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ABNORMAL UTERINE BLEEDING Dr. Shahid Islam, MD, PhD, FRCPC

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1 ABNORMAL UTERINE BLEEDING Dr. Shahid Islam, MD, PhD, FRCPC
Unit II ABNORMAL UTERINE BLEEDING Dr. Sony Singh, MD, FRCSC Director of Minimally Invasive Gynecology The Ottawa Hospital Dr. Mina Wesa, MD, FRCSC Fellow in Minimally Invasive Gynecology Dr. Shahid Islam, MD, PhD, FRCPC Associate Professor and Program Director , Lab Medicine-Anatomical Pathology, University of Ottawa Staff Physician, Ottawa Hospital

2 Disclosure You may only access and use this PowerPoint presentation for educational purposes. You may not post this presentation online or distribute it without the permission of the author. Unit II – AUB – Dr. Sony Singh

3 Objectives Describe menorrhagia, metrorrhagia, menometrorrhagia, oligomenorrhea Classify abnormal uterine bleeding in ovulatory and anovulatory bleeding Categorize abnormal uterine bleeding into anatomical, medical/pharmacological and biochemical hormonal causes – using PALM-COEIN nomenclature! Elaborate a clinical approach to abnormal uterine bleeding in premenarchal, reproductive, peri and post-menopausal women Unit II – AUB – Dr. Sony Singh

4 Objectives Elaborate a clinical approach to abnormal uterine bleeding and briefly discuss available treatment options Compare the normal menstrual cycle with anovulatory conditions such as PCOS, POF and menopause Formulate a differential diagnosis of vaginal bleeding with respect to pre-menarchal, pre-menopausal and post-menopausal causes Describe pharmacological and surgical management of menorrhagia Describe the etiology and presenting signs and symptoms of anovulatory vaginal bleeding (including menopause, PCOS and ovarian tumors) Unit II – AUB – Dr. Sony Singh

5 Case Presentation (Live speaker) Unit II – AUB – Dr. Sony Singh

6 INTRODUCTION Abnormal Uterine Bleeding (AUB)
Refers to menstrual bleeding of abnormal quantity, duration, or schedule Common gynecologic complaint, accounting for over 30% of outpatient gynecologic visits Wide differential Structural uterine pathology (fibroids, polyps, adenomyosis) Anovulation Disorders of hemostasis Neoplasia ALWAYS RULE OUT PREGNANCY!!!

7 TERMINOLOGY - Traditional
Amenorrhea: absence of menstruation for at least three usual cyclic lengths Oligomenorrhea: cyclic length > 35 days Polymenorrhea: Cyclic length < 24 days

8 TERMINOLOGY - Traditional
Menorrhagia: regular, normal intervals with excessive volume and durations of flow Metrorrhagia: irregular intervals with normal or reduced volume and duration of flow Menometrorrhagia: Irregular intervals and excessive volume and duration of flow

9 in the Reproductive Years
TERMINOLOGY - Revised FIGO Classification System for Abnormal Uterine Bleeding in the Reproductive Years For the “Menstrual Agreement Process”: Malcolm G. Munro MD, FRCS(c), FACOG Professor, Department of Obstetrics & Gynecology David Geffen School of Medicine at UCLA Director of Gynecologic Services Kaiser Permanente Los Angeles Medical Center Ian S. Fraser MD, FRCOG, FRANZCOG Professor in Reproductive Medicine Department of Obstetrics & Gynaecology Queen Elizabeth II Research Institute for Mothers and Infants University of Sydney Hilary O. D. Critchley MD, FRCOG, FRANZCOG Professor of Reproductive Medicine Section of Obstetrics & Gynaecology Head, Division of Reproductive and Developmental Sciences University of Edinburgh

10 Ovulatory Dysfunction
FIGO Classification System for Causes of Abnormal Uterine Bleeding in the Reproductive Years Polyp Adenomyosis Leiomyoma Malignancy & Hyperplasia Coagulopathy Ovulatory Dysfunction Endometrial Iatrogenic Not Yet Classified Structural abnormality No structural abnormality

