1. Abnormal Uterine Bleeding
P. Michael Kidder, DO, FACOOG
Primrose OB/GYN
Springfield, MO

2. Disclosure No disclosures to report.
I have no financial relationships with any pharmaceutical or equipment manufacturers.

3. Question 1
Which imaging modality is considered first line for imaging the pelvic anatomy?
A. Magnetic Resonance Imaging
B. Computed Tomography
C. Sonography
D. Hysteroscopy

4. Question 2
Combined Estrogen/Progesterone containing birth control works by feedback inhibiting the production of FSH in the pituitary gland.
True
False

5. Question 3 Menopause is diagnosed by using the following criteria?
A. The onset of climacteric symptoms, i.e, hot flashes and night sweats
B. Absence of menstruation for a period of at least 12 months
C. Follicle Stimulating Hormone level <20pcg/dL
D. When a woman reaches the age of 55

6. Question 4
Treatment options for women with AUB can include all of the following except;
A. Combined Oral Contraceptives
B. Tranexemic Acid
C. Saline infusion Sonohysterogram
D. LnG52/5 Progesterone IUD
E. Hysterectomy

7. Question 5 What is the genetic inheritance of Hemophilia A and B?
Autosomal Dominant
Autosomal Recessive
X-Linked Recessive
X-Linked Dominant

8. Dysfunctional (Abnormal) Uterine Bleeding
Definition
Background
Differential Diagnosis
Terminology
Evaluation
Physical Exam
Laboratory Assessment
Imaging
Treatment and Management

9. Definition Abnormal uterine bleeding:
Menstrual bleeding of abnormal quantity, duration, or schedule.
So what is considered normal?
Cycle Length: days
Average blood loss: ~80cc
Clinical definition is subjective: volume that does not interfere with a woman's physical, social, emotional, and/or quality of life
Days of bleeding: <8 days

10. Background- Uterine Anatomy

11. Background The Menstrual Cycle: More than you will ever want to know.
Primary Hormones: GnRH, FSH, LH, E2, P4
Hypothalamic-Pituitary-Ovarian Axis
Birth Control- How does it work?!?!

12. Background-Endometrial Anatomy

13. Differential Diagnosis of AUB
There’s a lot!
Different age groups and developmental stages!

18. Terminology
Old terminology- Menorrhagia, Menometorrhagia, Oligomenorrhea
2011 – Federation of Obstetrics and Gynecology (FIGO)
PALM-COEIN
Polyps Coagulopathy
Adenomyosis Ovulatory Dysfunction
Leiomyoma Endometrial
Malignancy/Hyperplasia Iatrogenic
Not Yet Classifies
AUB-P, AUB-A, AUB-E, etc…

19. Evaluation- History Gynecologic and obstetric history, including:
Menstrual history
There’s an App for that!
Sexual history
Assess risk for pregnancy or sexually transmitted infections
History of obstetric or gynecologic surgery
C-sections, Myomectomy
Contraceptive history
OCP’s, IUD, Implants

20. Evaluation- History Continued
Is the uterus the source of the bleeding?
Bleeding from the vulva, vagina, or cervix
volume of bleeding
Large Volume- Likely uterine
 color of the blood 
Dark = old blood
 bleeding is consistently postcoital
Suggests cervical pathology
Urinary or gastrointestinal tract bleeding?
Hemorrhoids, fistula, fissures
Is the patient premenarchal or postmenopausal?
average age of menarche is 12 years
average age of menopause is 51 years
Definition of menopause!!!

21. Evaluation- History Continued
Other medical history
Bleeding disorders
VwB, anticoagulation, thrombocytopenia, hematologic malignancy
Hemophilia? (Rare in women?)
Thyroid disease
1-2% of women
Galactorrhea
Hyperprolactinemia

22. Evaluation- Continued
Is the patient pregnant?
Just do the pregnancy test!!!
Look pretty dumb when radiologist calls you up!!!

