED)
TSH
CHLAMYDIA

16. 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

18. TREATMENT MEDICATIONS SURGICAL OPTIONS HORMONAL NON-HORMONAL
DILATATION & CURETTAGE
HYSTEROSCOPIC RESECTION
UTERINE ARTERIAL EMBOLIZATION
MYOMECTOMY
ENDOMETRIAL ABLATION
HYSTERECTOMY

19. MEDICATION HORMONAL NON-HORMAL OCP’S (Monophasic 35 mcg pills)
4 X 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) mg IV Q 4-6hrs
PROGESTINS
PROVERA 10 mg PO Q 4 hrs or 20 mg PO TID x 7 days
PROVERA 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

20. SURGICAL UTERINE ARTERY EMBOLIZATOIN / UFE DILATATION & CURETTAGE
HYSTEROSCOPIC RESECTION / SYMPHION
ABLATION
HTA / NOVASURE / MEA / HER OPTION / THERMACHOICE
HYSTERECTOMY
SUPRACERVICAL
MYOMECTOMY
LAVH
LTH
TVH
TAH

21. 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

23. ABLATIONS
HTA
MIA
NOVASURE
HER OPTION
THERMACHOICE

24. MEA

25. HER OPTION

26. THERMACHOICE

27. NOVASURE

28. HYDROTHERMAL

29. DEMOSTRATION OF HTA ‪

30. OBAMACARE??

31. “A HAPPY WIFE IS A HAPPY LIFE…”