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Abnormal Uterine Bleeding by Kemi Dele


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Acute and Chronic Abnormal Uterine Bleeding

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Abnormal Uterine Bleeding by Kemi Dele

  3. 3. Introduction: Abnormal Uterine Bleeding Most common complaint in Gynecological and Family practice. It accounts for 70% of all Gynaecologic Consults. Affects 1/3 of women at some stage in their life. Key to management include: •establishing cause •instituting appropriate therapy
  4. 4. Normal Uterine Bleeding Age of patient: reproductive-aged women (from menarche to menopause) Frequency / Cycle Length: 21 days to 35 days interval Duration of Flow: 2 days to 8 days; usually 4-6 days Flow: Average of 35 ml although 10ml – 80ml is considered normal. (1 normally soaked regular pad / tampon holds +/- 5mls of blood. However, depending on the brand, a pad can hold between 5 and 15 ml of blood)
  5. 5. Menstrual Assessment Chart
  6. 6. Volume of blood flow assessed by number of pads / tampons used
  7. 7. Normal Uterine Bleeding  Menarche: • 9-16 years (mean 12,8) usually 2,3 years after 1st sign of breast development.  Reproductive years: • Cycle length 23-39 days (mean 30). • Duration of menstrual bleeding 2-8 days (mean 5). • Normal blood loss 10-55ml (=/< 80mls)  Menopause: • 48-55 years (mean 51,3); 40 – 48 = early menopause
  8. 8. Normal Menstrual Cycle • Menstruation is a cyclic physiological phenomena • Starting at the age of Menarche (10-12years) till establishment of Menopause (45-55 yrs.). • It is regulated by hypothalmo-pituitary- ovarian hormones secreted in pulsatile and cyclic pattern. • Also influenced by endometrial response to the Oestrogen & Progesterone hormones and coagulation cascade.
  9. 9. Regulation By Hypothalmo- pituitary- Ovarian Hormones
  10. 10. Phases of Menstrual Cycle • Follicular • Begins with Menses ends with luteinizing (LH) hormone surge • Ovulation (30-36 hours) • Begins with LH surge and ends with ovulation • Luteal (14 days) • Begins with the end of the LH surge and ends with onset of menses
  11. 11. Phases of Menstrual Cycle
  12. 12. Arrest of Menstrual bleeding Haemostasis by platelet plug and clot formation: important in the functional endometrium Prostaglandin dependent vasoconstriction important in the basalis layer Tissue Repair the raw area of remaining basal endometrium is completely epithelized under Estrogen effect
  13. 13. I’m on my period….
  15. 15. Abnormal Uterine Bleeding • What is abnormal uterine bleeding? • Bleeding from the uterine corpus that is abnormal in regularity, volume, frequency or duration, and occurs in absence of pregnancy • 3 Main Factors: Volume, Duration and Frequency ACOG: American Congress of Obstetricians and Gynecologists, 2013
  17. 17. AUB vs DUB: Why Talk About It? • Prior definitions had some gray areas. • “Dysfunctional uterine bleeding” is a term used synonymously with AUB in literature… • But unlike AUB, DUB is a diagnosis of exclusion for which no cause was identifiable • FIGO in 2011 eliminated misleading terms • Articles also unanimously recommend discontinuing use of the term DUB. FIGO: International Federation of Gynecology and Obstetrics, 2011
  18. 18. Some Older classification/Clinical Types • Dysfunctional Uterine Bleeding: uterine bleeding, diagnosis of exclusion • Menorrhagia: heavy menstrual bleeding (>80 mL) • Metrorrhagia: bleeding between periods – irregular intervals, excessive flow and duration • Polymenorrhea: bleeding that occurs more often than every 21 days • Oligomenorrhea: bleeding that occurs at intervals longer than every 35 days
  19. 19. Some Older classification/Clinical Types • Amenorrhea: no menstruation. primary (if no menses by age of 16 years) and secondary (if no menses for at least 3 months after menarche has occurred). • Oligomenorrhoea: normal menstrual duration and intensity but decreased frequency. lengthened cycle >39 days. usually associated with anovulation • Post-menopausal bleeding: vaginal bleeding in a woman who has reached menopausal age OR had 6 months of amenorrhea preceding the episode of vaginal bleeding.
