Surgical Block

GYNECOLOGY
2012

Abnormal Uterine Bleeding

Dr. Richard Jordias

NORMAL MENSTRUAL CYCLE  Uterine bleeding occurring at intervals from >35 days
to 6 months
AMENORRHEA
Requirements  No menses for at least 6 months
Intact, properly functioning hypothalamic-pituitary- INTERMENSTRUAL BLEEDING
ovarian system  Bleeding of variable amounts occurring b/w regular
Estrogen-induced proliferative endometrium in first half menstrual periods
of menstrual cycle  Bleeding b/w clearly defined cyclic & predictable
Ovulation at midcyle with progesterone production from menses
the corpus luteum DYSFUNCTIONAL UTERINE BLEEDING
Progesterone-induced secretory endometrium in second  Abnormal uterine bleeding with no demonstrable
half of cycle organic cause (usually secondary to anovulation)
If pregnancy does not occur, hormones decline &  No LONGER used
withdrawal bleeding occurs  REPLACED BY: Anovulatory Bleeding
ANOVULATORY BLEEDING
Characteristics of Normal Menstrual Cycle  Abnormal bleeding secondary to anovulation
 Preferable to the term Dysfunctional Uterine
Vary greatly among women
Bleeding
Change dramatically from cycle to cycle
Normal cycle length: 21-35 days
Menstrual length: < 7 days Cultural Context of Menstruation
Average blood loss: 35 ml (range: 20-60 mL) THE AFFECTED POPULATIONS

Documenting Menstrual Cycle Length

Instruct patients on “what is normal”
 Normal cycle is 21-35 days
Determined by counting the number of days from the
first day of menstrual flow (not the last day) to the first
day of the nest menstrual flow
The first day of menstrual flow is defined as Cycle Day 1

CHARACTERISTICS OF NORMAL MENSTRUATION

Clinical Dimenstions Normal Limits
of Menstruation & Descriptive Terms (5th & 95th
Menstrual Cycle Percentiles)
frequent < 24
frequency of menses
normal 24-38
(days)
infrequent > 38
regularity of menses, Absent --
cycle-to-cycle
regular variation + 2+20 days
variation over 12
mos irregular variation > 20days
Prolonged > 8.0
Duration of Flow
Normal 4.5-8.0
(Days)
Shortened < 4.5 Etiology of Bleeding
Heavy > 80 Until now, there has been no universally accepted
Volume of Monthly
Blood Loss (mL)
Normal 5-80 method of categorizing etiologies of bleeding
Light <5

Acute vs Chronic AUB

ABNORMAL BLEEDING ACUTE AUB
 Significant amount of uterine bleeding to warrant
prompt intervention to prevent further blood loss
Definitions of Abnormal Bleeding CHRONIC AUB
MENORHRHAGIA OR HYPERMENORRHEA  Abnormality in volume, regularity, and/or timing of
 Excessive (>80mL) or prolonged (>7days) bleeding bleeding for the past 6 months
that occurs at regular intervals  Does not require immediate intervention
 NOW CALLED as: Heavy Menstrual Bleeding
METRORRHAGIA
Causes of AUB
 Bleeding occuring at irregular intervals of < 35 days
 NOW CALLED as: Intermenstrual Bleeding FIGO Classification System (PALM-COEIN) for causes of
MENOMETRORRHAGIA AUB in NONGRAVID women of Reproductive Age
 Prolonged uterine bleeding occurring at irregular  STRUCTURAL (PALM)
intervals ⚜ Polyp
POLYMENORRHEA  Request for transvaginal US
 Uterine bleeding occurs at regular intervals of < 21  Has a single feeding vessel
days ☀ Differentiate polyp from submucus
OLIGOMENORRHEA type

