Changes_before_the_Change powerpoint

1. Changes before the change:
Changes before the change:
Perimenopausal Bleeding
Perimenopausal Bleeding
World Menopause Day 2017
World Menopause Day 2017

2. IMS theme Series: Perimenopausal Bleeding
World Menopause Day 2017
Abnormal Uterine Bleeding (AUB) -
Definition
Bleeding that is unlike normal menstrual flow in terms
of frequency, duration and quantity. It includes
infrequent or frequent bleeding, heavy menstrual
bleeding or intermenstrual bleeding
AUB is a leading cause for gynecological consultations
in the peri- and post-menopausal age groups.

3. AUB subsets in the Perimenopause
Ovulatory AUB
Ovulatory bleeding may be heavy and can be
associated with typical premenstrual symptoms
and painful periods.
IMS theme Series: Perimenopausal Bleeding
World Menopause Day 2017

4. World Menopause Day 2017
Anovulatory AUB
Anovulatory bleeding, which is found more frequently during
the perimenopause compared to the premenopause, is often
linked to prolonged periods, heavier flow and an irregular
cycle. If prolonged (e.g. in PCOS or associated with obesity),
anovulatory bleeding has a stronger link to endometrial
cancer and endometrial hyperplasia
IMS theme Series: Perimenopausal Bleeding
AUB subsets in the Perimenopause

5. Abnormal Uterine Bleeding - Etiology
1. Hormonal Changes
2. Benign Anatomic Changes
 Uterine Polyps
Uterine Fibroids
Adenomyosis
Low Thyroid Function
Other medical conditions, i.e. coagulopathy
3. Cancer
Primarily endometrial, but also cervical.
IMS theme Series: Perimenopausal Bleeding
World Menopause Day 2017

6. The goal of diagnosis is to distinguish women with
anatomic causes from women with normal anatomy.
Identifying endometrial malignancy, although
uncommon among the AUB etiologies, is often the
main purpose of the investigations.
Abnormal Uterine Bleeding -
Diagnosis
IMS theme Series: Perimenopausal Bleeding
World Menopause Day 2017

7. FIGO Nomenclature: PALM-COEIN
Adapted from Practice Bulletin No. 128. ACOG Obstet Gynecol 2012;120:197–206
IMS theme Series: Perimenopausal Bleeding
World Menopause Day 2017

8. Before
• AUB
• HMB
• DUB
• Menorrhagia
• Menometrorrhagia
• Oligomenorrhe
Now
• AUB-P
• AUB-A
• AUB-L
• AUB-M
• AUB-C
• AUB-O
• AUB-E
• AUB-I
• AUB-N
IMS theme Series: Perimenopausal Bleeding
World Menopause Day 2017

9. Assessment of abnormal uterine
bleeding
General assessment
History and bleeding pattern
Physical, pelvic and speculum examination
Laboratory tests including:
Full blood count, iron studies, (thyroid, hCG – if indicated)
Disorders of hemostasis (if indicated)
Evaluate pelvic organs and endometrium
ultrasound scan
Hysteroscopy
MRI (if indicated)
IMS theme Series: Perimenopausal Bleeding
World Menopause Day 2017

10. Imaging Techniques
The primary imaging test for the evaluation of abnormal
uterine bleeding is transvaginal ultrasound. This maybe more
difficult in cases of co-existing myomas, previous surgery,
marked obesity, axial uterus or adenomyosis. In such cases
SIS - saline infusion sono-hysterography can be helpful.
Hysteroscopy as a diagnostic tool may also be employed if
intra-uterine pathology is suspected. It can be done in an
outpatients setting using small telescopes and usually
requires no analgesia. An inpatient procedure will be
required in 15-20%
IMS theme Series: Perimenopausal Bleeding
World Menopause Day 2017

11. Endometrial Sampling
Endometrial sampling is required to diagnose endometrial
abnormality.
This can be done, usually after an ultrasound or
hysteroscopy, with a vacuum aspiration system, e.g. Pipelle.
However, this will only sample a small proportion of the
cavity and there is a high incidence of false negative results,
and cancer may be missed. AUB will often require further
evaluation.
IMS theme Series: Perimenopausal Bleeding
World Menopause Day 2017

12. Treatment of abnormal uterine bleeding
Treatment goals for patients with AUB include regulation of
menstrual cycles, minimization of blood loss and improvement
in quality of life.
Treatment options include pharmacological approaches (either
hormonal or non-hormonal), and surgical or radiological
procedures.
Awareness, reassurance and keeping a healthy lifestyle will
contribute to the treatment options for AUB.
IMS theme Series: Perimenopausal Bleeding
World Menopause Day 2017

13. Management of abnormal uterine bleeding (1)
Non-hormonal medical treatments
Non-steroidal anti-inflammatory drugs
Anti-fibrinolytic agents (ie, tranexamic acid)
Iron supplements, in case of anemia
Hormonal medical treatments
Cyclical or long-acting progestogens
Combined oral contraceptives
GnRH analogs (fibroid-associated)
Selective progesterone receptor modulators (fibroid-associated)
Levonorgestrel intrauterine system (LNG-IUS)
IMS theme Series: Perimenopausal Bleeding
World Menopause Day 2017

14.  Endometrial ablation
 Uterine artery embolization (fibroid-associated)
 Hysterectomy
IMS theme Series: Perimenopausal Bleeding
World Menopause Day 2017
Management of abnormal uterine bleeding (2)