Changes before the change: Perimenopausal Bleeding World Menopause Day 2017 Changes before the change: Perimenopausal Bleeding

IMS theme Series: Perimenopausal Bleeding Abnormal Uterine Bleeding (AUB) - Definition Bleeding that is unlike normal menstrual flow in terms of frequency, duration and quantity. It includes infrequent or frequent bleeding, heavy menstrual bleeding or intermenstrual bleeding AUB is a leading cause for gynecological consultations in the peri- and post-menopausal age groups. World Menopause Day 2017

IMS theme Series: Perimenopausal Bleeding AUB subsets in the Perimenopause Ovulatory AUB Ovulatory bleeding may be heavy and can be associated with typical premenstrual symptoms and painful periods. World Menopause Day 2017

IMS theme Series: Perimenopausal Bleeding AUB subsets in the Perimenopause Anovulatory AUB Anovulatory bleeding, which is found more frequently during the perimenopause compared to the premenopause, is often linked to prolonged periods, heavier flow and an irregular cycle. If prolonged (e.g. in PCOS or associated with obesity), anovulatory bleeding has a stronger link to endometrial cancer and endometrial hyperplasia World Menopause Day 2017

IMS theme Series: Perimenopausal Bleeding Abnormal Uterine Bleeding - Etiology 1. Hormonal Changes 2. Benign Anatomic Changes Uterine Polyps Uterine Fibroids Adenomyosis Low Thyroid Function Other medical conditions, i.e. coagulopathy 3. Cancer Primarily endometrial, but also cervical. World Menopause Day 2017

IMS theme Series: Perimenopausal Bleeding Abnormal Uterine Bleeding - Diagnosis The goal of diagnosis is to distinguish women with anatomic causes from women with normal anatomy. Identifying endometrial malignancy, although uncommon among the AUB etiologies, is often the main purpose of the investigations. World Menopause Day 2017

FIGO Nomenclature: PALM-COEIN IMS theme Series: Perimenopausal Bleeding FIGO Nomenclature: PALM-COEIN Abnormal Uterine Bleeding (AUB) -Heavy menstrual bleeding (AUB/HMB) -Intermenstrual bleeding (AUB/IMB) PALM: Structural Causes Polyp (AUB-P) Adenomyosis (AUB-A) Leiomyoma (AUB-L) Submucosal myoma (AUB-Lsm) Other myoma (AUB-Lo) Malignancy & hyperplasia (AUB-M) COEIN: Nonstructural Causes Coagulopathy (AUB-C) Ovulatory dysfunction (AUB-O) Endometrial (AUB-E) Iatrogenic (AUB-I) Not yet classified (AUB-N) World Menopause Day 2017 Adapted from Practice Bulletin No. 128. ACOG Obstet Gynecol 2012;120:197–206

IMS theme Series: Perimenopausal Bleeding Before Now AUB HMB DUB Menorrhagia Menometrorrhagia Oligomenorrhe AUB-P AUB-A AUB-L AUB-M AUB-C AUB-O AUB-E AUB-I AUB-N World Menopause Day 2017

IMS theme Series: Perimenopausal Bleeding Assessment of abnormal uterine bleeding General assessment History and bleeding pattern Physical, pelvic and speculum examination Laboratory tests including: Full blood count, iron studies, (thyroid, hCG – if indicated) Disorders of hemostasis (if indicated) Evaluate pelvic organs and endometrium ultrasound scan Hysteroscopy MRI (if indicated) World Menopause Day 2017

IMS theme Series: Perimenopausal Bleeding Imaging Techniques The primary imaging test for the evaluation of abnormal uterine bleeding is transvaginal ultrasound. This maybe more difficult in cases of co-existing myomas, previous surgery, marked obesity, axial uterus or adenomyosis. In such cases SIS - saline infusion sono-hysterography can be helpful. Hysteroscopy as a diagnostic tool may also be employed if intra-uterine pathology is suspected. It can be done in an outpatients setting using small telescopes and usually requires no analgesia. An inpatient procedure will be required in 15-20% World Menopause Day 2017

IMS theme Series: Perimenopausal Bleeding Endometrial Sampling Endometrial sampling is required to diagnose endometrial abnormality. This can be done, usually after an ultrasound or hysteroscopy, with a vacuum aspiration system, e.g. Pipelle. However, this will only sample a small proportion of the cavity and there is a high incidence of false negative results, and cancer may be missed. AUB will often require further evaluation. World Menopause Day 2017

IMS theme Series: Perimenopausal Bleeding Treatment of abnormal uterine bleeding Treatment goals for patients with AUB include regulation of menstrual cycles, minimization of blood loss and improvement in quality of life. Treatment options include pharmacological approaches (either hormonal or non-hormonal), and surgical or radiological procedures. Awareness, reassurance and keeping a healthy lifestyle will contribute to the treatment options for AUB. World Menopause Day 2017

IMS theme Series: Perimenopausal Bleeding Management of abnormal uterine bleeding (1) Non-hormonal medical treatments Non-steroidal anti-inflammatory drugs Anti-fibrinolytic agents (ie, tranexamic acid) Iron supplements, in case of anemia Hormonal medical treatments Cyclical or long-acting progestogens Combined oral contraceptives GnRH analogs (fibroid-associated) Selective progesterone receptor modulators (fibroid-associated) Levonorgestrel intrauterine system (LNG-IUS) World Menopause Day 2017

IMS theme Series: Perimenopausal Bleeding Management of abnormal uterine bleeding (2) Endometrial ablation Uterine artery embolization (fibroid-associated) Hysterectomy World Menopause Day 2017