23. Evaluation
Gotta have algorythms!!!

26. Evaluation- Laboratory
Initial tests:
Serum or Urine HCG
Sensitivity of Urine vs Serum
CBC
Additional tests
TSH
Prolactin
Sex hormones
FSH, LH, Estradiol, progesterone, free testosterone
Coagualtion studies

27. Evaluation- Imaging Pelvic ultrasound MRI Hysteroscopy
Transvaginal superior to Transabdominal
Saline Infusion sonogram
Good for intrauterine pathology
MRI
Further evaluation of fibroids/advanced disease
Hysteroscopy
Direct imaging

28. Evaluation- Pelvic Ultrasound

29. Evaluation
Your detailed history will guide your work-up!

30. Treatment and Management
Choosing a treatment — Management of reproductive-age women with AUB with a benign etiology is based upon the following factors:
Etiology
Severity of bleeding (eg, anemia, interference with daily activities)
Associated symptoms and issues (eg, pelvic pain, infertility)
Contraceptive needs and plans for future pregnancy
Medical comorbidities
Underlying risk for venous thromboembolic disease and/or arterial thrombotic events

31. Treatment and Management
Medical vs Surgical treatment
Medical
Oral Contraceptives (varying dose) vs LnG52/5 (Progesterone IUD)
Progestins- cyclical and long term therapy
Estrogen
Tranexemic Acid
Surgical
Endometrial ablation
Hysterectomy
Myomectomy
58% of women that were medically treated for AUB underwent surgery within 2 years

32. Case #1: “Millie”
19 yr old college student presents complaining of heavy bleeding for the past 4 days- markedly heavier than her normal period. She also has nausea, vomiting for the past week. Her bleeding is bright red, and she notes passing some quarter sized clots. She is sexually active with one partner. She has been using the vaginal ring for contraception.
PMH: Treated for URI 6 weeks ago with Azithromycin
PSH: No surgeries
What else do you want to know?
Millenial

33. Case #1: “Millie” More History Physical Exam Labs
Large amount of blood in the vault, uterus is difficult to palpate due to tenderness, no adnexal masses, cervix is clear.
Labs

34. Case #1: “Millie”
Urine HCG: Positive
CBC
Serum HCG?

35. Case #1: “Millie”
Serum HCG: 198,000
What next?
Ultrasound!

36. Case #1: “Millie” Ultrasound results:
Numerous discrete anechoic (cystic) spaces with central area of heterogeneous echotexture 

37. Case #1: “Millie”
Diagnosis???
Molar Pregnancy

38. Case #1: “Millie” Treatment Course…
Transfusion, D&C, Follow HCG levels…
Wait at least a year to get pregnant!

39. Case #2: “Alice”
47 yr old morbidly obese woman comes to your office complaining of vaginal bleeding for the past 6 weeks. She reports having irregular periods for the past 20 years- after the birth of her child (G2P1011). Husband had a vasectomy 18 years ago. Menarche at age 9. Her last period prior to her current bleeding was 4 months ago.
What else do you want to know?

40. Case #2: “Alice”
More History
Physical Exam
Labs
Imaging

41. Case #2: “Alice”
Ultrasound:
Endometrial thickness of 2.16cm

42. Case #2: “Alice” What is your next step to make a diagnosis?
Hysteroscopy, Dilation and Currettage!

43. Case #2: “Alice” Hysteroscopy Results:
Endometrial Currettings Pathology:
Complex Endometrial Hyperplasia with Atypia

44. Case #2: “Alice”
So… what’s next for Alice?

45. Case #2: “Alice”
Surgical video – Robotic Assisted Total Laparoscopic Hysterectomy with Bilateral Salpingoopherectomy

46. AUB- Huge Topic Main points
Have a broad understanding of the differential diagnosis
Low threshold to refer to specialist

47. Question 1
Which imaging modality is considered first line for imaging the pelvic anatomy?
A. Magnetic Resonance Imaging
B. Computed Tomography
C. Sonography
D. Hysteroscopy

48. Question 2
Combined Estrogen/Progesterone containing birth control works by feedback inhibiting the production of FSH in the pituitary gland.
True
False

49. Question 3 Menopause is diagnosed by using the following criteria?
A. The onset of climacteric symptoms, i.e, hot flashes and night sweats
B. Absence of menstruation for a period of at least 12 months
C. Follicle Stimulating Hormone level <20pcg/dL
D. When a woman reaches the age of 55

50. Question 4
Treatment options for women with AUB can include all of the following except;
A. Combined Oral Contraceptives
B. Tranexemic Acid
C. Saline infusion Sonohysterogram
D. LnG52/5 Progesterone IUD
E. Hysterectomy

51. Question 5 What is the genetic inheritance of Hemophilia A and B?
Autosomal Dominant
Autosomal Recessive
X-Linked Recessive
X-Linked Dominant