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GYNECOLOGY
2012

FIGO PALM-COIEN CLASSIFICATION ⚜ Ovulatory Dysfunction

 CAUSES OF OVULATORY DYSFUNCTION
 Obesity
STRUCTURAL NON-STRUCTURAL
☀ BMI > 35
 Low body weight
 Weight change
 Psychological stress
 Elite athletes
 Endocrinopathy
 Idiopathic
 Hypothyroidism
☀ Hyperthyroidism has a better
chance of getting pregnant vs
hypothyroidism
 Tx: remove polyp  PCOS/ Hyperandrogenic disorder
⚜ Adenomyosis  Hyperprolactinemia
 Infiltration of endometrial glands inside the  Luteal out of phase cycles
myometrial layer ☀ Halbans Syndrome
 Have icelets of blood secondary to the ❧ d/t Persistent Corpus Luteum
infiltration of endometrial glands in the  CAUSES OF ANOVULATION OR OLIGO-
myometrium OVULATION
 Uterus appears thickened w/c can be  Perimenarchal/ Perimenopausal
mistaken as Fibroids  POC
⚜ Leiomyoma  Endocrine Disorders (Thyroid, Pituitary,
 SUBMUCOSAL: MOST important Adrenal)
 0: pedunculated intracavitary  Anorexia Nervosa
 1: <50% intramural  Excessive Exercise
 2: > 50% intramural  Stress
 Other  Psychotropic Drugs
 3: contacts endometrium; 100%  Brain Tumors
intramural ⚜ Endometrial
 4: Intramural  Caused by local disturbances in endometrial
 5: subserosal; 50% intramural function
 6: subserosal; < 50% intramural  Deficiencies or excesses of proteins or
 7: subserosal pedunculated other entities that have an adverse
 8: Other (eg, cervical, parasitic) impact on hemostasis
 CAUSES
 Heavy or prolonged bleeding that
occurs at regular intervals
☀ (i.e. ovulatory)
 Abnormal prostaglandin levels in the
endometrium
  Prostaglandin F2alpha
(Vasoconstrictor) and Thromboxane
(platelet aggregator)
  Prostaglandin E2 (vasodilator) and
Prostacyclin (platelet inhibitor)
 PATHOLOGY
 Lack of progesterone  unopposed
estradiol stimulation  endometrial
growth surpassing estrogen support
 The result is irregular shedding of the
endometrium w/ resultant
unscheduled bleeding
 Too much estrogen  Potential for the
development of endometrial
hyperplasia or cancer
⚜ Iatrogenic
⚜ Malignancy & Hyperplasia  Systemic pharmacotherapy
 Tx: curettage for diagnostic endometrial  gonadal steroids
biopsy
☀ estrogens
 NONSTRUCTURAL (COEIN)
☀ progestins
⚜ Coagulopathy
☀ testosterone
 Von Willebran disease: MC
 others
☀ Overall prevalence: 13%
☀ Phenothiazides
 Idiopathic thrombocytopenic purpura
 Leukemia ☀ TCA
 Prothrombin deficiency ☀ Others
 Systemic Illness (Cirrhosis, sepsis)  MEDICATION causing AUB
 Hormone preparations
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 Oral Contraceptives ⚜ Partial thromboplastin time

☀ Non-compliance ⚜ Bleeding time
☀ Pill type: 20 μg > 30-35 μg > 50 μg ⚜ Platelet count
☀ Tobacco abuse
☀ Endometritis Diagnostic Procedures
☀ Polyps Endometrial Biopsy Indications
☀ Leiomyoma uteri  > 40 w/ AUB
☀ Concomitant medications  Younger than 40 w/ AUB & significant risk factors for
❧ e.g antiepileptics endometrial CA
☀ hormone replacement therapy ⚜ chronic anovulatory bleeding
☀ Depo-medoxyprogesterone ⚜ obesity
acetate (DMPA) ⚜ PCOS
☀ Levonorgestrel implants  Abnormal perimenopausal bleeding
 Psychotropic Drugs ⚜ Heavy, prolonged or intervals for fewer than 21
 Anti-coagulants days
⚜ Not Yet Classified  Patients in whom medical management of AUB fails
 Arteriovenous malformations & who have not previous undergone biopsy
 Myometrial hypertrophy  Atypical Endometrial Cells or Atypical Glandular
 a/w some systemic diseases Cells of Undetermined Significance (AGCUS) on PAP
 other smear
 REPRODUCTIVE TRACT DISORDERS  Patients suspected w/ endometritis
☀ Pregnancy ⚜ Empiric antibiotic treatment without EMB may
❧ Threatened or incomplete be acceptable
abortion Transvaginal Sonography Indications
❧ Ectopic pregnancy  Premenopausal patients in whom medical
❧ Gestational trophoblastic management of AUB has failed
diseases  History or examination suggesting possibility of
intraluminal lesions
EVALUATION OF AUB Saline Infusion Sonography Indication
 Premenopausal AUB unexplained by EMB
 Failed medical mx
History  Alternative for diagnostic hysteroscopy
Age  Differentiate cystic from submucus
Parity Diagnostic Hysteroscopy Indications
Cycic vs non-cyclic bleeding  Premenopausal AUB unexplained by EMB
Singular vs chronic episodes  Failed medical mx
Duration & amount of bleeding
Method of birth control MANAGEMENT OF AUB
Marital status or Sexual History
History of bleeding disorders
Operative Procedure
Medical illness
Medications Dilation & Curettage
Operative Hysteroscopy, Fractional & Currettage
 INDICATIONS
Physical Examination
⚜ A stenotic cervix or obstructive mass precludes
VS, pelvic & breast exam office EMB
Body habitus  d/t need of anesthesia
Evidence of endocrinopathies ⚜ persistent AUB despite medical treatment
 Hirsutism
⚜ endometrial lesion detected on TVS, SIS or office
 Hyperprolactinemia
diagnostic HYS
 Hypothyroidism
⚜ persistent hyperplasia on EMB despite medical
 Hyperthyroidism
treatment
 Cushing’s syndrome
 rule out occult malignancy
⚜ Atypical hyperplasia detected with EMB
Laboratory Exams  Rule out occult malignancy
Pregnancy test ⚜ Therapy for acute profuse bleeding and
Complete blood count & platelet count responsive to medical management
PAP smear
 Cervicitis
 Cervical polyp Factors Involved In Deciding Treatment
Cervical culture Amount of bleeding
 If at risk for STD or persistent breakthrough bleeding Cause of Bleeding
on OC Age of patient
Coagulation Studies Medical status
 If suspicious history, family history or excessive Desire for future fertility
bleeding not responsive to medical management, Need for contraception
especially in teenagers Coexistent gynecologic problems
⚜ Prothrombin time Significance to the patient
Results of endometrial biopsy, if performed