  20. 20. Old Definitions Polymenorrhoea: Menstruation with normal duration and flow, but shorted cycle with intervals < 25 days Menorrhagia/ Hypermenorrhoea: Heavy cyclical bleeding - increased duration and/or increased flow Metrorrhagia: acyclical, irregular or continuous Uterine bleeding independent of menstrual pattern Menometrorrhagia: •Increased flow during menstruation and between menstrual periods Dysfunctional Uterine Bleeding
  22. 22. PALM-COEINClassification • A new classification system known is by acronym “PALM-COIEIN” • It classifies by bleeding pattern & aetiology. • It was introduced by FIGO in 2011, to create universal nomenclature system to describe uterine bleeding abnormalities in reproductive-aged women • ACOG also supported adopting PALM-COEIN classification/nomenclature to standardize terminology used to describe AUB FIGO: International Federation of Gynecology and Obstetrics; ACOG: American Congress of Obst & Gyne
  23. 23. • Keywords: Menstrual Disorders, Menorrhagia, Heavy Uterine Bleeding, Classification
  24. 24. FIGO Classifications cont. • Abnormal Uterine Bleeding (AUB): quantity, regularity and/or timing • Acute AUB: episode of heavy bleeding that is sufficient amount to require immediate intervention to prevent further blood loss • Chronic AUB: AUB present for most of previous 6 months • Acute AUB can be spontaneous or in context of chronic AUB
  25. 25. FIGO Classifications cont. • Intermenstrual bleeding (IMB): bleeding between clearly defined cycles • Heavy menstrual bleeding (HMB): excessive menstrual blood loss affecting quality of life – physical, emotional, social, material • Objective HMB: blood loss > 80ml/ cycle. 60% of these women will have evidence of iron deficiency anaemia. • Subjective HMB: 50% of women presenting with heavy menses will have measured blood loss within normal limits but must still be considered abnormal, and investigated accordingly.
  27. 27. PALM-COEIN Classification; FIGO: International Federation of Gynecology and Obstetrics, 2011
  28. 28. PALM-COEINClassification Structural Imaging, Histology Or Both • Polyp • Adenomyosis • Leiomyoma • Malignancy and hyperplasia Unrelated To Structural Abnormalities • Coagulopathy • Ovulatory disorders • Endometrium • Iatrogenic • Not classified
  30. 30. PALM COEIN
  31. 31. Distribution of study population based on PALM-COEIN classification PALM-COEIN FIGO Classification for diagnosis of Abnormal Uterine Bleeding: Practical Utility of same at Tertiary Care Centre in North India. Priyanka Goel, Samta Bali Rathore. Published 2016
  32. 32. AUB: Differential Diagnoses • Cervix: Polyp, cervicitis, ectropion, dysplasia, invasive carcinomas • Uterus: FIBROIDS (1/3 of patients); • Uterus: endometritis, endometrial polyp, endometriosis, adenomyosis, adenocarcinoma • Ovary: Anovulatory cycles, Ovarian failure, Polycystic ovaries, Obesity • Ovarian Tumours: germ cell tumours, sex cord (stromal) tumours • Iatrogenic: Hormonal Contraceptives, IUCD, Hormone replacement therapy, Phytoestrogens, ginseng, SSRIs
  33. 33. AUB: Differential Diagnoses, cont. • Prolactinomas • Thyroid disease • Coagulation defects: ITP; von Willebrand’s Disease (inherited disorder) • Hepatic and renal failures • Trauma • Foreign bodies • Pregnancy related complications: ectopic pregnancy, inevitable abortions, GTD
  34. 34. Common Differential by Age 13-18 19-39 40-Menopause Anovulation OCP Pelvic infection Coagulopathy Tumor (the most common cause among Adolescents is persistent anovulation due to immaturity/dysregulation of the H-P-ovarian axis) Pregnancy Structural Lesions (leiomyoma, polyp) Anovulatory cycles (PCOS) OCP Endometrial hyperplasia Endometrial cancer (less common) Anovulatory bleeding Endometrial hyperplasia and carcinomas Endometrial atrophy Leiomyoma
