Abnormal Uterine Bleeding

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Abnormal Uterine Bleeding

• Todd May, M.D.

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Abnormal Uterine Bleeding

• Common in women of all ages
• 5 women of reproductive age seek help annually
• Life phase determines most likely cause, and the
  likelihood of serious pathology
• Take your time to properly assess the problem
• Work-up and treat in a rational manner

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Complications of pregnancy Systemic disease
Intrauterine pregnancy Hepatic disease Ectopic
pregnancy Renal disease Spontaneous
abortion Coagulopathy Gestational trophoblastic
disease Thrombocytopenia Placenta previa von
Willebrand's disease Leukemia Infection C
ervicitis Medications/iatrogenic Endometritis
Intrauterine device Hormones (oral
contraceptives, Trauma estrogen,
progesterone) Laceration, abrasion Foreign
body Hormonal imbalance Anovulatory cycles
Malignant neoplasm Hypothyroidism Cervical
Hyperprolactinemia Endometrial Cushings
disease Ovarian Polycystic ovarian syndrome
Adrenal dysfunction/tumor Benign pelvic
lesions Stress Cervical polyp Excessive
exercise Endometrial polyp Leiomyoma
Adenomyosis
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Abnormal Bleeding Cause

• Pregnancy
• Hormonal/Dysfunctional
• Anatomic
• Coagulopathy/bleeding disorder

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History

• Characterize menses
• Age, parity, past pregnancies, sexual history,
  contraception, past gyn problems, medications
• Personal or family history of bleeding disorder
• Symptoms of thyroid disease
• History of liver disease

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Physical Exam

• Orthostatic VS if indicated by Hx
• Pelvic exam vagina, cervix, uterus, adnexa, PAP
• Skin ecchymoses, hirsutism
• Thyroid gland
• Liver and assoc. stigmata
• Signs of virulization

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Labs

• CBC with Plts
• Urine ß-HCG if reproductive age

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Additional Tests (not routine)

• TSH anovulatory
• LFTs, coagulation studies liver dz or FHx
• Complete coagulation profile consider for
  non-pregnant teens
• GC, Chlamydia if risk or exam suggests
• Androgen excess free testosterone, DHEA-S (PCOS
  evaluation)
• FSH suspect premature ovarian failure
• Progesterone confirm ovulation, draw in luteal
  phase

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Adolescents

• Usually anovulation due to immature Hypothal-Pit
  axis
• Rule out pregnancy
• Consider bleeding disorder
• Observe or Rx with cyclic MPA or OCs

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Consider Bleeding Disorder

• von Willebrands Disease
• Underdiagnosed present in 1 of population
• Autosomal dominant affects women and men equally
• Dx ?Bleeding time, ?Factor VIII, vW factor,
  ristocetin co-factor activity
• Rx Desmopressin (ADH) IV or intranasal
• Increases vW factor, factor VIII,
• plasminogen activator

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Reproductive Age

• HP
• Check urine ß-HCG
• Genital tract lesionBx or refer
• Enlarged uterus
• r/o pregnancy
• sono for anatomic cause (e.g., fibroids)

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Reproductive Age

• If not pregnant and normal exam
• Usually DUB (i.e., hormonal)
• Determine ovulatory status ? key!
• Treatment Usually hormonal

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Ovulatory Cycles

• Regular cycle length
• Presence of premenstrual symptoms
• Breast tenderness, dysmenorrhea
• Mittleschmertz
• Biphasic temperature curve

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Anovulatory Cycles

• Unpredictable cycle length
• Unpredictable bleeding pattern
• Frequent spotting
• Infrequent heavy bleeding
• Monophasic temperature curve

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Anovulatory Bleeding

• 90-95 of reproductive age
• Cause systemic hormonal imbalance
• Always a relative progestin-deficient state

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Anovulatory Bleeding

• Assess for secondary hypothalamic disorder
• stress, eating disorder, excessive exercise, wt
  loss, chronic illness
• Check TSH
• Test for PCOS if indicated
• obesity, hirsutism, insulin resistance
• Consider chronic anovulation

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Anovulatory DUB Treatment

• Address underlying disorder
• Treat with monthly OCs or progesterone withdrawal
  every 3 months (MPA or DMPA)
• Regulate cycles, protect against endometrial CA
• Clomiphene for ovulation induction in select cases