11 PREVALENCE Up to 30% of women in Canada will seek medical assistance for this problem during their reproductive years Significant health care burden for women, their families, and society Major impact on women’s quality of life, productivity, utilization of healthcare services

12 The Affected Populations
The Cultural Context of Menstruation The Affected Populations Menarche Menopause Premenarche Rep roductive Early Late Birth - 10 60 - Death Perimenarche Perimenopause Postmenopause

13 Impact of Heavy Menstrual Bleeding
The Cultural Context of Menstruation Impact of Heavy Menstrual Bleeding Quality of Life

14 Regulation of Normal Menstruation

15 Characteristics of Normal Menstruation
ABNORMAL Duration of flow 4 – 6 days <2 days or >7 days Volume of flow 30 mL >80 mL Length of cycle 24 – 35 days

16 ETIOLOGY OF AUB Neonatal period Prepubertal period Adolescence
Reproductive years Peri- menopause Post- menopause Estrogen withdrawal Foreign body Infection Blood dyscrasia Hypothalamic Anovulation (central, intermed, gonadal) Carcinoma (uterus, cervix) Atrophic vaginitis Sarcoma immaturity Functional (blood dyscrasia, hypothyroid, Climacteric Carcinoma (uterus, botryoides Ovarian tumor Inadequate luteal function luteal dysfunction) Iatrogenic (contraception, Polyps ovarian) Estrogen Trauma Psychogenic (including anorexia, bulemia) anticoagulation, hemodialysis) Pregnancy (abortion, ectopic, RPOC, GTD) replacement Uterine

17 ETIOLOGY OF AUB – Reproductive years
Neonatal period Prepubertal period Adolescence Reproductive years Peri- menopause Post- menopause Estrogen withdrawal Foreign body Blood dyscrasia Anovulation (central, intermed, gonadal) Carcinoma (uterus, cervix) Atrophic vaginitis Infection Hypothalamic immaturity Climacteric Carcinoma (uterus, ovarian) Functional (blood dyscrasia, hypothyroid, luteal dysfunction) Sarcoma botryoides Inadequate luteal function Polyps Ovarian tumor Estrogen replacement Psychogenic (including anorexia, bulemia) Trauma Iatrogenic (contraception, anticoagulation, hemodialysis) Pregnancy (abortion, ectopic, RPOC, GTD) Uterine

18 Ovulatory Dysfunction
FIGO Classification System for Causes of Abnormal Uterine Bleeding in the Reproductive Years Polyp Adenomyosis Leiomyoma Malignancy & Hyperplasia Coagulopathy Ovulatory Dysfunction Endometrial Iatrogenic Not Yet Classified Structural abnormality No structural abnormality

19 Ovulatory Dysfunction
FIGO Classification System for Causes of AUB in the Reproductive Years Polyp Adenomyosis Leiomyoma Malignancy & Hyperplasia Coagulopathy Ovulatory Dysfunction Endometrial Iatrogenic Not Yet Classified Structural abnormality No structural abnormality

20 POLYPS: AUB-P Common cause of abnormal genital bleeding in pre- and postmenopausal women Hyperplastic overgrowths of endometrial glands and stroma around a vascular core, sessile or pedunclulated Single, multiple, variable size and location, may be asymptomatic Prevalence rises with increasing age, premenopausal > postmenopausal Malignancy Risk Factors: Risk factors: Tamoxifen, obesity, HRT Size > 1.5 cm Tamoxifen use Postmenopausal 95% benign

21 TREATMENT - Polyps All symptomatic polyps should be removed
Asymptomatic polyps: Premenopausal women – remove if: Polyp > 1.5 cm diameter Multiple polyps Polyp prolapsed through cervix Infertility Risk factors for endometrial cancer Postmenopausal women – remove all endometrial polyps