  35. 35. AGE GROUP AETIOLOGY TREATMENT Prepubertal child (< 10 years) • Precocious puberty • Non-menstrual bleeding e.g. • foreign bodies, tumours • Iatrogenic (taking mother’s OCP) • assess secondary sexual characteristics • proper exam to exclude local causes • direct treatment at cause Adolescent anovulatory (AUB) usually • exclude a pathological cause • treat cause if found • if DUB(AUB) and mild, reassure, counsel, haematinics, menstrual calendar • if DUB(AUB) and severe, admit, FBC, exclude blood dyscrasias, blood transfusion, COC/cyclical progestogens, haematinics
  36. 36. AGE GROUP AETIOLOGY TREATMENT Reproductive female • Benign polyps • Fibroids • PID • Abnormal pregnancy • Ovulatory DUB (AUB) • Examination • Pregnancy test • Pap smear • Ultrasound • Hysteroscopy • Endometrial sampling • Direct treatment of underlying cause • If tests normal, COC • If bleeding continues, exclude blood dyscrasias, thyroid abnormalities.
  37. 37. AGE GROUP AETIOLOGY TREATMENT Perimenopausal Female • Anovulatory DUB (AUB) • Organic disease • Exam • Pap Smear • Endometrial sampling • Hysteroscopy, D&C • Treat particular cause • If DUB(AUB), may settle after D&C • If endometrial hyperplasia after DD&C and is complex/atypical  hysterectomy • If simple hyperplasia progestogens • If problem recurs  hysterectomy Postmenopausal Female • Vaginal atrophy • Cervical ca • Endometrial ca • HRT • Topical oestrogen • Hysterectomy & bilateral oophorectomy • Chemo-radiation • Palliation
  38. 38. DIAGNOSIS
  39. 39. Assessment of Patient with Acute AUB • General Approach: i. Assess rapidly the clinical picture to determine patient’s acuity ii. Determine most likely cause of bleeding iii. Choosing the most appropriate treatment for the patient
  40. 40. History: Focus • 1. guided by palm-coein system • 2. focus on details of current bleeding episodes – length, duration, amount, presence of clots, and related symptoms e.g. dizziness • 3. past menstrual and gynaecological history; pap smears, recent surgery, previous medical treatment for gynaecological disorders. • 4. Sexual history and contraceptive hormone use. • 5. medical history, medications: warfarin, heparin, NSAID, OCP, ginseng • 6. Personal/family history of bleeding disorders family history
  41. 41. Physical Examination: Focus • 1. sign of acute blood loss e.g. Vital signs, evidence of hypovolemic shock • 2. findings suggesting the aetiology – “palm coein” e.g. obesity and hirsutism in PCOS; cold/heat intolerance and proptosis in thyroid dysfunction; petechiae in bleeding disorder; splenomegaly - haematological disorders • 3. confirm it is bleeding from genital tracts (and not other places – pelvic examination, speculum and bimanual • 4. differentiate between acute and chronic AUB e.g. admit, refer or discharge
  42. 42. Labs: Acute AUB • Pregnancy test (b-hcg) • FBC, UEC • Group and cross match blood • Coagulation study – e.g. PTT/INR; when indicated – vW-factor assay, ristocetin cofactor assay, Factor VIII etc. • TSH, LFT, Nutritional/iron studies, renal, adrenal function in most patients
  43. 43. Labs: Chronic AUB • Pap Smear / Cervical cytology • Hormonal Assay – FSH/LH, Prolactin levels, • Nutritional/iron studies • Gonorrhea/Chlamydia in high risk patients • Retroviral screen • Endometrial biopsy / endometrial sampling in an older patient
  44. 44. Imaging • Pelvic Ultrasound • TVUS: (transvaginal US is the primary imaging of uterus for evaluation of AUB) • Sono-hysterography (aka saline infusion sonohysterography) • Hysteroscopy • MRI
  45. 45. Evaluation cont. Others: • Cytopathology: • Pap smear, • Cervical biopsy, • Endometrial biopsy • Surgical • D&C hysteroscopy