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GYNECOLOGY
2012

Role of Observation & Reassurance in Treatment ⚜ Synthetic steroid derivative w/ ANDROGENIC

properties
of Dysfunctional Uterine Bleeding  Dose
Singular episode of AUB in low-risk patients ⚜ 200 mg/day
Unsure if abnormal uterine bleeding exists  Disadvantages
Menstrual calendar & close follow-up
⚜ Androgenic side effects
⚜ Expensive
Treatment Regimens for Profuse Bleeding In GnRH AGONISTS
Anemic Patients  MOA
COMBINATION OCs ⚜ Inhibits ovulation & ovarian steroid production,
inducing amenorrhea
 OCs one tab TID for 7 days (one 21 day pill pack)
 Continue OCs OD without a pill-free interval to  Can only decrease to 30-40% in size
 DOSE
prevent withdrawal bleeding until anemia is
corrected ⚜ Depoleuprolide
CONJUGATED ESTROGEN  3.75 mg IM q month
 CEE  DISADVANTAGES
 Expensive
⚜ Dose:
 Hypoestrogenic state
 1.25mg PO 3-4x/day
MEDICATED INTRAUTERINE DEVICES
 2.5 mg of CEE, 0.6 x 4 = 2.5 mg q 6 hours
 Effective in reducing mean blood loss in ovulatory
⚜ High dose Estrogen is given so that there will be
DUB by 50% -100%
uniform proliferation of the endometrium 
 Progesterone:
bleeding stops
⚜ Effective for 1 year
 Continue & initiate MPA 10 mg/day & continue until
 Levonorgesterol
anemia is corrected
 D/C CEE + MPA and allow a withdrawal bleed ⚜ Effective for 7 years
 When bleeding stops, give progesterone MPA
(POVERA) 10 mg for 10-12 days a month or low dose Surgical Treatment
OCs OPERATIVE HYSTEROSCOPY/FRACTIONAL D & C
 Direct visualization & removal of intraluminal lesions
Treatment of Anovulatory Bleeding ENDOMETRIAL ABLATION
PROGESTIN  Menorrhagia not responsive to medical
 MPA, 10 mg management
 Norenthindrone acetate, 5-10 mg  Small intraluminal lesions (submucosal fibroids,
COMBINATION OCs endometrial polyps) may be removed concurrently
 Breakthrough bleeding is common the first 3-6  Future child-bearing not desired
months  Contraindicated in the presence of endometrial
DMPA INTRAMUSCULAR hyperplasia or CA
 15-250 mg IM q 2-3 months HYSTERECTOMY
CLOMIPHENE CITRATE or other ovulation-inducing  Failed medical management of AUB
medication if pregnancy is desired  Severe atypical endometrial hyperplasia
 Other coexistent gynecologic problems
⚜ To allow patient to ovulate
⚜ 15 mg/tabs on day 2 to day 6 per cycle ⚜ Myomatous uterus
⚜ Prolapse
⚜ Stress incontinence
Treatment for Menorrhagia
⚜ Endometriosis
NSAIDS
 Ibuprofen 800 mg 3-4x daily
 Naproxen sodium 550mg TID
 Mefenamic acid 500 mg TID
 Meclofenamate sodium 100 mg TID
st
 Beginning day prior to or 1 day of menses for 3-4
days
COMBINATION OC
ORAL PROGESTINS
 Medroxyprogesterone acetate: 10-30 mg/day
 Norethindrone acetate: 5-15 mg/day
 Regimen
⚜ Given 12 days of each cycle during LUTEAL
phase
⚜ Days 14-25 of cycle if menses > days apart
⚜ Days 12-23 of cycle if menses < 26 days apart
DEPOMEDROXYPROGESTERONE ACETATE
 Dose: 150-250 mg IM q 2-3 months
 Disadvantage
⚜ High incidence of irregular bleeding
DANAZOL
 Description