OB-GYN Abnormal Uterine Bleeding

Tests

-first step is to r/o pregnancy: urine or serum HCG -regular, cyclic menses is most likely ovulatory: BBT (basal body temp every morning) and cycle charting is helpful to determine if pt ovulates regularly -determine ovulatory status: luteal phase (day 20-22) serum progesterone level of >2 ng/mL is consistent with ovulation

Labs

-HCG - pregnancy test -CBC - r/o anemia -TSH - thyroid stimulating hormone -liver, thyroid or renal function testing may reveal another medical cause/diagnosis -PTT, PT, platelet count, factor VIII or Von Willebrand's antigen levels -prolactin levels -FSH >30 mIU/mL suggests premature ovarian failure -FSH, LH, total testosterone, 17 hydroxyprogesterone, and DHEAS (POCS)

Summary of AUB

-atrophy - most common cause of AUB in post menopausal female -TVS (transvaginal ultrasound sonogram) - excellent screening tool for evaluation of AUB (especially PMB) -women with recurrent AUB may require definitive follow up -Gold standard for diagnosis - hysteroscopy and biopsy -endometrial cancer risk factors - obestity, unopposed estrogen, DM, HTN

Mechanism of action OCP & progestins

-OCP: decreases estrogen through negative feedback, turning off intrinsic pathway, thereby reducing estrogen -Progestins: inhibit endometrial growth by inhibiting estrogen receptors; promote conversion of estradiol to estrone; inhibits LH; stimulates arachidonic acid formation (precursor to PG2Fa) causing uterine contraction and vasoconstriction

Antifibrinolytic therapy

-Tranexamic acid - FDA approved oral form (Lysteda) for Rx of heavy menstraul bleeding -could cause nausea, leg cramps, and thrombotic event -no more than 6 tabs in 24 hours -slows fibrin activity -used as Rx of DUB associated with uterine fibroids -inhibits endometrial plasminogen activator and prevents fibrinolysis and the breakdown of clot -side effects uncommon - increased of thrombotic tendency

Age groups

-age 12-18: immature HPO axis - irregular cycles -age 19-39: common structural causes are polyps and fibroids (molimina- nonmenstral systems, mood swings, fatigue, headaches); PCO- common in reproductive age women, often causes anovulatory cycles; malignancy is less common in this age group -age 40 and older: endometrial atrophy most common in this age group

menorrhagia

-heavy or prolonged menstrual bleeding (>7 days duration) -regular intervals -gushing of blood

procedures/surgery

-endometrial biopsy is indicated in women >35 to rule out hyperplasia or malignancy -hysteroscopy and biopsy is "Gold standard" for diagnosis -biopsy may be warranted in younger women with significant risk factors such as unopposed estrogen use, obesity, anovulation, FH of breast, ovarian, or uterine cancer

post coital/post menopausal bleeding

bleed after sex bleed after one year of no periods

COEIN: nonstructural causes

-coagulopathy (AUB-C) -ovulatory dysfunction (AUB-O) -endometrial (AUB-E) -iatrogenic (AUB-I) -not yet classified (AUB-N)

menometrorrhagia

-heavy bleeding, occurring at irregular intervals -prolonged, usually >7 days duration

amenorrhea

absence of period

Hypomenorrhea

light periods

polymenorrhea

periods that are too frequent, usually less than 21 days apart

Goals of treatment

(rule out cancer and pregnancy before giving hormones) -control bleeding -prevent future episodes -replenish iron stores (give sulfate by mouth) -restore cycle -preserve fertility (if desired)

AUB key points

-AUB is broad spectrum of menstrual irregularities -diagnosis depends on the pt's history, age, and physical exam findings -treating AUB depends on whether or not the pt ovulates (ovulatory vs. anovulatory) -normal: 28 days +,- 7 days; 3-7 days duration; volume 30-75 cc -abnormal; <21 or >35 days length; more than 7 days duration; volume >80 mL

Surgical options

-Endometrial ablation (thermal/laser ablation) Thermachoice, Novasure - stop bleeding all together (beware of uteran cancer) -hysterectomy -uterine artery embolization - destroys uterine lining

Physical exam

-breast exam (glactorrhea), speculum exam, bimanual exam, rectal exam, pap test, STI testing, examination of vaginal discharge -look for weight gain, acne, hirsutism, or other signs of virilization -look for bleeding gums, easy bruising -examine thyroid, neck, heart, and lungs -wet smear may indicate signs of vaginitis, STI testing is indicated to r/o PID or cervicitis -pap smear can evaluate for cervical changes (cancer) that may cause intermittent or post coital bleeding -rectal exam - hemorrhoids, and tests for occult blood in fecal matter (GI bleeding)

Anovulation

-corpus luteum is not produced -ovary does not produce progesterone -estrogen production continues causing endometrial proliferation (and cancer due to growth in uterine lining and becoming top heavy) and AUB

Progestin secreting treatments

-cyclic medroxyprogesterone (Provera) 10mg daily for 10-14 days PO -continuous Provera 2.5-5 mg daily -Progesterone in oil, 100 mg every 4 weeks IM -DepoProvera 150 mg IM every 3 months -Mirena IUD (IUS) 5 years

DUB

-dysfunctional uterine bleeding -abnormal uterine bleeding for which an organic etiology has been ruled out