  46. 46. Uterine Evaluation
  47. 47. MANAGEMENT
  48. 48. Management: General Considerations • 1. Medical management should be initial treatment for most patients • 2. Need for surgery (including type of surgery) is based on various factors: • stability of patient • severity of bleed • contraindications to med management, • underlying cause • desire for future fertility • 3. Long term maintenance therapy after acute bleed is controlled
  49. 49. Initial Approach • Determine if AUB acute vs. chronic • If acute AUB, are there signs of hypovolemia/hemodynamic instability? • If yes, resuscitate: • IV access with 1 to 2 large bore IV; • Crystalloids vs colloids • Prepare for blood transfusion +/- clotting factor replacement
  50. 50. • Once stable, evaluate etiology (PALM-COEIN) • Determine Treatment
  51. 51. Medical Management: Hormonal • First line medical therapy for AUB (for patients not known with bleeding disorders) Treatment options: • 1. Combined oral contraceptive pills – different combination • 2. Progesterone therapy • (medroxyprogesterone acetate – Cyclic Provera 2.5-10mg daily for 10-14 days / Continuous Provera 2.5-10mg daily / DepoProvera® 150mg IM every 3 months / Levonorgestrel IUCD 5 years / Implants )
  52. 52. Medical Management: Hormonal cont. • 3. Conjugated oestrogen (e.g. IV estrogen 25mg qid or Premarin 1.25 po qid x 24hrs) • 4. Progestin: Local – Mirena (IUCD), 20mcg levonorgestrel daily 5years • 5. Progestin: Implantable – Implanon (etonogestrel,3rd generation progestin), daily for 3years • 6. GnRH analogue • 7. Danazol
  53. 53. Medical Management: Hormonal cont.
  54. 54. Medical Management: Hormonal cont. Note: Long term therapy: levonorgesterel IUD, OCPs, progestin (PO or IM); Unopposed oestrogen should not be used long term OCPs are generally considered effective in management of both ovulatory and Anovulatory AUB
  55. 55. Medical Management: Antifibrinolytics • They are used as inhibitors of fibrinolysis without significant increase in GIT side effects • They reduce virtually all cases bleeding by 40-60% • Examples: Tranexamic acid (Cyclokapron) and aminocaproic acid • Tranexamic acid 1g QID x 4 days cycle for ovulatory DUB • MOA – prevent plasminogen activation and decrease fibrinolysis, so decreasing bleeding
  56. 56. Medical Management: NSAIDs • Cyclo-oxygenase inhibitors (NSAIDS) • Mode of action unclear, ?Vasoconstriction, ?suppress prostaglandin synthesis • Examples: • Trials usually used Mefanamic acid (Ponstan) 250-500mg 2-4x daily, • Also naproxen and ibuprofen
  57. 57. Medical Management: Summary Fe (Iron) therapy 01 Anti- fibrinoly tics 02 Cyclo- oxygena se inhibitor s/ NSAIDS 03 Progesti n 04 Continuo us / cyclic 05 Local 06 Implanta ble 07 Oestrog ens plus progesti n 08 Androge ns 09 GNRH agonists and antagoni sts 10
  58. 58. Surgical Management • . Need for surgery (including type of surgery) is based on various factors: • stability of patient • severity of bleed • contraindications to medical management, • patient not responding to medical management • underlying cause • desire for future fertility
  59. 59. Surgical Management Options Dilatation & Curettage Endometrial Ablation Uterine Artery Embolization Hysterectomy Others include: •hysteroscopy with D&C •polypectomy •myomectomy
  60. 60. References Committee Opinion no 557: management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Obstet Gynecol. 2013 Apr;121(4):891-6. doi: 10.1097/01.AOG.0000428646.67925.9a Malcolm G. Munro, Hilary O.D. Critchley, Michael S. Broder, Ian S. Fraser (2011). FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. International Journal of Gynecology and Obstetrics 113 (2011) 3–13
  61. 61. THANK YOU!