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Ovulatory Bleeding

• Usually underlying prostaglandin imbalance (DUB)
• Defects in local endometrial hormonal hemostasis
• Structural lesions
• Leiomyoma, adenomyosis, polyps
• Systemic disease
• Liver dz, renal failure, bleeding disorder

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Ovulatory Bleeding

• Much less common5-10
• Consider empiric treatment without further w/u
  (normal exam)
• NSAIDs, OCs, progesterone IUD
• If Rx fails, proceed with work up
• Metabolic labs
• Imaging, EMB

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Ovulatory DUB Treatment

• NSAIDs (prostaglandin synthetase inhibitors)
  e.g., Ibuprofen, Naproxen, Mefenamic acid
• First 5d of menses
• Cyclic OCs x 3-6 mos
• Progesterone IUD most effective
• Tranexamic acid anti-fibrinolytic

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Evaluating endometrial cavity

• Consider EMB
• Higher risk women
• Prolonged exposure to unopposed estrogen
• Age gt 40
• Failure to respond to initial management

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Evaluating endometrial cavity

• Endometrial Biopsy (EMB)
• Safe, simple office procedure
• Rule out endometrial CA
• Confirm ovulatory status
• EMB best done while bleeding
• Proliferative confirms anovulation
• Secretory confirms ovulation
• Hyperplasia chronic unopposed estrogen
• Atrophy menopause or continous OCs, HRT,
  DMPA

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Evaluating endometrial cavity

• Dilation and Curettage (DC)
• OR procedure, less commonly used
• Rule out endometrial carcinoma or hyperplasia
• Yield slightly higher than EMB, but still blind
  sampling technique

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Evaluating endometrial cavity

• Transvaginal Ultrasonography (TVSono)
• Alternative to EMB to assess endometrium,
  comparable accuracy
• Endometrial stripe gt5mm ? EMB for tissue
  diagnosis
• Often can detect atrophic endometrium,
  leiomyomas, and endometrial polyps

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Evaluating endometrial cavity

• Sonohysterography (water sono)
• TVSono with saline infusion into endometrial
  cavity
• Enhances detection of submucosal fibroids and
  polyps

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Evaluating endometrial cavity

• Hysteroscopy
• Gold standard for endometrial assessment
• Office procedure
• Thorough, direct inspection of endometrial cavity
• Directed biopsy or treatment possible (e.g.,
  polyp excision)

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Perimenopause

• HP
• Check urine ß-HCG
• Genital tract lesionBx or refer
• Enlarged uterus
• r/o pregnancy
• TV Sono for anatomic evaluation (e.g., fibroids)

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Perimenopause

• If not pregnant and normal exam
• Consider early EMB or TV Sono
• r/o edometrial hyperplasia, CA
• If negative, Rx with low dose OCs or monthly
  Medroxyprogesterone
• Sonohysterography or hysteroscopy if Rx fails
• r/o anatomic causes

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Postmenopause

• 5-10 endometrial carcinoma
• Proceed directly to EMB or TV Sono
• DDx endometrial hyperplasia, cervical cancer,
  cervicitis, atrophic vaginitis, endometrial
  atrophy, submucosal fibroids, endometrial polyps
• Rx specific to cause

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Treatment Acute Bleeding

• Conj. Eq. Estrogens x 21d
• MPA last 710d
• Use Estrogen IV for severe bleeding hospitalized
• High dose OC 1 QID x 7d
• then OC daily x 3 months
• or MPA x 10d q month x 2-3 more cycles

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Surgical Treatment

• Therapeutic DC
• fastest method to stop bleeding in unstable
  patients
• must follow with hormones to prevent recurrence
• Endometrial Ablation/Resection
• laser or electrocautery
• good option if fertility not desired

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Surgical Treatment

• Hysterectomy
• if all else fails or patient prefers
• subtotal hysterectomy is an option to preserve
  optimal sexual and bladder function
• hysterectomy now is rarely necessary solely for
  uterine bleeding

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Adolescents

• Most likely anovulatory due to immature
  Hypothal-Pit axis
• Rule out pregnancy
• Consider bleeding disorder
• Observe or Rx with cyclic MPA or OCs

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Anovulatory Adults

• Identify secondary causes of Hypothal-Pit
  dysfunction, thyroid disease, PCOS
• Address underlying cause
• Manage bleeding with cyclic MPA, DMPA, or OCs

