Approach to Abnormal Uterine Ble e d ing in Primary Care

b y Liz Rohr, FNP- BC

I’m Liz Rohr

● Family nurs e p rac titione r, MSN from UCLA, 20 15

● BSN from Bos ton Colle ge , 20 0 9● Found e r and CEO of Re a l World NP LLC● Online cours e s , pod cas t, YouTub e ,

Ins tagram & Face b ook channe ls

IN THIS PRESENTATIONWE WILL COVER:

● Identify common causes of abnormal uterine bleeding in primary care

● Explain the diagnostic approach

● Distinguish the most important diagnoses not to miss

IN THIS PRESENTATIONWE WILL COVER:

● Terminology - clarify language

● Expected norms● High quality history -

taking to get your diagnosis faster

● “Bucket” approach to diagnosis

● Simplified workup steps based on your history

SCOPE OF PRESENTATION

- Adolescents through adults

- Doesn’t cover pregnant patients

DEFINITIONSABNORMAL UTERINE BLEEDING

● Any variation in frequency, regularity, duration, volume from the expected norm

○ Also includes intermenstrual bleeding and unscheduled bleeding when using hormonal therapies/ contraceptives

● Unexpected menstruation in patients who have uteruses

○ Patients of all genders -centered around anatomy

New Terminology & General Categories

Terms to leave behind:

● Hype rme norrhe a , me norrhag ia → He avy, p rolonge d

● Polyme norrhe a → Fre que nt● Oligome norrhe a , ame norrhe a

→ Infre que nt/ab s e nt● Dys func tiona l ute rine b le e d ing

→ Ab normal ute rine b le e d ing

TYPICAL NORMS FOR MENSTRUAL FLOW

● Frequency : 24 - 3 8 d ays● Regularity: me as ure d from cyc le d ay

1 to the ne xt d ay 1○ Should s tay the s ame within 7- 9

d ays of cyc le le ng th● Duration: <= 8 d ays , no lowe r limit● Volume: s ub je c tive , d oe s n’t inte rfe re

with qua lity of life - s oc ia l, e motiona l, phys ica l (FIGO guid e line s )

NOTE ABOUT VOLUME● Ne e d ob je c tive me as ure s to as s e s s volume● Norms :

○ Changing me ns trua l p rod uc ts > or = e ve ry 3 hours○ Se ld om ne e d to change prod uc ts ove rnight○ Blood c lots < 1 inch in d iame te r○ Not ane mic

“BUCKETS” OF ABNORMAL UTERINE BLEEDING

● He avy, prolonge d - >8 days , volume + ● Infre que nt - > 3 8 days be twe e n cyc le s● Abs e nt - no me ns e s for 3 + mos● Fre que nt - <24 days be twe e n cyc le s● Irre gula r - cyc le fre que ncy va rying more than 7- 9

days in le ngth

“BUCKETS” OF ABNORMAL UTERINE BLEEDING

Structural

● Ute rine , vag ina l, ce rvica l, vulva r, fa llop ian tub a l, ovarian

○ Be nign or malignant

Nonstructural

● Me d ica tions - hormona l and othe rwis e

● Infe c tious ● Sys te mic cond ition- re la te d

○ Ble e d ing d is ord e r, e nd ocrine

● Non- ge nita l trac t s ource ○ Re cta l, b lad d e r

Structural or non -structural

RED FLAGS1. Cancer2. Infection 3. Systemic illness4. Pregnancy*

MENOPAUSAL STATUS NOTE

Any single episode of post -menopausal bleeding needs to be investigated

TRIAGEAre they hemodynamically stable?

USING THE HISTORY TO SHORTCUT THE DIAGNOSTIC PROCESS

● Me d ica tions , PMH, FH, PSH○ Inc lud ing pre vious OBGYN his tory:

s urge rie s , p roce d ure s○ FH b re as t , e nd ome tria l, colon,

ovarian cance r● LMP (firs t d ay), las t s e ve ra l pe riod s (~ 6

months )● Ons e t: any trauma? Proce d ure ?● Fre que ncy, d ura tion, re gula rity, volume

○ How many d ays , quantity of b le e d ing

○ Numb e r of tampons , pad s , me ns trua l cups in a d ay, light b le e d ing ve rs us b rown s ta ining , changing ove rnight, la rge c lots , ane mia his tory

● Ble e d ing be twe e n me ns e s ? Re gula r or irre gula r? How many mis s e d pe riods in the la s t 6 -12 months ?