Acute AUB treatment

-if ultrasound shows <5 mm endometrium, treat with estrogen -if ultrasound >10-12 mm consider curettage (get biopsy) -estrogen causes rapid growth of the endometrium -premarin 2.5 mg orally QID or 25 mg IV q 4-6 hours until bleeding stops -if bleeding stops add oral Progesterone 10 mg daily for 7-10 days (sustain endometrium)

Metrorrhagia

-irregular bleeding between periods -lighter flow -may be associated with ovulation

AUB prognosis/complications

-most will respond to treatment -iron deficient anemia if bleeding prolonged or frequent -unopposed estrogen exposure may lead to endometrial carcinoma (exogenous or from chronic anovulation) -infrequent or irregular periods, perimenopause, and anovulation can result in infertility -ICD-9 codes: 626.2 excessive bleeding; 626.6 metrorrhagia; 627.1 PMB

Endometrial cancer risk factors

-nulliparity (never been pregnant) -diet: high fat intake, alcohol, coffee/tea -diabetes, HTN -obesity: estrogen produced by adipose tissue -unopposed estrogen: 4-8 times greater risk, anovulation (given exogenous progesterone to counteract estrogen)

AUB treatment options

-oral contraceptives induce withdrawal bleeding in anovulatory women, reduce menstrual flow, and improve cycle regularity in ovulatory women -cyclic progestins induce bleeding in anovulatory women with adequate estrogen (progesterone challenge test)(16-25 mg cycle progesterone; 10 mg provera) -Mirena IUD significantly reduces amount of blood loss (intrauterine device) -OCP's are helpful in women with PCOS

Acute blood loss treatment

-oral contraceptives: 1 pill by mouth, 3 times daily x7 days or 1 pill twice daily x 5 days, then one pill daily until pack is finished -estrogen contraindications: h/o thrombosis, estrogen dependent cancers, active liver disease -D&C is the quickest way to stop acute bleeding; indicated in hypovolemic pt

oligomenorrhea

-periods more than 35 days apart -infrequent uterine bleeding varies between 35-60 days -usually anovulation from endocrine causes or systemic causes

PALM: structural causes

-polyp (AUB-P) -adenomyosis (AUB-A) -Leiomyoma (AUB-L) (uterine fibroid) - subtypes: submucosal leiomyoma (AUB-SM), other leiomyoma (AUB-LO) -Malignancy, hyperplasia, endometriosis (AUB-M)

Management of NSAIDS

-reduces bleeding -ibuprofen 600-1200 mg/d, divided doses, with food -Mefenamic acid (ponstel) 500-1500 mg/d, divided doses, FDA approved for menorrhagia -Naproxen sodium (anaprox DA) 500 mg bid -other NSAIDS, COX 2 inhibitors?

Management: Estrogen

-screen for contraindications prior to treatment (uteran cancer, thrombotic events) -short term -acute hemorrhage: 25 mg IV every 4-6 hours -for less severe bleeding: Premarin 1.25 mg 2 tabs orally four times daily until bleeding stops

Imaging

-transvaginal ultrasound (TVUS) can detect structural lesions and measure the thickness of the endometrial lining (endometrial stripe, may be abnormal if >5mm and >45y/o) -fibroid <5mm may not be detected -polyps may not be visible unless sonohystography is performed -sonohystography is operator-dependent and costly -bladder must be full

signs and symptoms

-unusually heavy bleeding -irregularities in the amount of flow or timing of menses -bleeding after intercourse or defecation -symptoms of anemia - fatigue, dyspnea, lightheadedness, fingers numb, ice chewing

AUB risk factors

-vaginal/pelvic/abdominal trauma/foreign body -personal of FH of AUB -personal or FH of coagulation defects -FH of premature ovarian failure/ early menopause/atrophy -associated symptoms of acne, weight gain or hirsutism (polycystic ovaries) -thyroid disorders, ITP, von Willebrand's, leukemia (organic disorders) -medication use (neuroleptics, hormonal contraceptives) -eating disorders/low BMI/ excessive exercise -severe physical/emotional stress, including medical and psychiatric illness -intra-uterine device (IUD) -oral/injectable steroids

Mechanisms of hemostasis

-vasoconstriction, localized -platelet vasoconstriction -platelet plug forms - at basis of endometrium basal layer where period originates -reinforcement of the plug with fibrin -fibrinolytic mechanisms remove coagulated material -hemostatic plug formation - most important in proper endometrial function -vasoconstriction - most important in the basalis layer -prostaglandins regulate vasodilatation and vasoconstriction and the clotting process -PGE2 produces vasodilation -PGF2a produces vasoconstriction -progesterone is required to increase arachidonic acid, a precursor to PGF2 -decrease in progesterone promotes vasodilation thereby promoting AUB -PGF2/PGE2 ratio is decreased due to elevated estrogen/lack of progesterone secretion in anovulatory cycles

NSAIDS

-vasocontriction/increased platelet aggregation by correcting Prostaglandin imbalance inhibiting Cycloxygenase in the Arachidonic cascade -reduce blood flow and dysmenorrhea but have no effect on frequency (cycle length) -in severe cases GnRH agonists (Leuprolide, buserlin) may be used to induce a hypogonadotropic state