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Ovulatory Adults

• Causes endometrial modeling defect, structural
  lesions, systemic disease
• Consider empiric Rx without further w/u if
  history and exam are normal
• NSAIDs, OCs, Progesterone IUD
• If Rx fails, w/u with metabolic labs, imaging,
  and EMB if indicated

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Perimenopause

• Progressive anovulation due to declining ovarian
  function
• Rule out pregnancy
• Consider early EMB or TVSono
• (esp. with endometrial CA risk factors)
• Rx with OCs or monthly MPA

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Postmenopause

• Rule out endometrial CA (5-10)
• Proceed directly to EMB or TVSono
• Evaluate for other causes
• endometrial hyperplasia, cervical cancer,
  cervicitis, atrophic vaginitis, endometrial
  atrophy, submucosal fibroids, endometrial polyps
• Rx specific to underlying cause

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Summary

• Abnormal uterine bleeding is very common
• Life phase and detailed menstrual history are key
• Employ rational evaluation and treatment strategy
• You can manage it!

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Cervical Cancer Screening

• Todd May, MD

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Cervical Cancer

• 12,800 cases/yr
• 50 never screened
• Death rate ? 70 since 1940s
• Pap introduced

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Natural History

• HPV acquired in teens, 20s
• Prolonged pre-malignant phase
• Spontaneous HPV clearing common
• CIN peaks 20s-30s
• Small number progress to invasive cancer

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Risk Factors for Neoplasia

• Multiple sexual partners
• HPV
• Smoking
• HIV

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Routine Screening Recs

• Start
• 3yrs after first vaginal intercourse
• Age 21 (unless virginal?)
• Interval
• Annually age lt30
• Age gt30 q2-3yrs if normal x 3 annuals
• Stop
• Age 65-70 if consistently normal
• After hysterectomy for benign condition

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High-Risk Screening Recs

• Pap every 6 months x 2, then annually for
• HIV positive
• Immunocompromised by organ transplant, chemoRx,
  chronic steroid use
• Prior Rx for CINII/III or cancer
• Rationale Progression to HSIL and CA more common
  and more rapid

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Essentials of Pap Sampling

• Collect cells before bimanual exam
• Gently remove cervical mucus/dc
• Visualize entire portio of cervix
• Use scraper for ectocervix brush for
  endocervical specimen
• Fix slide immediately (lt3-4sec)

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Cytologic Interpretation

• Adequacy of specimen
• Satisfactory or unsatisfactory
• Descriptive diagnosis
• Bethesda 2001
• Presence/absence of endocervical cells

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Negative for IEL or Malig.

• Benign cellular changes
• Trichomonas
• Fungus c/w candida sppNo action
• Floral shift/BVNo action
• Suspect Chlamydiacall back to test
• HSVnotify patient
• HPV/koilcytosismanage as LSIL
• Actinomyces (IUD)Rx with Amox

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Negative for IEL or Malig.

• Reactive changes
• InflammationNo action
• Atrophy w/ inflam. (atrophic vaginitis)Rx w/
  topical estrogen, repeat if no ECC
• RadiationNo action
• Reactive/reparative AtypiaNo action
• Squamous metaplasiaNo action

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Squamous Cell Abnormalities

• ASCUSundetermined significance
• ACS-Hcannot exclude HSIL
• LSILlow gradeincludes HPV, mild dysplasia/CINI
• HSILhigh gradeincludes mod-severe dysplasia,
  CINII/III, CIS
• Invasive SCCa

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Glandular Cells

• Endometrial cellsconsider EMB if agegt40 or
  abnormal bleeding
• Atypical Endocervical cellscolpo, Bx, ECC
• Atypical Endometrial cellsEMB, DC, or
  hysteroscopy
• Endocervical, Endometrial, or Extrauterine
  Cadefinitive Rx

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ASC US
HPV DNA Testing
HIV
Repeat 4-6 months
HPV Positive
HPV Negative
(for high risk types)
Negative gt ASC US
Colposcopy
Routine Screening
Repeat PAP
12 months
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ASCH / LSIL
Colposcopy

CIN 2 or 3, CIS
Neg or CIN 1
PAP q6 mos x 2 RX
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HSIL
Colposcopy ECC

Satisfactory
Unsatisfactory
No CIN or CIN 2, 3
Diagnostic CINI
Excision
Diagnostic Excision
Rx
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Bottom Line

• When to refer for colposcopy
• ASC-US x 2 (x1 if HIV)
• ASC-H
• LSIL
• HSIL