  63. 63. QUESTION 1 Thembi is a 8 year old girl. Her mother brings her to the ED because she has noticed blood on her pant. What are the potential causes? • Foreign Bodies – most common • Sexual Abuse • Tumors – uncommon • Early menarche
  64. 64. How to assess her? • History : • caregiver, onset, duration, medication (coc) • Examination: • Secondary sexual characteristics, bruises in and around the perineum
  65. 65. Investigation • EUA – using nasal speculum • Vaginal Swabs • Rape Kit if suspicion of abuse
  66. 66. QUESTION 2 Thembi, now 17yrs old P0 presents with the complaint of heavy, irregular periods since her menarche at 16yrs of age. She has recently started sexual activity and she is not on contraceptives. How do we assess her? • Urinary/Blood β-HCG (i.e. urine/Blood pregnancy test)
  67. 67. Pregnancy Test Positive • threatened miscarriage • inevitable miscarriage • incomplete miscarriage • ectopic pregnancy • induced termination of pregnancy • gestational trophoblastic disease • antepartum haemorrhage
  68. 68. Pregnancy Test Negative • genital tract pathology • congenital uterine abnormalities • trauma • infection e.g. PID • endometriosis/adenomyosis • benign neoplasms e.g. polyps, fibroids, endometrial hyperplasia • malignant neoplasms e.g.. carcinomas, sarcomas
  69. 69. Pregnancy Test Negative, cont. • Iatrogenic: hormones; anticoagulants - needs a more complete history • endocrine causes: Hypothyroidism; adrenal disorders • systemic disorders: Hepatic; Renal; obesity • blood dyscrasias: Van Willebrand’s; thrombocytopenia etc.
  70. 70. Consideration • For Thembi, take into consideration • her young age, • hasn’t completed her family, • expectant and medical management are most appropriate – • i.e. hematinic and hormone therapy (COC, cyclical progestogens) should be used 1st.
  71. 71. QUESTION 3 • Suppose Thembi is a 36-year-old P1G1. • She is sexually active with HMB and post-coital bleeding.
  72. 72. What are the potential causes of the problem? • Most likely to be pregnancy related OR • Genital tract pathology • Other likely causes: • Cervical – dysplasia, cervicitis, malignancy • Endometrial – endometritis, hyperplasia, polyps, fibroids.
  73. 73. QUESTION 3 cont. After thorough history, examination, and investigation, Thembi was found to have CINI • She was then referred to GOPD for further repeat test in 6 months, assessment and staging. • P.S.: in our environment premalignant and malignant cervical disease have high prevalence.
  74. 74. QUESTION 4 • Thembi is a 65yrs old female, 10yrs postmenopausal not on HRT presenting with complain of 3 days history of PV bleeding.
  75. 75. What to consider here? • Cancer until proven otherwise: • Cervical ca; Endometrial ca Others • Systemic: • Hematological; Hepatic • Local: • Infection e.g. viral, bacterial, fungal; • Vaginal atrophy; • Trauma • Iatrogenic: Hormone; warfarin
  76. 76. Assessment: • History • Examination: general, focused • Investigation: speculum, PAP, endometrial sampling, trans-vaginal ultrasound, DD&C
  77. 77. Management: • Hemodynamic stability • Treat underlying cause: topical estrogen, antifungal, correct abnormal INR and PTT. • If ca. cervix or endometrial  staging with CXR, AUS, CT abdomen  treat accordingly