● As s oc ia te d s ymptoms : dys pa re unia , dys me norrhe a (?e ndome trios is )

● Source : is the re any chance it’s a re c ta l or b ladde r s ource ? Only whe n going to the ba throom?

● Se xua l his tory: wha t a re the ge nde rs of your pa rtne rs ? How many have you had in the la s t 6 months ? Se e king p re gnancy? Us ing contrace p tive s ? Ris k for STI, inte rme ns trua l b le e d ing , e tc

Heavy, prolonged

● Structural : Fib roid s , ad e nomyos is , e nd ome tria l polyps , e nd ome trios is

○ End ome tria l hype rp las ia /ca rc inoma, ute rine s a rcoma● Infectious : End ome tritis● Systemic : Hypothyroid is m, b le e d ing d is ord e rs (von Ville b rand ,

thromb ocytope nia ), acute le uke mia , anticoagulants , live r d is e as e● Medication : contrace p tive s

Heavy, prolonged - te s ting

● Depends on history and exam● Pregnancy test

○ Urine hcg - 50 % d e te c tab le b y 11 d ays , 9 8% b y 14 d ays a fte r conce ption

○ If urine is ne ga tive , che ck a s e rum hCG (can d e te c t b y 1 we e k a fte r conce ption)

● Physical exam○ Pe lvic e xam - curre nt s igns of b le e d ing? From os ? Le s ion? Fore ign

b od y? Size and contour of ute rus ? Mas s e s ? Te nd e rne s s ?○ Thyroid e xam○ Pe te chiae /b ruis ing

Heavy, prolonged - te s ting

● Lab testing○ CBC with fe rritin, +/- d iff○ PT/INR○ TSH

● Ultrasound● Endometrial biopsy/sampling - per risk factors

RISK FACTORS FOR ENDOMETRIAL HYPERPLASIA

● Incre as ing age (ove r 4 0 +)● Unoppos e d e s troge n the rapy,

tamoxife n the rapy● Early me na rche /la te me nopaus e (ove r

55)● Nullipa rity● PCOS (chronic anovula tion), ob e s ity,

d iab e te s● Othe rs (ra re ): e s troge n- s e cre ting

tumor, Lynch s ynd rome , cowd e n s ynd rome , family his tory of b re a s t, e nd ome tria l, ova rian or colon cance r

INFREQUENT/ABSENT/IRREGULAR

● Structural : Pregnancy , ?endometrial hyperplasia● Infectious : STI?● Systemic : hypothalamic -pituitary dysfunction (intense exercise, eating

disorders, stress, recent menarche or perimenopausal status, hyperprolactinemia, pituitary adenoma)○ PCOS, hyper/hypothyroidism, CKD, liver disease, cushing’s

disease, congenital adrenal hyperplasia○ Rare: Kallman syndrome, tumors/trauma in pituitary area,

Sheehan’s syndrome, empty sella syndrome, autoimmune diseases, idiopathic hypogonadism

● Medication : contraceptives, steroids, antidepressants/antipsychotic drugs, chemotherapy

INFREQUENT/ABSENT/IRREGULAR

● Assessment and testing○ History questions : s tre s s , e xe rc is e , e a ting d is ord e rs , ga lac torrhe a○ Physical exam: s ign of hirs utis m, ga lac torrhe a , pe lvic , BMI, ha ir

los s○ Labs :

■ TSH■ Prolac tin■ And roge n le ve ls for s igns of hype rand roge nis m (acne ,

hirs utis m)■ FSH or LH - FSH a lone for s us pe cte d me nopaus e , b oth if

s us pe cting hypotha lamic d ys function■ Es trad iol le ve ls if s us pe cting me nopaus e

○ Endometrial sampling if >6 mos and risk factors

Intermenstrual bleeding

● Structural : Pregnancy , cervical (polyps, cervicitis, ectropion, cervical cancer), endometrial polyps, etc.

● Infectious : STI● Medication : contrace p tive s

Intermenstrual bleeding

● Assessment & testing○ Physical exam○ Labs :

■ Pre gnancy te s t■ STI te s ting as appropria te

○ Ultrasound +/ - endometrial biopsy pe nd ing ris k and find ings

When to refer

Patie nt ne e ds e ndome tria l s ampling , unc le a r e tiology, s urg ica l inte rve ntion ne e de d , ris k for cance r

Real World NP

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Handout: www.realworldnp.com/NPA

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