22 Hysteroscopic Polypectomy - Scissors

23 Hysteroscopic Polypectomy – Electrosurgical Loop Resectoscope

24 FIGO Classification System for Causes of AUB in the Reproductive Years
Polyp Adenomyosis Leiomyoma Malignancy & Hyperplasia Coagulopathy Ovulatory Dysfunction Endometrial Iatrogenic Not Yet Classified Structural abnormality No structural abnormality

25 ADENOMYOSIS: AUB-A Ectopic endometrial glands and stroma within the uterine musculature Hypertrophy and hyperplasia of surrounding myometrium, diffusely enlarged uterus “globular” True incidence unknown as definitive diagnosis based on histopathology (following hysterectomy) Pathogenesis – endometrial invagination versus mullerian rests. PATHOGNOMONIC on microscopy: Presence of endometrial tissue within the myometrium Pathology: Uniformly enlarged, boggy uterus Thickened myometrium

26 Clinical Manifestations
ADENOMYOSIS: AUB-A Clinical Manifestations: Heavy menstrual bleeding Painful menstruation Chronic pelvic pain Enlarged, globular uterus on exam, may be tender Symptoms typically noted in women years old, given traditional diagnosis by hysterectomy. Newer MRI criteria for diagnosis suggest disease may cause dysmenorrhea and chronic pelvic pain in adolescents and younger reproductive-age women as well. Often the diagnosis of “pure” adenomyosis may be obscured by other pathology McElin TW, Adenomyosis of the uterus, Obstet Gynecol Annu. 1974;3(0):425. Kunz G et al., Adenomyosis in endometriosis – prevalence and impact on fertility. Evidence from magnetic resonance imaging, Hum Reprod. 2005;20(8):2309.

27 Diagnosis ADENOMYOSIS: AUB-A
Definitive diagnosis only by histopathology (hysterectomy) Preoperative diagnosis by characteristic clinical manifestations (menorrhagia, dysmenorrhea, enlarged uterus) MRI is best imaging technique Increased signal in areas of adenomyosis Exclude malignancy Distinguish adenomyosis from fibroids Transvaginal ultrasound up to 83% sensitive and 85% specific (Meredith SM, 2009)

28 Treatment ADENOMYOSIS: AUB-A Hysterectomy – definitive treatment
Hormonal options Progestins (Levonorgestrel IUD) Gondaotropin releasing hormone (GnRH) analogs Aromatase inhibitors ? Combined hormonal contraception Recurrent symptoms within 6 months after cessation of hormonal therapy Conservative surgery Endometrial ablation or resection Laparoscopic myometrial electrocoagulation Excision of adenomyosis – no plane, “woody” tissue consistency Uterine artery embolization (UAE) – some success Kim MD et al., Long-term results of uterine artery embolization for symptomatic adenomyosis, AJR Am J Roentgenol. 2007;188(1):176.

29 FIGO Classification System for Causes of AUB in the Reproductive Years
Polyp Adenomyosis Leiomyoma Malignancy & Hyperplasia Coagulopathy Ovulatory Dysfunction Endometrial Iatrogenic Not Yet Classified Structural abnormality No structural abnormality

30 LEIOMYOMA (Fibroids or Myomas): AUB-L
Most common pelvic tumor in women Benign, originate from myometrial smooth muscle Women of reproductive age Symptoms: AUB Pelvic pain or pressure Infertility or adverse pregnancy outcomes Clinically apparent in 12-25% women, noted on pathological exam in approx. 80% of uteri

31 Terminology LEIOMYOMA: AUB-L
European Society of Hysteroscopy Classification System for Submucosal Fibroids

32 Risk Factors LEIOMYOMA: AUB-L INCREASED RISK
Incidence is 2 to 3 fold greater in black women than in white women Baird DD et al., Am J Obstet Gynecol ;188(1):100 Early menarche (< 10 yrs old) Red meats Alcohol (beer) Other – hypertension, family history DECREASED RISK Higher parity Green vegetables, fruits Dietary vitamin A Smoking

