Abnormal Uterine Bleeding Douglas Brown M.D.

GYNOSPEAK Dysfunctional Uterine Bleeding – non- menstrual bleeding due to failure of ovulation Dysfunctional Uterine Bleeding – non- menstrual bleeding due to failure of ovulation May be frequent e.g. every 2 weeks May be frequent e.g. every 2 weeks May be infrequent e.g. every 6 months May be infrequent e.g. every 6 months Generally heavier than menses Generally heavier than menses

More Gynospeak Menorrhagia – heavy menstrual bleeding Menorrhagia – heavy menstrual bleeding Menometrorrhagia – heavy irregular bleeding – may be DUB or organic Menometrorrhagia – heavy irregular bleeding – may be DUB or organic Midcycle bleeding – periovulatory bleeding, usually light, lasting 1-5 days Midcycle bleeding – periovulatory bleeding, usually light, lasting 1-5 days Premenstrual bleeding – spotting or light bleeding 2-7 days prior to menses, leading into menses Premenstrual bleeding – spotting or light bleeding 2-7 days prior to menses, leading into menses

Even More Gynospeak Breakthrough bleeding (BTB) – irregular bleeding associated with exogenous hormone use such as OCPs ot HRT Breakthrough bleeding (BTB) – irregular bleeding associated with exogenous hormone use such as OCPs ot HRT Oligomenorrhea – infrequent menses, generally less often than every 6 weeks Oligomenorrhea – infrequent menses, generally less often than every 6 weeks Postmenopausal bleeding – occurs afer 1 year following cessation of menses Postmenopausal bleeding – occurs afer 1 year following cessation of menses

Adolescent Expect DUB with the first several “periods” as the hypothalamus matures Expect DUB with the first several “periods” as the hypothalamus matures Regular menses may take a year to develop Regular menses may take a year to develop DUB more likely to be chronic in obese teens (?genetic?) Watch for PCO DUB more likely to be chronic in obese teens (?genetic?) Watch for PCO Watch for amenorrhea in athletic teens Watch for amenorrhea in athletic teens Consider OCPs, calcium supplement Consider OCPs, calcium supplement

Adolescent Menorrhagia Distinguish menorrhagia from DUB Distinguish menorrhagia from DUB 15-20% of teens requiring transfusion will have a coagulation disorder 15-20% of teens requiring transfusion will have a coagulation disorder Von Willebrand’s is most common Von Willebrand’s is most common If VW test other women in family If VW test other women in family

Isolated Early or Late Menses Most common etiology is stress Most common etiology is stress Change in environment Change in environment Short term corticosteroid use Short term corticosteroid use Exclude pregnancy with home test or serum HCG Exclude pregnancy with home test or serum HCG The Holiday Rule The Holiday Rule

Meds and Medical conditions Hyper and hypo thyroidism Hyper and hypo thyroidism Chronic renal or endocrine disease Chronic renal or endocrine disease Endometriosis Endometriosis Hyperprolactinemia due to CNS or pituitary disease Hyperprolactinemia due to CNS or pituitary disease Phenothiazenes Phenothiazenes Metoclopromide Metoclopromide Tricyclics Tricyclics

Postcoital Bleeding Cervical lesion – polyp, cancer, ectropion Cervical lesion – polyp, cancer, ectropion Vaginal atrophy Vaginal atrophy Endometritis Endometritis Unstable or atrophic endometrium due to OCs, HRT or Depoprovera Unstable or atrophic endometrium due to OCs, HRT or Depoprovera Endometrial polyp or myoma Endometrial polyp or myoma Have a low threshold for endometrial biopsy Have a low threshold for endometrial biopsy

Bleeding with Contraception BTB with OCs – change pills – increase estrogen, change progestin BTB with OCs – change pills – increase estrogen, change progestin Depoprovera or minipill – add estrogen until bleeding stops Depoprovera or minipill – add estrogen until bleeding stops Paraguard copper IUD –irregular bleeding, menorrhagia – may be endometritis Paraguard copper IUD –irregular bleeding, menorrhagia – may be endometritis Mirena levonorgestrel IUD – may cause 2- 4 months irregular bleeding, then hypomenorrhea or amenorrhea Mirena levonorgestrel IUD – may cause 2- 4 months irregular bleeding, then hypomenorrhea or amenorrhea

