Diagnosis and Management of Dysfunctional Uterine Bleeding

1
Diagnosis and Management of Dysfunctional Uterine
Bleeding

• INMED INTENSIVE COURSE, June 4, 2009
• John O. Gibson, MD
• JPS Department of Family Medicine

2
Introduction

• DUB vs. AUB
• DUB Large majority of AUB outside of pregnancy
  related causes.
• Excludes Pregnancy, Systemic, Anatomic,
  Traumatic or Infectious causes of abnormal
  bleeding
• Caused by functional abnormalities of the
  hypothalamic-pituitary axis

3
Definitions
4
Normal Menstrual Cycle
5
Pathophysiology of DUB

• Anovulatory DUB ( 70 to 90 )
• Unopposed Estrogen Stimulation of Endometrium
• Lack of Progesterone mediated maturation
• Excessive and fragile Endometrium
• Irregular shedding with heavy and or prolonged
  bleeding
• Most prevalent in Perimenarcal and Perimenopausal
  years

6
Pathophysiology (cont)

• Ovulatory DUB ( 10 to 30 )
• Some are from Luteal Phase deficiency
• Diminished progesterone with low, normal or high
  estrogen
• Prolonged progesterone secretion
• Diminished potency of estrogen
• Lack of hypothalamic feedback and withdrawal

7
Differential Diagnosis and Testing

• Driven by age, risk factors from history and
  physical exam.
• Evaluation that is always appropriate
• Exclusion of pregnancy (child bearing age women)
• Confirmation of bleeding from Uterine source
• Exclusion of vulvar, vaginal, cervical, urinary
  tract or GI tract as source of bleeding
• Exclusion of Infection and Malignancy
• Exclusion of Structural, Endocrine or Systemic
  disease

8
Common Causes of Genital Bleeding
9
Evaluation of Adolescent DUB

• Exclusion of Pregnancy
• Examination to look for structural, traumatic and
  infectious etiology
• Obesity/ Signs of androgen Eval for PCOS
  (testosterone levels, ? Prolactin, TSH,
  Cortisol)
• Progesterone Challenge
• Consider evaluation for Bleeding disorders
• (Extremely heavy 1st menses, hypovolemia,
  transfusion, refractory sx with anemia)
• Check for STDs/PID

10
Evaluation of DUB, age 20 to 35

• Exclusion of Pregnancy
• Ovulating vs Non Ovulating still predominately
  anovulatory, but less than adolescent or
  perimenopausal
• Ovulatory Cyclic but heavy Etiology likely
  to be from anatomic or physical lesion ( polyp,
  fibroid, adenomyosis, neoplasm, foreign body),
  hemostatic defect, infection, trauma, etc
• Anovulatory Irregular, non cyclic, most likely
  to be true DUB
• Consider PCOD if clinical signs or risk factors
• Evaluate endometrium if risk of CA

11
Evaluation of DUB, Age 35 to Menopause

• Exclusion of Pregnancy
• Evaluation and Differential similar to younger
  EXCEPT
• Anovulation increases again as menopause
  approaches
• Risk of CA increases endometrial, cervical,
  ovarian
• Imaging and Sampling of endometrium is critical

12
Evaluation of DUB, Post Menopause

• Etiology
• Atrophy (59 percent)
• Polyps (12 percent)
• Endometrial cancer (10 percent)
• Endometrial hyperplasia (9.8 percent)
• Hormonal effect (7 percent)
• Cervical cancer (less than 1 percent)
• Other (eg, hydrometra, pyometra, hematometra 2
  percent)
• Imaging and Sampling of Endometrium becomes
  mandatory

13
Evaluation of Endometrium
Endometrial Biopsy (EB) Contraindications
Pregnancy, untreated infections Transvaginal
Ultrasound (TVUS) Post Menopause Thickness of
5mm or less very low risk for CA Not as
standardized for Pre Menopausal women Saline
Infusion Sonohysterography Saline infusion
into endometrial cavity before TVUS Better at
finding polyps and small lesions Hysteroscopy Not
an easy outpatient procedure, but superior
results for sampling DC ? Past Tense ?
14
Endometrial Sampling Methods
Endometrial Suction Curette Pippelle most
commonly used, least discomfort Vabra Aspirator
and Karman Cannula Endometrial Brush Superior
in Post-Menopausal Same as Pipelle in
Pre-Menop.
(A) Pipelle endometrial suction curette. (B)
Vabra aspirator.
Tao Endometrial Brush
15
TVUS

• Simple in office procedure
• Equipment issues
• Experience issues
• Able to identify pathology of endometrium as
  well as other pelvic abnormalities
• Thickened (gt5mm) endometrial stripe in
  postmenopause ALWAYS needs further evaluation.
• Usually does NOT replace endometrial sampling in
  eval of DUB

16
Saline Infused Sonohysterography
Enhanced contrast/relief of endometrial lesions
fibroids, polyps CA Sensitivity/Specificity at 93
to 94 for focal lesions ( vs 75 for TVUS
alone) Combined with EB very high rate of
Dx Focal lesions then result in Hysteroscopy
17
Hysteroscopy

• Provides direct visualization of endometrium
• More costly and requires higher skill and
  training levels
• Often done in OR
• Allows for directed biopsy and curretage

Also used for non-invasive surgical treatment of
bleeding that does not respond to medical therapy
18
Treatment for DUB

• Refers to anovulatory DUB, other causes would
  receive specific treatment
• Medication/Hormonal
• Surgery/Ablation

19
Hormonal Methods

• Acute Management
• Management of acute bleeding If severe oral or
  IV estrogen regimens. Treat anemia, and
  hypovolemia
• Uterine tampanade with Foley catheter with 30cc
  balloon
• Emergency DC when medial Rx fails
• Chronic Management
• cyclic combined oral contraceptives vs
  progesterone only
• Progesterone secreting IUD
• Surgical management

20
Endometrial Ablation

• For women no longer desiring fertility
• Failure of medical therapy or repeated bouts of
  severe hemorrage
• STANDARD VERSUS GLOBAL TECHNIQUES
• Standard rollerball, laser or loop
  electrodessication
• Global can be done in the office in some cases
• Cryoablation
• Hot liquid filled balloons
• Hydrothermal ablation (circulating hot water)
• Bipolar radiofrequency ablation ( Novasure - a
  three dimensional bipolar mesh )
• Microwave ablation

21
ENDOMETRIAL ABLATION VERSUS HYSTERECTOMY

• Pros for Ablation
• Lower cost
• Faster recovery
• Potential as office procedure
• Cons for Ablation
• Failure rates (re-bleeding) 10 to 25 percent
• Not reliable for contraception
• May need progestins if takes hormone replacement

22
ENDOMETRIAL ABLATION VERSUS HYSTERECTOMY

• Pros for Surgery
• 100 percent success to stop bleeding
• Reliable for contraception
• No risk of endometrial CA if on HRT
• Cons for Surgery
• Considerably more expensive
• More recovery time (even with minimally invasive)
• Significantly more risk

23
Summary

• DUB is a common disorder in FM
• Evaluation and workup varies with age and risk
  factors
• Endometrial imaging and sampling is critical in
  women over 35 and those younger who are higher
  risk
• Multiple options for treatment exist for both
  medical and surgical modalities.