33 Clinical Manifestations
LEIOMYOMA: AUB-L Abnormal uterine bleeding Pelvic pressure and pain Reproductive dysfunction

34 Clinical Manifestations
LEIOMYOMA: AUB-L Abnormal uterine bleeding Pelvic pressure and pain Reproductive dysfunction

35 Clinical Manifestations
LEIOMYOMA: AUB-L Abnormal uterine bleeding Pelvic pressure and pain Reproductive dysfunction

36 Clinical Manifestations
LEIOMYOMA: AUB-L Abnormal uterine bleeding Pelvic pressure and pain Reproductive dysfunction

37 Diagnosis LEIOMYOMA: AUB-L PHYSICAL EXAMINATION:
Bimanual pelvic examination – enlarged uterus Speculum examination – prolapsed submucous fibroid, cervical contour

38 Diagnosis LEIOMYOMA: AUB-L IMAGING: Transvaginal Ultrasound (TVS)
95-100% sensitive Most widely used modality – accessible, cost-effective Saline Infusion Sonography (Sonohysterography) Improved assessment of intracavitary fibroids Fibroid in 53 yo woman who presented with PMB Joizzo, JR et al., AJR Am J Roentgenol 2001 TVS SIS

39 Diagnosis LEIOMYOMA: AUB-L Diagnostic Hysteroscopy
Can be performed in office Saline or CO2 distension media ? accuracy compared to ultrasound

40 Diagnostic Hysteroscopy
LEIOMYOMA: AUB-L Diagnostic Hysteroscopy

41 Diagnosis LEIOMYOMA: AUB-L Magnetic Resonance Imaging Post UAE
To distinguish among leiomyomas, adenomyosis, and adenomyomas Expensive Reserved for complex surgical planning Also to distinguish fibroids from leiomyosarcomas, before uterine artery embolization (UAE) Post UAE

42 Treatment LEIOMYOMA: AUB-L
No role for prophylactic treatment – Exceptions: planning pregnancy, hydronephrosis Treatment choice based on: Type, severity of symptoms Size Location Patient age Reproductive plans Options: Expectant Medical management Surgical management

43 Medical Management LEIOMYOMA: AUB-L Hormonal therapies
Estrogen–progestin contraceptives Levonorgestrel–releasing intrauterine system (“Mirena IUD”) Progestin injections (Depot Medroxy Progesterone Acetate – DMPA) Progestin pills Gonadotropin-releasing hormone (GnRH) agonists, antagonists Selective progesterone receptor modulators (“SPRMs” – Ulipristal acetate) Antifibrinolytics (?) Danazol - ++ side effects

44 Surgical Management LEIOMYOMA: AUB-L UAE Hysteroscopy Myomectomy
Laparoscopy/Laparotomy AUB-L Vaginal Hysterectomy Laparoscopic Abdominal

45 Hysteroscopic Myomectomy
LEIOMYOMA: AUB-L

46 Laparoscopic Myomectomy
LEIOMYOMA: AUB-L

47 FIGO Classification System for Causes of AUB in the Reproductive Years
Polyp Adenomyosis Leiomyoma Malignancy & Hyperplasia Coagulopathy Ovulatory Dysfunction Endometrial Iatrogenic Not Yet Classified Structural abnormality No structural abnormality

48 MALIGNANCY / HYPERPLASIA: AUB-M
Endometrial hyperplasia Proliferation of endometrial glands that may progress to or coexist with endometrial cancer Result of chronic UNOPPOSED estrogen stimulation without balancing effects of progesterone Women present with abnormal uterine bleeding Histologic diagnosis – ENDOMETRIAL BIOPSY

49 MALIGNANCY / HYPERPLASIA: AUB-M
HISTOLOGY % RISK OF COEXISTING CA Simple hyperplasia without atypia 1 Complex hyperplasia without atypia 3 Simple hyperplasia with atypia 8 Complex hyperplasia with atypia 29 Normal proliferative endometrium Normal endometrium