DUB Due to anovulation Due to anovulation Distinguish from oligomenorrhea Distinguish from oligomenorrhea Risk is endometrial hyperplasia or Ca Risk is endometrial hyperplasia or Ca Consider endometrial biopsy (later) Consider endometrial biopsy (later) If chronic evaluate for PCO If chronic evaluate for PCO Draw fasting glucose and insulin Draw fasting glucose and insulin

DUB Acute therapy IV premarin 25mg q 4-6 hrs – vasospasm IV premarin 25mg q 4-6 hrs – vasospasm Monophasic OCs “OCP Taper” – qid for 4 days, tid for 3 days, bid for 2 days, daily for remainder of two packs Monophasic OCs “OCP Taper” – qid for 4 days, tid for 3 days, bid for 2 days, daily for remainder of two packs MPA (provera,cycrin) – 10 mg 2-3x/day for 2 weeks MPA (provera,cycrin) – 10 mg 2-3x/day for 2 weeks

DUB long term therapy OCPs OCPs Withdrawal with progestin for days every 6-8 weeks Withdrawal with progestin for days every 6-8 weeks Use provera 10 mg, prometrium 100 mg, aygestin 2.5 – 5 mg Use provera 10 mg, prometrium 100 mg, aygestin 2.5 – 5 mg

Menorrhagia Myoma Myoma Polyp Polyp Coagulation Disorder Coagulation Disorder “Humoral” “Humoral” Idiopathic Idiopathic

Uterine Myoma Menorrhagia is most common symptom Menorrhagia is most common symptom Look for intramural or submucous myomas Look for intramural or submucous myomas Interruption of contractile hemostasis Interruption of contractile hemostasis Dx with ultrasound Dx with ultrasound Smell any fish? Smell any fish?

Therapy for Myomas Continuous OCPs Continuous OCPs GnRH agonists e.g Lupron GnRH agonists e.g Lupron Myomectomy/Hysterectomy Myomectomy/Hysterectomy Operative hysteroscopy Operative hysteroscopy Uterine artery embolization Uterine artery embolization Post-DUBYA – Mifepristone 50 mg/day Post-DUBYA – Mifepristone 50 mg/day

Humoral Menorrhagia Diagnosis of exclusion Diagnosis of exclusion Consider coagulopathy workup – 10% Consider coagulopathy workup – 10% Diff Dx: VWDz, thrombocytopenia,TTP, ITP,vasculitis, liver disease Diff Dx: VWDz, thrombocytopenia,TTP, ITP,vasculitis, liver disease Desmopressin nasal spray for VW Dz Desmopressin nasal spray for VW Dz

Medical Therapy NSAIDs – Ibuprofen, Naproxen, Mefenamic acid (meclomen, ponstel) NSAIDs – Ibuprofen, Naproxen, Mefenamic acid (meclomen, ponstel) OCPs – consider continuous regimen OCPs – consider continuous regimen Depoprovera Depoprovera Iron replacement Iron replacement Endometrial ablation – Rollerball, Novasure (mesh), Thermachoice (balloon), MEA (microwave) Endometrial ablation – Rollerball, Novasure (mesh), Thermachoice (balloon), MEA (microwave)

Perimenopause Oligomenorrhea if you’re lucky Oligomenorrhea if you’re lucky Anovulatory biweekly “menorrhagia” if you’re not Anovulatory biweekly “menorrhagia” if you’re not Therapy – low dose OCPs or higher dose HRT such as Activella or FemHRT Therapy – low dose OCPs or higher dose HRT such as Activella or FemHRT Don’t forget space-occupying disease Don’t forget space-occupying disease

Postmenopause All postmenopausal bleeding is cancer until proven otherwise All postmenopausal bleeding is cancer until proven otherwise 90% of BTB due to atrophy 90% of BTB due to atrophy Prove it with endometrial Bx or TV U/S Prove it with endometrial Bx or TV U/S On U/S endometrial “stripe” should be less than 5 mm On U/S endometrial “stripe” should be less than 5 mm BTB common in new start HRT BTB common in new start HRT Obese patients may require withdrawal Obese patients may require withdrawal