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ACOFP 53rd Annual Convention & Scientific Seminars

Dysfunctional Uterine
Bleeding

Michele Tartaglia, DO
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Michele Tartaglia, DO, FACOOG, CS

Assistant Professor and Residency Program Director
Rowan University School of Osteopathic Medicine
Department of Obstetrics & Gynecology

Objectives

1. Define normal and abnormal uterine
bleeding (AUB)
2. Describe a patterns based approach to AUB
3. Understand the diagnostic modalities
commonly used in the workup of AUB
4. Describe the different options for both the
medical and surgical management of AUB

Financial Disclosure

 No financial disclosures to report

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Misc. Disclosure

 Entire talk based on one article with some
evidence based updating and commentary
from me

I’m not the only author of this talk!!!

JABFM Article

• Authors = 2 family docs and 2 gynecologists
• MEDLINE search for algorithms for clinical
management AUB
• Also examined care of 100 random women in university
gyn clinic
• Then honed own clinically based algorithm
• Noticed that gyns usually immediately group all AUB
patients into one of 4 groups

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JABFM Article

1. Severe acute bleeding
2. Irregular bleeding
3. Menorrhagia
4. Abnormal bleeding associated with contraceptive
use
• Oral contraceptives
• Depo-medroxyprogesterone
• Intrauterine devices

Normal Uterine Bleeding


 Normal interval is 21-35 days
 Normal duration is 1-7 days
 Gyn textbook answer – two to eight days
 Normal amount is less than 1 pad or tampon every 3
hours

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Severe Acute Bleeding



Severe Acute Bleeding


 Bleeding that requires more than one pad/tampon
per hour
AND/OR
 Vital signs indicating hypovolemia

Severe Acute Bleeding


 Common causes:
 Adolescents – coagulopathy (vonWillebrand disease,
leukemia)
 Fibroids – especially submucosal
 People on anticoagulants
 Obesity – anovulatory cycles and adenomyosis
 Trauma
 Tailor your lab workup to the individual patient
 Ultrasound NOT as helpful in the adolescent

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Severe Acute Bleeding



“Cycle Provera” – consider starting high dose (10mg BID-TID) with taper then
standard dose (10mg qHS x 10-21 days) next two cycles

Severe Acute Bleeding


 Alternative medical therapies
 Tranexamic acid
 Antifibrinolytic agent
 Not studied for acute AUB
 IV and PO options
 Foley catheter placed into uterus
 Tamponade
 26F with 30mL saline – case reports proving efficacy
 Desmopressin or recombinant Factor VIII in patients
with vonWillebrand disease

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Severe Acute Bleeding


 Surgical options
 D&C
 Endometrial Ablation
 Uterine artery embolization
 Hysterectomy

Severe Acute Bleeding

Summary


Irregular Bleeding


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Irregular Bleeding

 Includes:
 Metrorrhagia
 Menometrorrhagia
 Oligomenorrhea
 Prolonged bleeding
 Intermenstrual bleeding
 Any other irregular pattern

Irregular Bleeding

 Not every patient needs evaluation!
 Adolescent in the first 2 yr after menarche
 immaturity HPO axis
 However may request intervention
 Perimenopausal patient
 Some shortening or lengthening of the cycle is expected
 Repeated cycles outside the normal range or other AUB
requires endometrial biopsy
 Reproductive age woman
 Some spotting just before, just after, or at ovulation can
be normal
 However, ANY midcycle bleeding in an older patient
should be worked up

HCG, TSH,
prolactin

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Endometrial Biopsy

 Paper: Age >35 with irregular bleeding REQUIRE biopsy
 ACOG
 >45yo as first line test
 <45yo if hx unopposed estrogen (PCOS, obesity), failed
medical management, persistent AUB
 Sensitivity of EMB in studies that use hysterectomy: 68%,
used D&C: 78%
 Samples an average of 4% of the endometrium
 Still a good test – just consider further eval if no response
to therapy in the face of a normal EMB

Transvaginal Ultrasound

 Identify polyps, fibroids, very thick EMS
 EMS < 5mm = VERY low likelihood of endometrial
hyperplasia or carcinoma
 Large meta-analysis: intrauterine abnormalities
found in 46.6% of women with AUB
 Try to schedule day 4-6 of cycle (EMS thin)
 Proliferative phase EMS usually 4-8mm
 Secretory phase EMS usually 8-14mm
 Saline infusion sonohysterography even more
accurate

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Systemic Causes

 Chronic endometritis – treat w doxy 100mg BID x 10d
 Medications – eg. TCAs, corticosteriods, antipsychotics
 Systemic disease – liver or kidney failure, thyroid d/o
 Hyperandrogenic syndromes
 PCOS
 Congenital adrenal hyperplasia
 Androgen secreting tumors
 Hyperprolactinemia

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Menorrhagia


Menorrhagia

 Heavy but regular, cyclic bleeding
 Blood loss greater than 80mL per cycle or patient
perception of very heavy bleeding
 Large clots
 Iron deficiency anemia

 If the bleeding lasts > 12 days (arbitrary set by

authors) follow irregular bleeding algorithm

Menorrhagia

 Up to 20% of women have an underlying bleeding
disorder – MUST SCREEN
 YES answer to any of the following is a +screen
 HMB since menarche
 One of the following:
 PP hemorrhage
 Surgery related bleeding
 Bleeding assoc w dental work
 Two or more of the following:
 Bruising 1-2x a month
 Epistaxis 1-2x a month
 Frequent gum bleeding
 Family hx bleeding symptoms

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Tranexamic Acid

 Oral antifibrinolytic FDA approved for treatment of
HMB of greater than 80mL per cycle
 Few case reports of arterial and venous thrombosis
 NO REPORTS of VTE
 Contraindicated in those w hx or high risk VTE
 No data on use with COCs - contraindicated
 Reduces blood loss by 40-65%
 TID dosing only on days of heaviest bleeding – max
5 days

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AUB from Hormonal

Contraception


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References

• Ely JW, Kennedy CM, Clark EC, Bowdler NC. Abnormal Uterine Bleeding: a
management algorithm. J Am Board Fam Med. 2006. 19(6):590-602.
• ACOG Practice Bulletin Number 557. Management of Acute Abnormal
Uterine Bleeding in Nonpregnant Reproductive-Aged Women. April 2013
(Reaffirmed 2015).
• ACOG Practice Bulletin Number 128. Diagnosis of Abnormal Uterine
Bleeding in Reproductive Aged Women. July 2012 (Reaffirmed 2014).
• ACOG Practice Bulletin Number 136. Management of Abnormal Uterine
Bleeding Associated with Ovulatory Dysfunction. July 2013 (Reaffirmed 2015).
• Curtis M, Overholt S, Hopkins M. Glass’ Office Gynecology. 6th Edition.
Lippincott Williams & Wilkins. 2006.
• Lysteda (package insert). Parsippany, NJ: Ferring Pharmaceuticals Inc.;
Rev 10/2013.
• Kost A, Pitney C. Tranexamic Acid (Lysteda) for Cyclic Heavy Menstrual
Bleeding. American Family Physician. Volume 84, Number 8. October 15,
2011.

Enjoy Puerto Rico!!!!

Michele Tartaglia, DO, FACOOG, CS

tartagmi@rowan.edu

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