50 Total Hysterectomy Bilateral salpingo-
Treatment MALIGNANCY / HYPERPLASIA: AUB-M High dose Progestin therapy Fertility desired Pre-menopausal Childbaring completed Atypical hyperplasia (often complex) Total Hysterctomy Total Hysterectomy Bilateral salpingo- oophorectomy Post-menopausal

51 FIGO Classification System for Causes of AUB in the Reproductive Years
Polyp Adenomyosis Leiomyoma Malignancy & Hyperplasia Coagulopathy Ovulatory Dysfunction Endometrial Iatrogenic Not Yet Classified Structural abnormality No structural abnormality

52 COAGULOPATHY: AUB-C Initial screening for an underlying disorder of hemostasis in patients with excessive menstrual bleeding should be structured by medical history. Positive screen comprises any of the following: Screening for bledding disorders in women with HMB Heavy menstrual bleeding (HMB) since menarche One of the following: Postpartum hemorrhage Surgery-related bleeding Bleeding associated with dental work Tow or more of the following symptoms: Bruising one to two times per month Epistaxis one to two times per month Frequent gum bleeding Family history of bleeding symptoms Von Willebrand disease identified in 13% of women with HMB.

53 Treatment COAGULOPATHY: AUB-C CONSULT HEMATOLOGY!! Options:
No desire for pregnancy: Combined oral contraceptives Levonorgestrel-releasing IUS Endometrial ablation If pregnancy desired: Antifibrinolytics Factor replacement therapy dDAVP at the onset of menses

54 Ovulatory Dysfunction
FIGO Classification System for Causes of AUB in the Reproductive Years Polyp Adenomyosis Leiomyoma Malignancy & Hyperplasia Coagulopathy Ovulatory Dysfunction Endometrial Iatrogenic Not Yet Classified Structural abnormality No structural abnormality

55 OVULATORY DYSFUNCTION: AUB-O
Unpredictable bleeding pattern Variable amount of flow Absence of cyclic production of progesterone

56 Ovulatory Dysfunction
FIGO Classification System for Causes of AUB in the Reproductive Years Polyp Adenomyosis Leiomyoma Malignancy & Hyperplasia Coagulopathy Ovulatory Dysfunction Endometrial Iatrogenic Not Yet Classified

57 ENDOMETRIAL: AUB-E Predictable cyclic menses, normal ovulation
No other causes of AUB identified Possible mechanism (s): Disorder of endometrial hemostasis – deficient vasoconstrictos (PGF2α, endothelin- 1), accelerated fibrinolysis Endometrial inflammation, infection Abnormal local inflammatory response Abnormal vasculogenesis  DIAGNOSIS OF EXCLUSION!

58 Ovulatory Dysfunction
FIGO Classification System for Causes of AUB in the Reproductive Years Polyp Adenomyosis Leiomyoma Malignancy & Hyperplasia Coagulopathy Ovulatory Dysfunction Endometrial Iatrogenic Not Yet Classified

59 IATROGENIC: AUB-I

60 Ovulatory Dysfunction
FIGO Classification System for Causes of AUB in the Reproductive Years Polyp Adenomyosis Leiomyoma Malignancy & Hyperplasia Coagulopathy Ovulatory Dysfunction Endometrial Iatrogenic Not Yet Classified

61 NOT YET CLASSIFIED: AUB-N
Rare entities Arteriovenous malformations (AVMs) Myometrial hypertrophy Other disorders not yet identified

62 Lets run through a case to consolidate all this 
(To be added)

63 Evaluation of AUB in Premenopausal Women
Unit II – AUB – Dr. Sony Singh

64 Evaluation of AUB in Perimenopausal Women
Unit II – AUB – Dr. Sony Singh

65 Evaluation of AUB in Postmenopausal Women
Unit II – AUB – Dr. Sony Singh

66 Non- hysteroscopic Endometrial Ablation Hysteroscopic AUB – Normal Cavity, No Malignancy Vaginal Hysterectomy Abdominal Laparoscopic

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